Preventing Prescription Drug Overdose:New Challenges, New Opportunities

National Rx Drug Abuse SummitOperation UNITE

Atlanta, GA

April 8, 2015

Thomas R. Frieden, MD, MPH

DirectorCenters for Disease Control and Prevention

Indiana HIV outbreak – sentinel impact ofprescription opioid epidemic

• ISHD reports 89 cases of HIV (as of April 7)

• >90% identified report injecting Opana

• All geographically linked to Scott County (Pop: 24,000, Austin: 4,300 people)

• Cases in at least 7 other counties

• Immediate response: case detection, linkage to HIV and drug treatment, safe injection

• Medium/long term: prescription practices, drug treatment, injection safety, HIV/HCV care & funding

• CDC has more than 10 experts currently in the field

• Working w/ state & county governments, SAMHSA, HRSA

Prescription drug abuse is apublic health epidemic

4X

The more than 4-fold increase in opioid overdose deaths parallels the 4-fold increase in sales since 1999

Prescription opioids are potentially dangerous drugs –overdoses have claimed more

than 145,000 lives over thepast decade

Prescription opioids:dangerous drugs

Highly addictive

• Just a few doses may lead to a lifelong struggle with addiction

Potentially lethal

• Just a few too many pills may suppress breathing and lead to death

• Increases risk of injection drug use including heroin

US opioid prescribing in 2012

IMS Health, National Prescription Audit, 2012.

259M

259M

Death rates from heroin overdose are increasing rapidly as death rates from prescription opioids are leveling off

0

1

2

3

4

5

6

7

8

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

De

ath

ra

te(p

er

10

0,0

00

, a

ge

ad

jus

ted

)

Heroin

Rx Opioids

All opioids (Heroin and Rx)

CDC Vital Statistics

While recent trends in opioid overdosevary by state, heroin overdose is

increasing everywhere

• Increases in heroin OD death rates were significantly associated with increases in Rx opioid death rates

• Heroin OD death rates increased in all subgroups –suggesting there is something besides replacement occurring

MMWR, Oct 3, 2014.

3 out of 4 people reporting Rx opioid and heroin use in past year took Rx opioids first

Jones, C.M., Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers –United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. (2013).

Two groups of people, two differentsets of needs

Addicted/Dependent

Need access

to services

At risk for addiction/dependence

Protect from

dangerous drugs

Progress is possible:Lessons from public health successes

Motor vehicle crashes

• Legal, law enforcement, public health & communities working together

Tuberculosis control

• Accountability for every single person started on treatment

Tobacco control

• Comprehensive approaches to make the product less appealing and accessible, highlight impact on others, offer treatment

Public health, law enforcement & communities working together cut crash deaths more than half…

We can do the same for overdoses

0

5

10

15

20

25

Dea

ths

pe

r 1

00

,00

0 p

op

ula

tio

n

Motor Vehicle Traffic Drug Poisoning (Overdose)

Source: NCHS.

Technical package

• Selected group of related interventions that, together, will achieve and sustain substantial improvements in specific risk factor or disease outcomes

• Ensures focus on specific interventions known to be most effective, feasible, sustainable, and scalable

• Avoids using large number of interventions, many of which may have only a small impact

• Can sometimes achieve synergy among intervention elements

• Simplicity is key to success

Possible technical package elements forRx opioid misuse/abuse and OD prevention

• Improve prescribing• PDMPs, pain clinic laws, prescribing defaults in EHR software,

prior authorization for risky prescriptions, and more

• Involve payors including Medicaid/Medicare, health systems, PBMs; clinicians; patients

• Treatment of opiate addiction and overdose: Increase access, quality, and accountability

• Reduce availability of illicit drugs

• Promote social awareness and economic development to reduce initiation and continuation of drug use

• Rigorous, real-time monitoring and appropriate action

Opioid prescribing rates are 3x higherin some states than others

MMWR Vital Signs, July 2014. Source: IMS, National Prescription Audit (NPATM), 2012.

We are making some

progress, but much

more is needed

State-based interventions areimproving outcomes

49 states have an operating PDMP –but only Oklahoma’s is updated in real time

NAMDSL. Annual Review of Prescription Monitoring Programs, 2015. Data through Dec. 2014.

