Transcript Title Page Option 1 (Title Case 38 Points) Presentation

Death by Prescription
NEHOUA
Betsy Sears, MSM, MT(ASCP)
EVP Sales Support
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Old news
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More recent
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No one is immune. . .
1 in 20 using Rx painkiller for non-medical use
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Outline
• History of prescription drug abuse
• Definition of “misuse”
• Statistics
• Demographics
• Who is at risk
• Drug culprits
• Quest Diagnostics studies
• Costs
• Protective solutions
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History of Rx drug abuse
• Laudanum – 1800’s; opium and alcohol (women)
• Morphine – 1827; Germany; painkiller of choice Civil War
• Cocaine – post Civil War; coca cola
• Heroin – 1898; Bayer Company Germany – remedy for morphine addiction
• Called “patent” medicines – secret ingredients
• Food and Drug Act – 1906; label ingredients
• Harrison Narcotic Tax Act – 1914; Rx needed
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Prescription drug misuse
• What is it?
Use of a medication without a
prescription in a way other than as
prescribed for the experience or
feelings elicited
Sell or give away medications
Combine prescribed and illicit drugs
Forgetfulness to take meds as directed
• Each pattern – potential for risk
• Is equivalent to the term "nonmedical use," used
by many of the national surveys or data collection
systems
www.drugabuse.gov
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Sobering statistics
• 116 million Americans suffer from chronic pain – more than the number of people
affected by diabetes, heart disease, and cancer combined
• 475,000 ER visits in 2009
• Drug fatalities increased 3% in 2010
• Prescription painkillers kill more people than heroin and cocaine
• Sales of oxycodone, hydrocodone and methadone up 300%: ’98–’08
• In 2010, 12 million using Rx painkillers non-medically; 2 million people reported using
for the first time within the last year
• Narcotic pain relievers now cause or contribute to nearly 3 out of 4 prescription drug
overdoses and about 20,000 deaths (2012)
Substance Abuse and Mental Health Services Administration.
Results from the 2010 National Survey on Drug Use and Health
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System
(WISQARS). (2012) [cited 2012 Feb 1].
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In 2008, there were 14,800 prescription painkiller deaths
CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers
—United States, 1999-2008. MMWR 2011; 60: 1-6
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Death rates – >100/day
http://www.cdc.gov/HomeandRecreationalSafety/pdf/PolicyImpact-PrescriptionPainkillerOD.pdf
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Where and how much – 300 million Rx/year!
Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement
Administration (DEA), 2010
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Source of prescription drugs
How nonmedical users of prescription pain relievers obtained the drugs
> One Doctor
1.9%
Other
5.0%
Internet
0.3%
Drug Dealer Stranger
3.9%
One Doctor
18.1%
Free From
Friend/Relative
55%
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Took from
Friend/Relative
4.4%
Bought from
Friend/Relative
12.2%
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Death rate by state - 2010
National Vital Statistics System. Drug overdose death rates by state. 2010
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Who is most at risk?
Good to know!
• Those who obtain multiple controlled substance prescriptions from multiple providers
• Those who take high daily dosages of Rx painkillers
• Those who misuse multiple commonly misused Rx drugs
• Those with history of substance misuse
• Those on Medicaid
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System
(WISQARS). (2012) [cited 2012 Feb 1].
