Transcript Utilizing the State Attorneys General Offices in Public Health

Solutions & Strategies for Preventing
and Reducing Opioid Overdose
Corey S. Davis
Injury Policy Opportunities Project
Nov. 16, 2016
Overview
• Pain is a serious and growing problem
• Fatal opioid overdose is at epidemic levels
• Law, regulation, and policy can help – or
hinder
• PDMPs
• Naloxone Access/Good Sam laws
• Physician regulation
• Access to care
• Parting thoughts
Background: Pain
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•
•
•
Pain is “a significant public health problem”
Most common cause of disability in US
~100 million Americans suffer chronic pain
25% had back pain that lasted 24h+ in past 3 mo
• Knee pain: 20%; Neck pain: 14%
• Costs $~600 billion annually
Background: Pain
• Hispanic and Latino Americans 22% less likely to be
prescribed opioid analgesics than Whites
• African-Americans 29% less likely
• Lower-income Americans more likely to be injured OTJ,
and less likely to be insured
“Freedom from pain should be seen as a right.. and access
to pain therapy as a measure of respect for this right.”
-WHO
Role of Opioids
• Opioids can be beneficial for some post-surgical pain,
cancer pain, HIV pain, palliative care
• Extremely useful for treatment of opioid addiction
• But they can have significant negative side effects
• Opioid scripts increased ~400% between 1999 and
2010
• Opioid-related deaths increase by ~400% between
1999 and 2010
Role of Opioids
• Not a trade-off between pain relief and safety
• Limited, no, or negative evidence for opioid therapy for
chronic back pain, osteoarthritis, rheumatoid arthritis,
chronic non-cancer pain, headache, fibromyalgia
• Opioids simply do not provide better relief than nonopioid therapy for most chronic pain
More opioids = More opioid OD
Not good
All-cause mortality, ages 45-54
*
**
* US non-Hispanics
** US Hispanics
Mortality by cause, ages 45-54
OD death by race/ethnicity
Does law matter?
Does law matter?
Policy Intervention Continuum
Reduce
improper
prescribing
• Prescriber and
dispenser education
• Modify insurance
incentives
• Improve
professional
regulation
• PDMPs?
• Modification of CS
licensing?
Treat
SUD/Addiction
• Patient education
• Increased $ and
insurance coverage
for evidence-based
treatment and nonopioid pain therapy
• Recognition of
addiction as
medical condition
• Ban ineffective
“treatment”
• Increase number of
adx/mh providers
Improve
access to
overdose care
• Naloxone access
laws
• Good Samaritan
911 laws
• Community
education
• Reduce naloxone
cost
• OTC naloxone?
Prescription Monitoring Programs
(PDMPs)
States with PDMP Enabling Legislation
1998 - 2015
Total Number of States (and DC)
60
50
40
30
20
10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Existing PMP legislation
New PMP legislation
PDMP Logic Model
1. Create and populate database
2. ???????
3. Overdose deaths go down
General PDMP thoughts
• Evidence of efficacy mixed
• Modern PDMPs w/ mandatory access provisions likely have
modest positive effect, particularly on outliers
• Just getting providers to check not enough
• Docs need to know what do to, be empowered and
incentivized to do it
• Need to re-frame as overdose prevention tools
• Including permitting data to be used for PH surveillance and
response
• Need evidence-based tx, easy way to link people to it
Naloxone Access Laws
Legal environment overview
• Prescribing naloxone to own patient is fully
consistent with state and federal law
• Risk of liability no higher than with any other
medications, and likely lower than some
• Many states have passed laws increasing access
and reducing liability risk
• However, prescription requirement and cost remain
significant barriers
Naloxone access laws
47 states + DC have modified law to increase access to
naloxone in at least one of several ways:
• Permit prescriptions to third parties
• Permit prescription and dispensing by standing or
protocol order
• Provide civil and professional immunity to prescribers,
dispensers, and administrators
• Permit lay dispensing and administration
• Provide protections for Good Samaritans who report
overdose
• Expand first responder scope of practice to include
naloxone
Overdose Good Samaritan
• Encourage bystanders to call 911 in
overdose by providing limited protection
from arrest/prosecution
• 38 states have passed laws
• Lots of variation between states
• Knowledge and enforcement often lacking
• Swimming upstream against prohibition
Spread of naloxone laws
50
45
40
35
30
25
Good Sam
20
Naloxone
15
10
5
0
2010
2011
2012
2013
2014
2015
2016
Evaluations
of Overdose Education and Naloxone Distribution Programs
Feasibility
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Piper et al. Subst Use Misuse 2008: 43; 858-70.