Missouri has PDMP legislation pending, DC has enacted legislation but PDMP is not yet operational.

But… no PDMP is yet:

• Universal,

• Real-time, and

• Actively managed

“The death rate is a fact.

Everything else is an inference.”

William Farr

Oregon

0

2

4

6

8

10

12

14

2006 2007 2008 2009 2010 2011 2012 2013

heroin overdose death rate (per 100,000)

Rx opioid overdose death rate (per 100,000)

Rx opioid prescribing rate (hundreds of MME/person)

2009: Research shows methadone associated with ~1/3 of opioid OD deaths in state; Prior authorization

required by Medicaid for non-preferred long-acting opioids

2014: Methadone removed from

Medicaid program formulary2010: Drug utilization letters sent to

Medicaid prescribers of methadone at doses more than 40 mg/day; Prior authorization required by Medicaid for Methadone doses >100mg/day

2012: Prior authorization required by Medicaid for all high-dose opioidprescriptions (>120 mg in morphine

equivalents (MME) per day)

Florida

0

2

4

6

8

10

12

14

16

2006 2007 2008 2009 2010 2011 2012 2013

heroin overdose death rate (per 100,000)

Rx opioid overdose death rate (per 100,000)

Rx opioid prescribing rate (hundreds of MME/person)

2010: Pain clinic registration; state/federal

investigation of pain clinics

2011: Joint law enforcement raids; physician dispending prohibited; mandatory PDMP

reporting

2012: Wholesale distributor regulations expanded

Florida: state action can make a difference

MMWR, July 4, 2014.

Buprenorphine worksOpioid overdose deaths declined 75% after

buprenorphine introduced in France

565

143

2900

25000

4900055000

60000

0

10000

20000

30000

40000

50000

60000

70000

0

100

200

300

400

500

600

1995 1996 1997 1998 1999

# o

n B

up

ren

orp

hin

eT

rea

tmen

t

# o

f O

pio

idO

D D

ea

ths

# of Opioid Deaths # on Bup Treatment

Ling et al. J Subst Abuse Treat 2002;23:87-92.Auriacombe et al. JAMA 2001;285:45.

States receiving pilot prevention funding2010-2013

2010 OPR

Prescriptions

per 100 people

State Rank:

2010 OPR

prescription

rate

2013 Projected

OPR prescriptions

per 100 people

State Rank: 2013

OPR Prescription

Rate

% Change

2010 to 2103

Kentucky 138 3 112 8 –19

West Virginia 145 1 130 2 –10

Tennessee 141 2 128 3 –10

Utah 87 24 82 23 –6

IMS Health. National Prescription Audit, 2014

Prescription Drug Overdose InitiativeApplications close May 8

• Funding will support up to 17 states to expand PDO prevention programs with community involvement

• States receiving funding must address prescribing and advance innovative prevention efforts on multiple fronts

• Expand and enhance their state PDMP

• Implement community and health insurer or health system interventions

• May also choose to also conduct policy evaluations or implement other prescribing innovations

• HHS proposes major expansion of program in 2016 to expand to all 50 states & DC

New HHS initiative (3/26/15)

Targeted initiative aimed at reducing prescription opioid and heroin related overdose, death, and dependence ($133M in new funding proposed)

• Training and educational resources, including updated guidelines and PDMP/HIT support, to improve opioidprescribing decisions

• Increasing use of naloxone and continuing support for development/distribution

• Expanding use of medication-assisted treatment (MAT) to provide a comprehensive treatment approach

Social media campaign

Public Education

• CDC education campaign will build on social media stories and momentum

• Educate about opioid risks

• Promote safe/effective pain management with health care providers

• Target people at increased risk of Rx opioid overdose death

• Work in conjunction with other evidence-based practices

• Campaign being developed to be piloted in select states

• Personal stories

Success is possible –key now is to scale up

Prevention, treatment, advocacy, laws/regulations, and changes to our

culture are interrelated and can be synergistic

Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Phone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

E-mail: cdcinfo@cdc.gov Web: www.cdc.gov