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Wizbangblue.com (Image)
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Commonly misused medications
• Opioids – derived from opioid poppy (or synthetic version) used for pain relief
Hydrocodone (Vicodin™)
Oxycodone (Oxycontin™, Percocet™)
Fentanyl ( Duragesic™, Fentora™)
Methadone
Codeine
• Benzodiazepines – CNS depressants used as sedatives
Alprazolam (Xanax™)
Diazepam (Valium™)
Lorazepam (Ativan™)
• Amphetamine-like – CNS stimulant used to treat attention deficit hyperactivity
disorder (ADHD)
Dextroamphetamine/Amphetamine (Adderall™, Adderall XR™)
Methylphenidate (Ritalin™, Concerta™)
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Prescription opiate dispensing
160
140
Total Rx (millions)
120
100
80
60
40
20
0
2005
2006
2007
hydrocodone/acetaminophen
2008
2009
2010
2011
oxycodone/acetaminophen
IMS Health, National Prescription Audit™
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Positivity rates for “expanded” opiates (percentages)
1.6
1.4
1.2
1
Codeine
0.8
Morphine
0.6
Hydrocodone
Hydromorphone
0.4
0.2
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Urine Drug Tests, General Workforce
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Hydrocodone
• Semi-synthetic opioid derived from codeine
• Lortab™, Vicodin™
• Treat moderate to severe pain; cough suppressant
• 1.5 x less potent than oxycodone
• Side effects: nausea, vomiting, dizziness, constipation, anxiety
• High dose: shallow or stopped breathing, slow, stopped heartbeat, loss of
consciousness, seizures, death
• U.S. consumes 99% of all hydrocodone in world
• Estimate of 131.2 million prescriptions written in 2010
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Hydrocodone overdose
en.m.wikipedia.org
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Positivity rates for Hydrocodone by testing reason
4
3.5
3
2.5
Pre-Employment
2
Random
1.5
Post-Accident
1
0.5
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Quest Urine Drug Tests, General Workforce –
8 million/year
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Oxycodone
• Synthesized from poppy-derived thebaine; developed 1916
• Oxycontin™, Roxicodone™, Oxecta™
• Prescribed for relief of moderate to severe pain
• Stronger than morphine - 1.5-2x; fewer side effects
• Side effects: nightmares, memory loss, constipation, dizziness, nausea
• High dose: bradycardia, apnea, hypotension, respiratory arrest, death
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Oxycodone side effects – recreational users
Commons.wikimedia.org
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Positivity rates from Oxycodone by testing reason
2.5
2
1.5
Pre-Employment
Random
1
Post-Accident
0.5
0
2005
2006
2007
2008
2009
2010
2011
2012
Urine Drug Tests, General Workforce
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The effect….
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Opiate-based prescription drug overdose
Source: Centers for Disease Control and Prevention
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Benzodiazepine
• CDC analysis of deaths caused by overdose of opioid painkillers
- in 30.1% of deaths, benzodiazepines present
• Possess sedative, hypnotic, anticonvulsant, muscle relaxant, and amnesic
actions; useful in a variety of indications such as alcohol dependence,
seizures, anxiety, panic, agitation and insomnia.
• Most common:
Ativan (lorazepam)
Klonopin (clonazepam)
Xanax (alprazolam)
Valium (diazepam)
• Well tolerated-safe but. . .
risk of dependence
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Amphetamine-like
• Dextroamphetamine/Amphetamine - Adderall® , Adderall® XR
• Methylphenidate (Ritalin, Concerta)
• CNS stimulant - controls symptoms of attention deficit hyperactivity disorder
(ADHD); used to treat narcolepsy
• Side effects: nervousness, restlessness, difficulty falling asleep or staying
asleep, uncontrollable shaking of a part of the body, headache, changes in
sex drive or ability, dry mouth, stomach pain, nausea, vomiting
• High dose: fast or pounding heartbeat, shortness of breath, chest pain,
excessive tiredness, slow or difficult speech, dizziness or faintness,
weakness or numbness of an arm or leg, seizures, sudden death, heart
attack, or stroke in adults or children, especially those with heart defects or
serious heart problems
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Top 10 in Southern California – L.A. Times
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Physiology of prescription painkillers
• Bind receptors in the brain to
decrease the perception of pain
• Create a feeling of euphoria, cause
physical dependence . . .addiction
• Cause sedation - slow down breathing
• A person who is misusing prescription
painkillers might take larger doses to
achieve a euphoric effect and reduce
withdrawal symptoms; larger doses
can cause breathing to slow down so
much that breathing stops, resulting in
a fatal overdose
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National Vital Statistics - multiple drug deaths - 2011
• 38,329 drug overdose deaths in USA; 58% - more than single drug
• Of the pharmaceutical-related deaths from overdose
74.3% were unintentional
17.1% were intentional (suicides)
8.4% were of "undetermined intent“
• Most common medications (in combination or alone)
75.2% - opioids
29.4% - benzodiazepines
17.6% - antidepressants
7.8% - drugs used for epilepsy and Parkinson's disease
• Opioids present in many deaths involving other drugs
In 77.2% of benzodiazepine deaths
In 65.5% of anti-epileptic and anti-parkinsonism drug deaths
In 58% of antipsychotic and neuroleptic drug deaths
In 57.6% of antidepressant drug deaths
In 56.5% other analgesics, anti-pyretics, and anti-rheumatics
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Quest Diagnostics Health Trends™
• Series of analyses on status of nation’s health
• Quest database – de-identified data
• 1.5 million patient encounters since 2000
• Laboratory information on majority of conditions and diseases
• Identify and track diseases and trends
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Quest Diagnostics Health Trends™
Prescription Drug Monitoring Report 2012
• 75,997 de-identified urine specimen results performed in 2011 (no rehab)
– Included results of patients of both genders
– ranging in age from 10 years old and above
– from 45 states and the District of Columbia.
