Transcript here

PRESCRIPTION
DRUG ABUSE
Bob Twillman, Ph.D., FAPM
Executive Director
American Academy of Pain Management
Chair, Advisory Committee
Kansas Prescription Drug Monitoring Program (K-TRACS)
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 year
• Increasingly seen as a gateway (or, at least, a
waystation) to heroin abuse
Overdose Deaths Involving Prescription
Drugs
• CDC estimates that 16,007 Americans died of
overdoses involving opioid pain relievers in 2012
• Statistics are somewhat “squishy” due to reliance
on death certificates
• Usually called “prescription painkiller overdose
deaths” by the media and advocates for reducing
opioid use
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 involved
• Among drug overdose decedents in Florida in the
first half of 2013, the state medical examiners’
network reported that 93.5% had multiple drugs
on board
How Do We Explain This?
NSDUH data: Non-medical use,
opioid use disorder rates (%) in
people > 12 years old
6.0
5.0
4.7
4.9
4.7
4.9
5.1 5.0
4.8 4.9 4.8
4.8
4.3
4.2
4.0
3.0
2.0
1.0
0.8 0.7 0.7
0.6 0.6 0.6 0.6 0.7 0.7 0.7
0.6 0.6
0.0
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
CDC graph of opioid sales,
overdose deaths, and treatment
admissions
Past Yr NMU
Past Year OUD
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 above
• People misusing > 200 days/year are more likely
to abuse by inhalation or injection
Jones CM : Arch Intern Med 2012:172(16):1265-7
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 pain
Two Public Health Problems:
More Commonalities than Differences
• Prescription drug abuse and chronic pain are
more alike than different:
• Both are highly prevalent
• Both are very costly, in economic and human terms
• Both highly stigmatized, and patients are blamed
• Both involve tremendous suffering
• Both are poorly understood by the medical profession
• Both are under-resourced vis-à-vis treatment
• Both are complex problems, with many moving parts
• Both are best understood from a biopsychosocial
perspective
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 pain
• Similarly, 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 abuse
• I believe this mis-states the case, and that it is possible to
address both problems without adversely affecting either
A Thought
“For every complex problem, there is a solution
that is neat, simple, and wrong”—H.L. Mencken
I believe that implementing overly simplistic policy solutions
for these two very complex problems leads to the zero-sum
game that we so often perceive
Perhaps the solutions we should be seeking are as
complex as the problems we are trying to solve
Good Pain Management Helps
Prevent Prescription Drug Abuse
• Appropriate treatment for chronic pain is multimodal and
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•
•
involves multiple providers
This kind of treatment focuses primarily on improving
function, recognizing that this can happen even with
minimal (or no) improvement in pain intensity
Using multiple types of treatment should reduce reliance
on opioid analgesics as the primary (and sometimes only)
means of treating pain
Multiple barriers exist to providing this type of care for
chronic pain
Policy change is necessary
State Pain Policy Advocacy Network
(SPPAN)
• A project of the American Academy of Pain Management,
focused on promoting good state pain policy
• More than 120 participating organizations
• For more information, visit sppan.aapainmanage.org or
contact Amy Goldstein, SPPAN Director, at
[email protected]
State Pain Management Policy Issues
(as of June 25, 2015)
• **Prescription Drug Monitoring Programs (35 states/110
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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)
Prescription Drug Monitoring Programs
• Prescription drug monitoring programs are now
authorized in 49 states, DC, and Guam
• Not yet fully operational in DC, NE
• Program in PA has been limited to C-II meds and only law
enforcement access to data, but legislation to update the program
passed last year
• Not authorized in MO
• 29 states currently share data through the NABP
PMPInterConnect program
• 2 additional states with MOUs executed
• 3 additional states with pending MOUs
• 2 involved with another data sharing hub
State PDMP Status
June 26, 2015
DC
Partially Implemented
No PMP
PMP Pending
PMP Operating
PMP Interconnect Status
June 26, 2015 (29 States)
DC
MOU Pending
MOU Executed
PMPI Operating
PDMPs as public safety tools
• Most people think of PDMPs as tools designed to
catch “doctor shoppers”
• This line of thought has been vital to getting
legislation establishing PDMPs passed
• But, “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 weight
PDMPs as healthcare delivery tools
• PDMPs are very useful healthcare delivery tools
• Help reassure prescribers that patients are behaving
appropriately
• Help diagnose substance use disorders
• Help ensure patient safety by revealing possible drug
interactions
• In Kansas, HCPs submit 99.97% of queries
Prescription Monitoring Programs:
Trends in Legislation
• Increased interest in:
• Mandatory registration and use
• Allowing interstate data sharing
• Allowing delegates to obtain reports
• Improved unsolicited reporting
• Expanding access to other relevant professionals
• Shortening reporting intervals
• Establishing secure ongoing funding
• Establishing multidisciplinary advisory committees
• Integration with EHRs and HIEs is viewed as a major
priority in many states and in the PMP community
Using Complementary Tools
with the PDMP
• PDMPs 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 enlightening
Using Complementary Tools
With the PDMP
• Complementing 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 efficiency
PDMPs are only part of the solution
• PDMPs are an important tool, but we also need:
• Better education for healthcare providers and patients
• Better payment for non-medication pain treatments
• Wider use of abuse-deterrent opioid formulations
• Greater 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…
Thank you for your attention