Transcript Opioid and Marijuana Policy - County Behavioral Health Directors

Trends in Drug Use and Policy
Challenges for Prevention and Treatment
Prescription Drug Abuse:
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Prescription drug abuse is the nation’s fastestgrowing drug problem. Prescription opioid
availability rose dramatically through the 1990s,
with large increases in diversion and abuse that
continued through 2012.
From 1999 to 2013, the drug poisoning death rate
more than doubled from 6.1 to 13.8 per 100,000
population, and the rate for drug poisoning deaths
involving opioid analgesics nearly quadrupled from
1.4 to 5.1 per 100,000.
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In 2010, 12 million people in the U.S. used
prescription painkillers, including oxycodone and
morphine, for nonmedical reasons.
In 2009, nearly half a million emergency
department visits were due to people misusing or
abusing prescriptions painkillers.
In that same year, health insurers spent $24 billion
on treatment for substance use disorders, of which
Medicaid accounted for 21% of all spending.
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According to the CDC, 22,767 Americans die each
year involving prescription drug overdose, that’s
62 deaths every day.
According to the CDC, health care providers wrote
259 million prescriptions for opioid painkillers in
2012, enough for every American adult to have a
bottle of pills.
Although the U.S. comprises less than 5% of the
world’s population, Americans consume 80% of the
global opioid painkillers, and 99% of the global
supply of hydrocodone.
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Vicodin and other drugs containing the narcotic
hydrocodone are now the most commonly
prescribed medications in the U.S.
It is estimated that up to 25% of people who use
prescription pain pills over the long term become
addicted to these medications.
70% of people who abuse prescription painkillers
obtain the drugs from a family member or friend.
Rates of emergency room visits and SUD treatment
admissions related to prescription opioids have
also increased markedly.
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Every day, 2,500 American youth abuse a
prescription pain reliever for the first time.
Nearly 1 in 20 high school seniors has taken
Vicodin, 1 in 30 has abused OxyContin.
The number of opioids prescribed to adolescents
and youth adults nearly doubled between 19942007.
Heroin Abuse:
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Overdose deaths linked to heroin jumped 39% in
2013 from the year before.
4 out of 5 heroin users started abusing prescription
drugs first.
The “whack-a-mole” theory: successful reductions in
prescription opioid abuse since 2012, combined with
the availability of high-purity, low-cost heroin, have
led to the unintended consequence of increasing
heroin abuse and the rise in fatal heroin overdoses.
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The simultaneous use of both heroin and
prescription painkillers has increased, especially
among young, white men.
While heroin users have more criminal justice
involvement than prescription drug abusers, those
who use both report more mental health problems
and higher rates of emergency room visits than
those using one drug or the other.
Each year since 2010, roughly 600,000
people in the U.S. used heroin.
According to the CDC, there are more
than 100 overdose deaths a day in the
U.S., and about 8,200 deaths annually
from heroin overdoses.
Nationwide, drug overdose deaths now
claim more lives than car accidents.
PREVENTION
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Refocus the education of health care providers and
prescribers, as it relates to pain and addiction, in
order to improve their prescribing decisions and
the ability to identify patients’ problems related to
opioid abuse.
• On average, U.S. medical schools provide
approximately 7 hours of education on pain,
compared to 75 hours for veterinarians.
• A survey from 2000 found that less than 20% of
primary care physicians considered themselves very
prepared to identify alcohol or drug dependence in
their patients, compared to 80% feeling comfortable
diagnosing hypertension and diabetes.
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Target education to raise public awareness of the
fact that, while prescription drugs may be safe and
effective when used properly, they can also be
harmful and addictive.
ONDCP and HHS should work with pharmacies
manufacturers to develop effective educational
materials for patients that address the appropriate
use of prescription drugs, the risks and signs of
addiction and abuse, seeking treatment for
addiction, and the need for safe disposal of unused
medications.
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Reduce inappropriate access to opioids through
prescription drug monitoring programs.
• Last session California passed legislation to provide
funding for the CURES system (Controlled Substance
Utilization Review and Evaluation System), which
provides information that can be used to support the
legitimate medical use of controlled substances,
prevent “doctor shopping” or diversion, and help
identify patients who may have an addiction problem.
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The FY 2015 Federal budget provides $20 million
to prevent prescription drug abuse through the
Centers for Disease Control and Prevention. CDC
has selected 16 states, including California, to
receive awards between $750,000 and $1 million
each year over the next 4 years. The President’s
2016 budget proposal includes a request to
expand the program to all states.
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Support the development and use of abusedeterrent medications.