Doe-Simkins et al. Am J Public Health 2009: 99: 788-791.
Enteen et al. J Urban Health 2010:87: 931-41.
Bennett et al. J Urban Health. 2011: 88; 1020-30.
Walley et al. JSAT 2013; 44:241-7. (Methadone and detox programs)
Increased
knowledge
and skills
• Green et al. Addiction 2008: 103;979-89.
• Tobin et al. Int J Drug Policy 2009: 20; 131-6.
• Wagner et al. Int J Drug Policy 2010: 21: 186-93.
No increase in
use, increase in
drug treatment
• Seal et al. J Urban Health 2005:82:303-11.
• Doe-Simkins et al. BMC Public Health 2014 14:297.
Reduction in
overdose in
communities
•
•
•
•
Maxwell et al. J Addict Dis 2006:25; 89-96.
Evans et al. Am J Epidemiol 2012; 174: 302-8.
Walley et al. BMJ 2013; 346: f174.
Bird et al. Addiction 2015; Dec 1.
Cost-effective
$438 (best)
$14,000 (worst )
per quality-adjusted
life year gained
Coffin and Sullivan. Ann Intern Med.
2013 Jan 1;158(1):1-9.
25
Access to Care
• Lack of access to evidence-based care –
throughout the continuum - increases risk of
untreated pain, addiction and negative health
outcomes
• POC more likely to be uninsured/underinsured
• Many insurance plans don’t cover evidencebased treatment for pain and addiction
Affordable Care Act
• 16.5 million fewer uninsured
• AA: 9.2 pp decline
• Latino: 12.3pp decline
• Women: 7.7pp decline
• Preventive services covered with no OOP cost
• Women no longer charged more for insurance
• Several pain-related initiatives
ACA: Adx & Tx coverage
• Mental Health Parity and Addiction Equity Act
requires MH/SUD services on same basis as
medical/surgical services
• ACA expands requirements to Medicaid MCOs,
Medicaid ABPs, CHIP, Medicare, individual
market plans, many employer plans
• But lack of compliance is widespread
Medicaid expansion
Legislators enter the fray
• Doctors get very little education in pain
management, addiction and drug tx
• Only 5 states require all docs to receive
relevant CME
• $1 billion/year industry funded education
• Result: Docs consistently report that they
don’t follow guidelines and aren’t comfortable
prescribing/referring
Direct practice regulation
• Contrary to beliefs of some, feds don’t meddle
much in practice of medicine
• State medical board model is demonstrably
ineffective in some states
• Should medicine really be a self-regulating
profession?
• State legislatures can, will, and are mandating
improved CS stewardship
Ex: Pain clinic laws
Ex: State Prescribing limits
Enacted
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DE: 100 MME dosage limit/31 days (24 Del. Admin.
Code CSA 4.7)
MA: Most 1st scripts limited to 7 days (HB 4056)
ME: 100 MME/day limit; 30/7 day supply (22 MRSA
§ 7246eff. 1/1/17)
NH: “Lowest effective dose” for acute pain
NY: 7 day 1st script limit; 30 day limit (NY Pub.
Health 3331)
TN: 30 day limit (Tenn. Code Ann. § 53-11-308(e))
VT: Health Comm’r to adopt rules after
consultation, may include number, time, and max
MME limits (18 V.S.A. § 53-11-308(e))
Direct practice regulation
Many states also:
• Impose non day/dose limits or non-binding
recommendations
• Require prescribers to check PDMP before some or all
prescriptions
• Require or recommend referral to or consult with pain
specialist
Ex: Mandatory take-back progams
• Eight municipalities now require industry to
pay for take-back programs
• Recently upheld in 9th Cir. (Pharmaceutical
Research and Manufacturers of America v.
County of Alameda)
• Under consideration in several large counties
Expecting different results
•
•
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Pressure to double down on failed policies – increased
penalties, charging dealers with homicide, etc
•
This never has never worked and likely never will
Some jurisdictions are implementing innovative,
common-sense policies – warm hand-offs, linkages to
care, etc
•
This makes a lot more sense
Need to consider true innovation
•
Supervised consumption spaces, decrim, regulated
tx providers etc
Not a good approach
Wrapup
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Untreated pain is a serious problem, but
opioids are often not the appropriate solution
Increased access to naloxone and evidencebased care needed
No magic bullets – coordinated, evidencebased approaches are necessary
We don’t always know what works, but we
know what doesn’t, and we should stop doing
it
Conclusion
Every system is perfectly designed to
produce exactly the results it’s
producing.
Questions?
Corey Davis, JD, MSPH, EMT-B
[email protected]