Prescription drug abuse - PowerPoint Presentation

Slide1

Prescription drug abuse

Bob Twillman, Ph.D., FAPMExecutive DirectorAmerican Academy of Pain ManagementChair, Advisory CommitteeKansas Prescription Drug Monitoring Program (K-TRACS)Slide2

Prescription Drug Abuse is a Major Public Health Problem

12.5 million non-medical users of opioid pain relievers per year$70-120 billion cost per yearIncreasingly seen as a gateway (or, at least, a waystation) to heroin abuseSlide3

Overdose Deaths Involving Prescription Drugs

CDC estimates that 16,007 Americans died of overdoses involving opioid pain relievers in 2012Statistics are somewhat “squishy” due to reliance on death certificatesUsually called “prescription painkiller overdose deaths” by the media and advocates for reducing opioid useSlide4

Overdose Deaths Involving Prescription Drugs: Not Just the Prescription Opioids

Yet, previous CDC research suggests that about 75-80% of decedents used multiple drugs, not including alcohol, and that as many as 55-60% did not have a prescription for the drugs involvedAmong drug overdose decedents in Florida in the first half of 2013, the state medical examiners’ network reported that 93.5% had multiple drugs on boardSlide5

How Do We Explain This?

CDC graph of opioid sales, overdose deaths, and treatment admissions

NSDUH data: Non-medical use, opioid use disorder rates (%) in people

>

12 years oldSlide6

Another CDC Observation

Prescription opioids misused > 200 days per year rose from 2.2/1000 in 2002-03 to 3.8/1000 in 2009-10 (74.6% increase)Perhaps it’s not that more people are dying because more people are misusing. It’s that more people are dying because people are misusing more/more often/in different ways/all of the abovePeople misusing > 200 days/year are more likely to abuse by inhalation or injectionJones CM :

Arch Intern Med

2012:172(16):1265-7Slide7

Chronic Pain is a Major Public Health Problem

>100 million with chronic pain, ~39 million adults with daily chronic pain, ~10 million disabled$560-635 billion cost per year

Suicide

risk

2.5 to 4X higher

than in those without chronic pain

39,500 suicide deaths in 2011

~

20,000

were people with chronic painSlide8

Two Public Health Problems: More

Commonalities than DifferencesPrescription drug abuse and chronic pain are more alike than different:Both are highly prevalentBoth are very costly, in economic and human termsBoth highly stigmatized, and patients are blamedBoth involve tremendous sufferingBoth are poorly understood by the medical professionBoth are under-resourced vis-à-vis treatmentBoth are complex problems, with many moving parts

Both are best

understood from

a biopsychosocial perspectiveSlide9

Not A Zero-Sum Game

Often, it feels like any attempt to rein in prescription drug abuse must, of necessity, rein in opioid prescribing, even for people with painSimilarly, it often seems as though any effort to improve pain management must involve increased opioid prescribing, which could, in turn, lead to increased prescription drug abuseI believe this mis-states the case, and that it is possible to address both problems without adversely affecting eitherSlide10

A Thought

“For every complex problem, there is a solution that is neat, simple, and wrong”—H.L. MenckenI believe that implementing overly simplistic policy solutions for these two very complex problems leads to the zero-sum game that we so often perceivePerhaps the solutions we should be seeking are as complex as the problems we are trying to solveSlide11

Good Pain Management Helps Prevent Prescription Drug Abuse

Appropriate treatment for chronic pain is multimodal and involves multiple providersThis kind of treatment focuses primarily on improving function, recognizing that this can happen even with minimal (or no) improvement in pain intensityUsing multiple types of treatment should reduce reliance on opioid analgesics as the primary (and sometimes only) means of treating painMultiple barriers exist to providing this type of care for chronic painPolicy change is necessarySlide12

State Pain Policy Advocacy Network (SPPAN)

A project of the American Academy of Pain Management, focused on promoting good state pain policyMore than 120 participating organizations