• A Washington University study found that the abusedeterrent formulation of extended-release oxycodone
curtailed its abuse by 35-40%.
• The White House has issued a policy that supports the
development and adoption of these new medications.
• A bill currently pending in the California Legislature
(AB 623) would prohibit health plans from requiring
step therapy where a patient must fail first on an
opioid medication before having access to a
medication with abuse-deterrent formula.
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Increase access to the opioid overdose antidote
Naloxone (Narcan).
• As of November 2014, twelve states have enacted
legislation or regulations to explicitly allow for the
dispensing of naloxone under standing orders from a
physician.
• Last year the California Legislature passed legislation
(AB 1535) that allows pharmacists to furnish
naloxone, without a prescription, to third parties in
accordance with standardized procedures and
protocols of the State Board of Pharmacy and Medical
Board. The new law includes provisions to ensure
training of pharmacists and education for the persons
to whom the drug is furnished.
• California also passed legislation last year (SB 1438)
that requires the Emergency Medical Services
Authority to establish training for all prehospital
emergency care personnel regarding the use of
naloxone to assist persons experiencing an overdose.
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The Clinton Foundation recently negotiated a lower
price for a device (Evzio) that delivers a single dose
of naloxone, which will be available to institutions
that can distribute this overdose antidote more
widely.
The World Health Organization has said that
increasing the availability of naloxone could
prevent more than 20,000 deaths in the U.S.
annually.
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Improve access to opioid dependence treatment,
including medication-assisted treatment.
• Currently only 15% of FQHCs provide medicallyassisted therapy for opioid abuse.
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Increase the capacity and willingness of health
providers to serve more patients with addiction.
• HRSA should encourage health clinics to report
measures of how many patients are screened for
opioid addiction and are provided clinical services for
treatment.
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Medication-assisted therapy, in combination with
counseling and behavioral therapies, can provide a
whole patient approach to the treatment of opioid
addiction.
• Federal law prohibits physicians from treating more
than 100 patients with buprenorphine at a given time.
(HHS is currently considering a revision to this
regulation.)
• Allied professionals, such as nurse practitioners and
physician’s assistants, are currently ineligible to
prescribe buprenorphine for addiction treatment,
which can severely limit access to this treatment in
rural areas.
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The good news: The White House Budget request
includes $12 million for discretionary grants to
states for the purpose of expanding treatment
services to those with heroin or opioid
dependence, including MAT.
The challenge: in spite of the effectiveness of MAT,
these medications are still way underutilized. Of
the 2.5 million Americans who were dependent on
opioids in 2012, fewer than 1 million received
medication-assisted treatment.
What are the barriers contributing to low utilization
of MATs?
 Not enough trained prescribers.
 Negative attitudes and misunderstandings about
addiction medications held by the public, providers
and patients.
 Policy and regulatory barriers, including utilization
management techniques such as limits on dosages,
annual or lifetime medication limits, minimal
counseling coverage, and “fail first” criteria.
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Emphasizing the treatment of SUD using a teambased approach that focuses on treatment
adherence, coordinated access to recovery, overall
health, counseling and case management would
provide a more holistic approach to health care for
individuals with opioid dependence that mirrors
the high quality care provided for other chronic
health conditions.
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To ensure that treatment is coordinated with other
needed physical and behavioral health services,
pursue new mechanisms, such as Medicaid Health
Homes, that promote integrated care for
individuals with opioid dependency.
• There is a proposal in California to leverage the
requirements of Narcotic Treatment Programs to
encompass key health home components. Given the
responsibility of these programs to provide daily
doses of methadone to patients, they have a “captive
audience” that is enviable in Medicaid health homes.
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Encourage information sharing among providers
who treat opioid dependent patients.
• Federal confidentiality requirements (42CFR) are often
cited as a barrier to effective integration of care and
sharing of vital information between the SUD
treatment provider and other medical professionals.
• Opioid dependency health home programs should
ensure that team members understand privacy laws,
and encourage the use of 42CFR-compliant release
forms.
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Reduce health insurance coverage barriers to
treatment in all treatment settings.
• Despite federal parity laws, private insurers still
implement benefits management, pre-approval and
re-approval approaches that interfere with patients
gaining timely access to treatment (i.e. “fail first”
requirements).
• In cases where a patient is on long-term medication
assisted treatment, a provider may be required to “reauthorize” continued treatment every 6 months, a
burden that is not required for medication
management of other chronic diseases.
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State Medicaid plans should be required to give all
individuals with diagnosed opioid dependency the
choice and opportunity to receive care in the
setting of the patient’s choice.
