slide presentation by Dr. Len Paulozzi - PDMP Center of Excellence

The Prescription Drug Overdose Epidemic
and the Role of PDMPs in Stopping It
Len Paulozzi, MD, MPH
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
National Center for Injury Prevention and Control
Division of Unintentional Injury Prevention
1

The Public Health Model
New or
Persistent
Problem
Identified
Remediable
Risk Factors
Identified
Surveillance
and
Assessment
Interventions
Developed
and Tested
for Efficacy
Proven
Interventions
Tested for
Effectiveness
2

Early surveillance data failed to detect a
problem: DAWN 1990-1996, (Joranson, 2000)
3

Perhaps because some data was left out:
DAWN 1990-1998 data available when
Joranson et al (2000) published
4

Identifying the problem of prescription drug
overdoses: First report, North Carolina, 2002
5

Identifying the problem of prescription drug
overdoses: Second Report, Maine, 2002
6

Rate of unintentional drug overdose death in
the United States, 1970-2007
Death rate per 100,000
10
9
8
7
6
5
4
3
2
1
0
'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06
7

Number of of drug-induced deaths deaths compared compared with with other types
of deaths, US, 1999-2006
other types of deaths, US, 1999-2006
8

Unintentional overdose deaths involving opioid
analgesics now exceed the sum of deaths
involving heroin or cocaine
Number of deaths
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Opioid analgesic
Cocaine
Heroin
'99 '00 '01 '02 '03 '04 '05 '06 07
Source: National Vital Statistics system, multiple cause of death dataset
9

Unintentional overdose deaths involving opioid
analgesics parallel per capita sales of opioid
analgesics in morphine equivalents by year,
U.S., 1997-2007
14000
12000
10000
8000
6000
4000
2000
0
Number of
Deaths
'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07
*
Opioid sales (mg/
person)
800
700
600
500
400
300
200
100
0
Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS
* 2007 opioid sales figure is preliminary.
10

Opioid-analgesic-related death rates in 1999-2004
and opioid analgesic prescription rates in 2002
among men, Kentucky (PDMP data courtesy of
KASPER)
11

Estimated numbers of ED visits for misuse or
abuse of drugs by drug type, DAWN,
United States, 2008
Source: Drug Abuse Warning Network
12

Age-specific rates of ED visits for nonmedical use of
opioid analgesics (OAs) and benzodiazepines (BZDs) ---
DAWN, United States, 2004 and 2008
MMWR June 18, 2010

Past month nonmedical use of prescription pain
relievers by age group, NSDUH, 2002-2009
18-25
12-17
12+

Past year initiates for specific illicit drugs
among persons aged 12 or older –
NSDUH 2008

Most recent source used by past year nonmedical
users of pain relievers aged 12 or older,
NSDUH, 2009
NSDUH summary of national findings, 2009
16

Health outcomes related to opioid analgesics,
United States, 2007-2009
>11,499
~1,854,000
Deaths: NVSS 2007; Treatment admissions are for primary use of opioids, TEDS data, 2008;
ED visits are DAWN 2008; Abuse/dependence and nonmedical use past month are NSDUH 2009
17

The Public Health Model
New or
Persistent
Problem
Identified
Remediable
Risk Factors
Identified
Surveillance
and
Assessment
Interventions
Developed
and Tested
for Efficacy
Proven
Interventions
Tested for
Effectiveness
18

The Public Health Model
New or
Persistent
Problem
Identified
Remediable
Risk
Factors
Identified
Surveillance
and
Assessment
Interventions
Developed
and Tested
for Efficacy
Proven
Interventions
Tested for
Effectiveness
19

Top Three Opioids in Overdose Deaths
State Year of Deaths 1st 2nd 3rd
North Carolina 2001 Meth 80 Oxy 41 Hydro

Characteristics of unintentional pharmaceutical
overdose deaths,
West Virginia, 2006
Characteristic No. (%)
History of substance abuse 231 (78.3)
Other mental illness 126 (42.7)
Any rx drug involved with no prescription 186 (63.1)
Nonmedical route of administration 66 (22.4)
5+ prescribers of controlled substances/yr 63 (21.4)
Previous overdose 50 (16.9)
Total 295 (100.0)
Sources: Hall et al, JAMA, 2008 and Toblin et al, J Clin Psych, 2010
21

Characteristics of unintentional drug overdose
deaths, Ohio, 2006-8
Characteristic %
Filled prescriptions from an average of five
prescribers/year over 3 years among deaths of
patients in state PDMP (N=1,047)
No prescription in the PDMP for an opioid among
prescription opioid-related deaths (N=508)
No prescription in the PDMP for methadone
among methadone-related deaths (N=157)
16
25
71
Source: Ohio Department of Health at www.healthyohioprogram.org/diseaseprevention/dpoison/drugdata.aspx
22

Risk factors for opioid poisoning/abuse among
privately insured patients,
Maine, last quarter of 2006
Behavior during
3 month period
Odds Ratio
(95% confidence
interval)
Use of 3+ pharmacies for opioids 1.96 (1.66-2.33)
Rapid opioid dose escalation 1.59 (1.33-1.89)
1+ early refill of an opioid
prescription
6.52 (5.39-7.89)
12+ opioid prescriptions in 3 months 2.12 (1.73-2.61)
Source: White et al, Am J Managed Care, 2009;15:897
23

