Transcript United States Case Study - Aaron Gilson

Drug Diversion, Sources, and Extent:
United States Case Study
International Pain Policy Fellowship
Pain & Policy Studies Group
WHO Collaborating Center for Pain Policy & Palliative Care
University of Wisconsin Carbone Cancer Center
August 7, 2012
Aaron M. Gilson, MS, MSSW, PhD
Research Program Manager/Senior Scientist
Pain & Policy Studies Group
U.S. National Retail Sales of
Opioid Analgesics
1980-2010
Morphine Equivalence (Mg/person)
400
Fentanyl ME
350
300
Hydromorphone ME
Methadone ME
Morphine ME
Oxycodone ME
250
Pethidine ME
200
150
100
50
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
0
Data sources:
Consumption data - International Narcotics Control Board
Population – United Nations World Population Prospects, 2010 Revision
ME conversion factors – WHOCC Centre for Drug Statistics Methodology
Past-Month Use of
Pain Relievers and Illicit Drugs
1990-2010
10
Percentage
Pain Relievers
Illicit Drugs
Illicit Drugs (Without Pain Relievers)
8
6
4
2
0
90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10
19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 20 20
Source: National Survey on Drug Use and Health – Substance Abuse and Mental Health Services
Administration.
Note: “Pain relievers” (previously called “Analgesics”) include opioid analgesics as well as noncontrolled
drugs such as tramadol
and now comprise almost 30 separate medications; “Illicit drugs” include cocaine, hallucinogens, heroin,
inhalants, marijuana/hashish, and prescription-type psychotherapeutics used non-medically (including pain
relievers).
Prescription Pain Medication Diversion
Event:
A. Increased prescribing of opioids for pain
Event:
A. Increasing reports of non-medical use
Causal Attribution:
A. Diversion is due primarily to increased availability
to patients for pain management
B. Prescribers and patients are to blame
–
Increased stigmatization
C. Safety of prescription opioids is questioned
Prescription Pain Medication Diversion
If attribution is correct,
Then the main solutions are:
 Increased monitoring of prescribers
 Tightening prescription requirements
 Imposing undue limits on legitimate prescribing
 Increased scrutiny of patients
 Publicize risks of pain medicines
But...
What if there are non-medical diversion sources?
1. DISTRIBUTION SYSTEM
(lawful distribution)
U
L
T
I
M
A
T
E
3. REDISTRIBUTION
(Layers of re- distribution;
illicit industry)
4. NON MEDICAL
USES
5. MEASUREMENT
OF IMPACTS
Abusers, addicts, impaired health
care professionals use what they
steal
Theft from
manufacturers and
distributors*
•Pharmacies
•Hospitals/Clinics
•Internet w/Rx
•Practitioners
Prescribers
Dispensers
•Nursing homes
•Hospices
PPSG, 2007
Internet sales without
Rx
Dealers
International
smuggling
Peers
Relatives
Theft of Rx/forgery
Patients
(Lawful medical
use)
U
S
E
R
•Theft from hospitals*
Pharmacies/robbery*
Employee/customer
Pilferage *
Unprescribed drugs
(Common
Carriers)
Theft in transit *
•Script docs/pill mills
•Inappropriate
prescribing
•Doctor shopping
•Patient sells or gives
•Theft from home
•Theft from patient
•Improper disposal
Prescribed
medications
R
E
T
A
I
L
Manufacturers
Distributors
(Prescribed
medication)
W
H
O
L
E
S
A
L
E
2. PRIMARY DIVERSION
(unlawful; supplies some
abusers and re-distribution)
* = Amounts reported by law on DEA Form 106
All
Nonmedical
users:
Used for
reward,
high,
recreation;
compulsive
use due to
addiction;
treatment of
withdrawal;
Self
medication
for mood,
sleep, pain
•Surveys
Postmarketing
Nonmedical use
Abuse
Addiction
Addiction treatment
Key informants
Pain patients
•Reporting systems
Adverse events
Accident/Poisoning
Emergency Dept
Internet surveillance
Medical Examiner
Treatment episodes
Arrests
Literature
Misuse, abuse,
addiction
Self medication
Diversion Schematic: Lawful distribution;
primary diversion; layers of redistribution,
non medical uses; measurement of impacts
Recent Federal and State Responses to
Medication Abuse and Diversion
 FDA Risk Evaluation and Mitigation Strategies
(REMS)
 Reducing Volume of Unused Medications
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DEA Take Back
DEA Disposal Regulations
Electronic Prescribing of Controlled Substances
Prescription Series for Controlled Substances
Prescription Monitoring Programs (PMP)
Office of National Drug Control Policy Prescription
Drug Abuse Prevention Plan
Office of National Drug Control Policy
(ONDCP)
White House Report:
Prescription Drug
Abuse Prevention
Plan
(April, 2011,
pp. 1-10)
Office of National Drug Control Policy
Prescription Drug Abuse Prevention Plan
Domain #1: Education
 Healthcare practitioners
CE
Curricula in health professional schools
Methods to facilitate and assess adequateness and
effectiveness of pain treatment
 Parent, youth, and patient
 Research and development
Office of National Drug Control Policy
Prescription Drug Abuse Prevention Plan
Domain #2: Tracking and Monitoring
 PMPs
 Electronic prescribing
 Epidemiology
Domain #3: Proper Medication Disposal
Domain #4: Enforcement
 Reduce “doctor shopping” and “pill mills”
Office of National Drug Control Policy
Prescription Drug Abuse Prevention Plan
Federal Agencies Involved
 ONDCP
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Bureau of Justice Assistance
Centers for Disease Control and Prevention
Centers for Medicare and Medicaid Services
Department of Justice
Environmental Protection Agency
Health Resources and Services Administration
High Intensity Drug Trafficking Area Program
Indian Health Service
National Institute of Justice
National Institute on Drug Abuse
Office of National Drug Control Policy
Prescription Drug Abuse Prevention Plan
Federal Agencies Involved
 Office of the National Coordinator for Health Information
Technology
 State Medical Boards
 Substance Abuse & Mental Health Services Administration
 U.S. Bureau of Prisons
 U.S. Department of Defense
 U.S. Department of Education
 U.S. Department of Health and Human Services
 U.S. Drug Enforcement Administration
 U.S. Food and Drug Administration
 Veterans Administration
Prescription Drug Abuse Prevention Plan
Addressing UNODC Recommendations
ONDCP Strategy
Other U.S. Activities
 Interagency cooperation  National policies
 Practitioner training
 Trandisciplinary
committees to share
 Model laws
information
 Medication monitoring
 Illegal internet sales
systems
 Engaging the public
Conclusions
 Medical use of pain medications has increased
contemporaneously with non-medical use, with little
understanding of the relationship
 Efforts to reduce pain medication abuse and
diversion historically has focused on the
prescriber/patient relationship
 A comprehensive approach has been slow to come
 The U.S. government has recently issued a
comprehensive strategy to reduce abuse/diversion
 More evidence is needed to guide interventions
Action Steps:
A Critical Need for More Information
 Target multiple sources of diversion
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Are there non-medical diversion sources?
Is diversion only/mostly the result of increased prescribing
for pain?
 Quantify amounts diverted and motivations for use
 Evaluate effectiveness of interventions attempted
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Improving prescribing and dispensing practices
Improving monitoring and coordination
Improving treatment of people who use non-medically
Limit adverse impact on medical availability
 Epidemiological understanding