In California, counties and providers are working to
change state law that currently prohibits Medi-Cal
reimbursement for more than one Medi-Cal service
in the same day. This law restricts access to
needed care for many individuals, especially in
rural areas, who may need MAT for opioid
dependency as well as treatment for other cooccurring health problems.
Bills in the 114th Congress:
Stop Overdose Stat Act of 2015 (H.R. 2850)
Supports prevention programs to reduce drug overdose deaths,
create a task force to recommend a national public health
campaign to Congress, and authorize funding to research and
test new treatment and prevention methods.
Status: House Energy & Commerce Committee
The Opioid Addiction Treatment Modernization Act
(H.R. 2872)
Helps increase patient awareness and access to all treatment
options for opioid addiction.
Status: House Energy & Commerce and Judiciary Committees
The Heroin & Prescription Opioid Abuse Prevention,
Education and Enforcement Act of 2015 (S. 1134)
Aims to improve healthcare providers’ and public health
officials’ ability to prevent prescription drug abuse; support law
enforcement efforts to remove heroin from the streets; give
more first responders access to naloxone, and increase
awareness among health care providers, patients, and the
public about prescription opioid abuse and heroin.
Status: Senate Judiciary Committee
The Safer Prescribing of Controlled Substances Act
of 2015 (S. 1392)
Establishes additional safeguards to educate providers who
prescribe opioid to treat addiction.
Status: Senate Health Committee
The Treatment and Recovery Act (S. 1410)
Expands existing funding to combat the nation’s addiction
crisis, increases funding for the SAPT Block Grant, and creates
news programming aimed at increasing access to and
strengthening SUD services for adolescents and perinatal.
Status: Senate Health Committee
Increasing the Safety of Prescription Drug Use Act
(S. 636)
Increases patients’ access to prevention services and treatment;
strengthens prescription drug monitoring programs and
training for medical professionals; and authorizes new grant
programs to increase patient assessment and referral to
treatment.
Status: Senate Health Committee
The Opioid Overdose Reduction Act of 2015
(S. 707)
Offers legal protections to first responders, family members,
and volunteers who are education to administer opioid
overdose prevention drugs.
Status: Senate Judiciary Committee
Comprehensive Addiction and Recovery Act (CARA)
(S. 524, H.R. 953)
Invests funding in prevention, evidence-based treatment, and
recovery supports to help individuals struggling with addiction
to heroin or narcotic painkillers.
Status: Senate Judiciary Committee; House Judiciary; House
Education & Workforce Committees
Prescription Electronic Reporting Reauthorization
Act of 2015 (S. 480)
Reauthorizes through FY 2020 the controlled substance
monitoring program; allows grants to be used to maintain and
operate existing state controlled substance monitoring
programs; requires a state receiving a grant to facilitate
prescriber and dispenser use of monitoring system.
Status: Senate Health Committee
Protecting Our Infants Act (S. 799)
Requires the Agency for Healthcare Research and Quality to
report on prenatal opioid abuse and neonatal abstinence
syndrome (symptoms of withdrawal in a newborn). The report
must include an evaluation of treatment for pregnant women
with opioid use disorders.
Status: Senate Health Committee
2014 National Survey on Drug Use & Health:
• Upward trends in marijuana use are largely responsible for an
overall increase in illicit drug use.
• Marijuana and prescription drugs used non-medically
continue to be the two most prominent illicit drugs.
• Current marijuana use overall was 8.4% in 2014, higher than
rates in any year in the 2002-2013 period.
• The rate of marijuana use among adolescents 12 to 17 was
7.4% in 2014, an increase of .3% from 2013 (7.1%), but a
decrease from the 7.9% rate in 2011.
• The rate of marijuana use among adults 18-25 was 19.6% in
2014, and the rate among adults 26 or older was 6.6%. Both
rates were higher than any year since 2002.
New California Medical Marijuana Regulatory Bills:
(AB 266, AB 243, SB 643 awaiting Governor’s action)
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Provide a statewide licensing and regulatory framework for
the medical marijuana industry.
Classify medical marijuana as an agricultural product,
requiring cultivators to abide by the same environmental
regulations as farmers.
Provide for local control protections, explicit county taxation
authority, and employer protections for workplace use of
medical marijuana..
Local jurisdictions have until March 1, 2016 to adopt their
own regulations and licensure scheme for the industry.
Should the county not adopt local rules, the state’s
regulations would take effect for that jurisdiction.
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To oversee this multiagency licensing and
regulatory framework, the legislation establishes a
new Bureau of Medical Marijuana Regulation, with
the appropriate acronym: BUMMR.