For more information, visit sppan.aapainmanage.org or contact Amy Goldstein, SPPAN Director, at agoldstein@aapainmanage.orgSlide13

State Pain Management Policy Issues

(as of June 25, 2015)**Prescription Drug Monitoring Programs (35 states/110 bills/34 passed)Good Samaritan/Naloxone Distribution and Administration/Safe Disposal (46/228/?)Abuse-Deterrent Formulations of Opioids (30/45/3)Prescribing Guidelines (16/28/2)Mandatory CME/CE (16/31/3)Pain Clinic Regulation (12/23/6)Reimbursement for integrative pain care (34/46/8+)

Prior Authorization

(29/67/11+)

Step

Therapy/Specialty

Tier

(26/49/5)Slide14

Prescription Drug Monitoring Programs

Prescription drug monitoring programs are now authorized in 49 states, DC, and GuamNot yet fully operational in DC, NEProgram in PA has been limited to C-II meds and only law enforcement access to data, but legislation to update the program passed last yearNot authorized in MO29 states currently share data through the NABP PMPInterConnect program2 additional states with MOUs executed

3 additional states with pending MOUs

2 involved with another

data sharing hubSlide15

State

PDMP StatusJune 26, 2015

PMP Pending

PMP Operating

No PMP

DC

Partially ImplementedSlide16

PMP Interconnect Status

June 26, 2015 (29 States)

MOU Executed

PMPI Operating

MOU Pending

DCSlide17

PDMPs

as public safety toolsMost people think of PDMPs as tools designed to catch “doctor shoppers”This line of thought has been vital to getting legislation establishing PDMPs passedBut, “doctor shoppers” represent a tiny percentage of patients in a PDMP

, and a

small

percentage of queries are from law enforcement

One study found “doctor shoppers” to constitute 0.7% of opioid purchasers, 1.9% of prescriptions, and 4% of opioids by weightSlide18

PDMPs as healthcare delivery tools

PDMPs are very useful healthcare delivery toolsHelp reassure prescribers that patients are behaving appropriatelyHelp diagnose substance use disordersHelp ensure patient safety by revealing possible drug interactionsIn Kansas, HCPs submit 99.97% of queriesSlide19

Prescription Monitoring Programs:Trends in Legislation

Increased interest in:Mandatory registration and useAllowing interstate data sharingAllowing delegates to obtain reportsImproved unsolicited reportingExpanding access to other relevant professionalsShortening reporting intervalsEstablishing secure ongoing fundingEstablishing multidisciplinary advisory committeesIntegration with EHRs and HIEs is viewed as a major priority in many states and in the PMP communitySlide20

Using Complementary Tools

with the PDMPPDMPs provide great information, but they do not provide the complete picture—cannot distinguish

between abuse

, dependence, tolerance, addiction, for

instance

Using

complementary tools can be very

important

Chief

among these tools is urine drug testing

PDMPs tell you what SHOULD

BE

in the patient’s

body

Urine

drug testing tells you what IS in the patient’s

body

Comparing these can be enlighteningSlide21

Using Complementary Tools

With the PDMPComplementing the PDMP report with information obtained from the patient’s family (when appropriate and with permission) also can be helpful

Discussing

the patient with previous prescribers, especially if the patient

has not

revealed them, may be very

important

Reviewing

the report with the patient can provide information about the effectiveness and side effects of previous treatments, increasing efficiencySlide22

PDMPs are only part of the solution

PDMPs are an important tool, but we also need:Better education for healthcare providers and patientsBetter payment for non-medication pain treatments Wider use of abuse-deterrent opioid formulationsGreater use of substance

abuse

screening tools in medical settings

Greater access to effective

substance abuse

A

cultural change with respect to how we expect medicines and healthcare providers to help us

A greater emphasis on prevention of both substance use disorders and chronic pain

And other approaches…Slide23

Thank you for your attention