Combined opioid and sedative-hypnotic use
increases risk of serious overdose events
Group Health Consort Study, 1997-2005, Dunn et al, 2010
24

High opioid daily dosage increases risk of
serious overdose events
Group Health Consort Study, 1997-2005, Dunn et al, 2010
25

Non-medical use per 10,000 retail
prescriptions by drug, DAWN, 2004 – 2006
* Includes all formulations
Source: National estimates from DAWN, 2004-2006; Verispan VONA
Presentation by Dr. Catherine Dormitzer to the Anesthetic and Life Support Drugs and Drug Safety and Risk
Management Advisory Committees, May 5, 2008
26

Non-medical use per 10,000 retail prescriptions,
oxycodone by release type, DAWN, 2004-2006
Sources: National estimates from DAWN, 2004-2006; Verispan VONA
Anesthetic and Life Support Drugs and Drug Safety and Risk Management Advisory Committees, May 5,
2008
27

Possible remediable risk factors include:
q Use without a prescription
q Doctor/pharmacy shopping
q Early refills and dose escalation
q Combined use of prescription opioids and sedativehypnotics
q Higher daily prescribed opioid dosages
q Use of specific opioids or formulations, eg,
methadone or extended-release formulations
q Nonmedical route of administration, eg, injection
28

The Public Health Model
New or
Persistent
Problem
Identified
Remediable
Risk Factors
Identified
Surveillance
and
Assessment
Interventions Developed and Tested for
Efficacy
Proven
Interventions
Tested for
Effectiveness
29

State prescription drug monitoring programs
VT
WA*
OR
NV
CA
MT
ID
WY
UT
CO
AZ NM
ND
MN
SD
WI
NE
IA
IL
KS
MO
OK
AR
MS
NY
MI
PA
OH
IN
WV
VA
KY
NC
TN
SC
GA
AL
ME
NH
MA
RI
CT
NJ
DE
MD
DC (no PMP)
AK
TX
LA
FL
Operational PDMPs
HI
Enacted PDMP legislation, but
program not yet operational
*Washington has temporarily suspended its PMP operations
due to budgetary constraints.
Research is current as of July 16, 2010
30

Single-copy, serialized paper prescription
forms

Changes with special prescription forms
during the 1980s
32

Pain clinic laws: LA, TX, and FL
33

Doctor shopping laws
34

Medicaid programs to reduce doctor
and pharmacy shopping
500+
clients

Changes in mean daily dosage of opioid
analgesics among Medicaid clients after
enrollment for inappropriate use, WA,
2006
36

Emergency Department Programs to
Manage Drug-Seeking Patients
37

ED visits per year by 40 patients making frequent
visits before and after regional program initiation,
Spokane hospitals, 2006-2007
38

Guidelines or laws
aimed at reducing
opioid dosage
Washington State limits
narcotic doses
____
ENGROSSED SUBSTITUTE HOUSE BILL 2876
__________________________________________
___
AS AMENDED BY THE SENATE
Passed Legislature - 2010 Regular Session
State of Washington 61st Legislature 2010
Regular Session
By House Health Care & Wellness (originally
sponsored by
Representatives Moeller, Green, and Morrell)
39

Other interventions underway
q Dispensing laws, eg, those requiring identification of
the person getting the prescription
q Laws requiring physical exams before prescribing
q Prescription limits, eg, number of days
q Harm reduction programs, including naloxone
q Good Samaritan Acts or laws ensuring immunity
from prosecution
q Drug take-back programs
40

PDMP data is critical in evaluating
interventions
Examples of Intervention
PDMP improvements
Single-copy serialized or
tamper-resistant forms
Doctor shopping & pain clinic
laws
Medicaid patient restriction
programs
Clinical guidelines or
mandates
PDMP Data Can Evaluate:
Changes in drug use, prescriber use of the
system
Changes in use and inappropriate use with
form changes
Rates of behaviors and prevalence of clinics
with extraordinary volumes
When linked to Medicaid enrollment, whether
Medicaid programs induce clients to pay outof-pocket
Average daily dosage and other prescribing
patterns and report request rates
Changes in drug formulation Rates of use and inappropriate use per 10,000
prescriptions by formulation
41

Advantages of using PDMP data in evaluation
• High level of drug detail, including formulation,
prescriber, and dispenser identifications
• Timeliness better than most other data sources
• Baseline has already been collected
• Statistical power, i.e., large enough numbers to detect
small changes
• Use of rates per 10,000 prescriptions avoids
confounding by changes in drug use
• Longitudinal linkage of patient and provider data
• Costs lower than use of commercial rx data

The Public Health Model
New or
Persistent
Problem
Identified
Remediable
Risk Factors
Identified
Surveillance
and
Assessment
Interventions
Being
Developed
and Tested
for Efficacy
You are
here
Proven
Interventions
Tested for
Effectiveness
43

Thank You
National Center for Injury Prevention and Control
Division of Unintentional Injury Prevention