• Objective - to assess the scope and demographic drivers of prescription drug
misuse in America and impact of laboratory testing on monitoring for
prescription drug adherence
• Patients tested for presence of up to 26 commonly prescribed medications,
including analgesics, and illicit drugs, such as cocaine and marijuana
• Laboratory results characterized as “Consistent” or “Inconsistent”
Quest Diagnostics 2012
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Misuse of Drugs
• “Consistent:”
only prescribed drugs were detected
• “Inconsistent:”
a) did not take prescribed drugs
b) took prescribed drugs plus other
unauthorized drugs/substances
c) took only unprescribed or unknown
drugs/substances
Quest Diagnostics 2012
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Gender breakdown
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Age range differences
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Summary of Quest Diagnostics 2012 study
• Majority of patients misused their prescription drugs – across all demographics
• “Inconsistent” does not necessarily mean misuse
• 6 out of 10 patients showed inconsistencies:
- Clinicians may not have asked pertinent questions about all medications
- If asked, patients may not have been forthright
• Further points on “inconsistent” results
- Less affluent may limit or forego
- Patients may not know what doctor has prescribed
- Can’t be assumed that follow-up testing will be the same
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Marijuana
• Cannabis sativa – affects areas of brain: pleasure, memory, thinking,
coordinated movement; THC – psychoactive chemical
• Health risks – neurological functioning, cardiovascular and mental health
risks in adults, carcinogens in smoke (not linked to lung CA)
• Some studies show marijuana use precedes use of other potentially
dangerous drugs; 2.5x more likely to misuse prescription drugs
• 29 million Americans (11.5%) using in 2010
• Eighteen states allow medical marijuana
• Colorado and Washington – 2012 legal
Fiellin L, Tetrault J, Becker W, Fiellin D, Hoff R. Previous use of alcohol, cigarettes, and marijuana
and subsequent abuse of prescription opioids in young adults. Journal of Adolescent Health,
August 2012
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Quest Diagnostics Health Trends™
Prescription Drug Monitoring Report 2013
• Report on marijuana and prescription drugs
• Quest Diagnostics medical and health informatics experts analyzed 227,402
de-identified urine specimen results performed in 2011 and 2012
– Included results of patients of both genders
– ranging in age from 10 years old and above
– from 45 states and the District of Columbia.
• Objective- to focus on the role of marijuana in the use, and misuse, of
prescription and other illicit drugs
• Patients tested for presence of up to 26 commonly prescribed and misused
drugs (pain medications, CNS meds, amphetamines) as well as illicit drugs
• Laboratory results characterized as “Consistent” or “Inconsistent”
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Key findings
• Prescription drug misuse continues to be highly prevalent – 60%
• Marijuana was the most misused drug - 26%
• Recreational marijuana users more likely than non-users to misuse other
drugs; 45% THC + used other non-prescribed drugs vs. 36% non-users
• Those using prescription cannabinoids: not more likely to misuse other drugs
than non-marijuana users
• Dr. Harvey Kaufman, Quest – “decline in misuse. . . not the case”
QuestDiagnostics.com/dms/Documents/healthtrends/2013_health_trends_prescription_drug_misuse.
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Other misused drugs
In Quest Diagnostics study, marijuana was the most frequently detected nonprescribed drug. Non-prescribed marijuana was detected in more than one in four
patients (26%) with inconsistent test results.
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Recreational marijuana users – 1.3x more likely to use more
Among recreational marijuana users, the most frequently detected additional nonprescribed drugs were sedative medications, such as alprazolam and oxazepam, and
narcotic pain killers, such as hydromorphone;
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Costs associated with prescription drug misuse
• Fighting wrong war? $15 billion on illicit drugs
• Coalition Against Insurance Fraud 2007 study: the annual cost to health
insurers due to the nonmedical use of prescription painkillers - $72.5 billion
• Doctor shoppers cost insurers $10,000 to $15,000 apiece
• 2011 Study: Loss in total productivity - $42 billion
Criminal justice costs - $8.2 billion
• Department of Justice - estimated annual costs related to health, crime and
productivity associated with illicit drug use, including prescription drug
misuse, total more than $193 billion
Centers for Disease Control and Prevention 2012
James O'Toole @CNNMoney February 24, 2012
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How do we reduce the abuse?
• Prescription Drug Monitoring Programs
(PDMPs) - databases used to track the
prescribing and dispensing of controlled
prescription drugs to patients
• Patient review and restriction programs
• Health care provider accountability
• State laws to prevent Rx drug misuse and
diversion-doc shopping & pill mills
• Better access to substance misuse
treatment
• Synthetic Drug Abuse Prevention Act of
2012 – outlaw 2C-E
• FDA – tighter regulations for Hydrocodone;
restrict to 90 day supply; Schedule II
• ER docs – “ask the right questions; save
more lives, they don’t want to die”
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Insurance drug screens
Drug 5
Drug 8
• Amphetamine/Methamphetamine
• Amphetamine/Methamphetamine
• Cocaine
• Cocaine
• Opiates (codeine, morphine)
• Opiates (codeine, morphine)
• Phencyclidine (PCP)
• Phencyclidine (PCP)
• Marijuana (THC)
• Marijuana (THC)
• Methadone
• Benzodiazepine
• Barbiturates
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Detection
• Screening by Immunoassay
• Confirmation by Gas Chromatography/Mass Spectrometry (GC/MS)
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Protective solutions
• Expanded opiate panel
• Prescription drug history
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Expanded opiate panel
• Current opiate panel – codeine, morphine, heroin
• Not sensitive enough!
• Opiate screen; 300 ng/mL cutoff; good cross-reactivity with hydrocodone
Will report - morphine/codeine/hydrocodone/hydromorphone/oxycodone,
if confirmed
• Oxycodone screen; 100 ng/mL; will report - oxycodone/oxymorphone,
if confirmed.
• More poppy seed positives
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Prescription drug history
• Broad access to prescription drug records
Results of five-year history
Detailed drug and insurance eligibility information
Treating physicians
Drug indications
Pharmacy information
• Critical real-time insight in assessing an applicant’s risk
• Data underwriters can utilize
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Possible?
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Raise awareness
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References
• LA Times Legal drugs, deadly outcomes By Scott Glover, Lisa Girion. Video and photos by Liz O. Baylen November 11, 2012
• Valarie Honeycutt Spears. Ky. sees rise in overdose deaths from pills obtained in Fla. Lexington Herald-Leader 2009 Apr 12.
Available from URL: http://www.kentucky.com/2009/04/12/758845/ky-sees-rise-in-overdose-deaths.html.
• Cathy McKitrick. Youth’s overdose sends strong message. Salt Lake City Tribune 2011 May 17. Available from URL:
http://www.sltrib.com/sltrib/news/51689248-78/prescription-drugs-drug-watson.html.csp.
• CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008. MMWR 2011; 60: 1-6
• Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network: selected tables of national
estimates of drug-related emergency department visits. Rockville, MD: Center for Behavioral Health Statistics and Quality,
SAMHSA; 2010.
• Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health:
volume 1: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of
Applied Studies; 2011. Available from URL: http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.htm#2.16.
• CDC. Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, 19992006. NCHS Data Brief;22 Sept 2009. Available from URL: http://www.cdc.gov/nchs/data/databriefs/db22.pdf .
• Substance Abuse and Mental Health Services Administration. Substance abuse treatment admissions by primary substance
of abuse, according to sex, age group, race, and ethnicity 2009 (Treatment Episode Data Set). Available from URL:
http://wwwdasis.samhsa.gov/webt/quicklink/US09.htm.
• Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SRB. Characteristics of opioid prescriptions in 2009. JAMA
2011;305(13):1299–1301.
• Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, Bixler D, et al. Patterns of abuse among unintentional pharmaceutical
overdose fatalities. JAMA 2008;300(22):2613-20.
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Thanks for your time
Betsy Sears
[email protected]
913.577.1306
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