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Robert Valuck, PhD, RPh Professor of Pharmacy, Epidemiology, and Family Medicine

And the Oscar for Best Actor Goes to…Hydrocodone? Prescription Drug Abuse in Modern American Film: Lessons for Treatment, Prevention, and Public Health. Robert Valuck, PhD, RPh Professor of Pharmacy, Epidemiology, and Family Medicine

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Robert Valuck, PhD, RPh Professor of Pharmacy, Epidemiology, and Family Medicine

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  1. And the Oscar for Best Actor Goes to…Hydrocodone?Prescription Drug Abuse in Modern American Film:Lessons for Treatment, Prevention, and Public Health Robert Valuck, PhD, RPh Professor of Pharmacy, Epidemiology, and Family Medicine Coordinating Center Director, Colorado Consortium for Prescription Drug Abuse Prevention May 18, 2014

  2. Objectives • Using a sample (real, but identity protected) patient and clips from modern American films as examples… • Describe the scope of the prescription drug abuse problem in the United States and Colorado • Discuss some of the factors contributing to the growth in prescription drug abuse • Highlight policy initiatives and programs at the federal and state levels (including Colorado) to address the problem • Offer examples of actions that physicians can take to promotesafe use, safe storage, and safe disposal of prescription drugs

  3. PrologueSo, what’s the big deal?

  4. Drug Overdose Mortality CDC/MMWR Jan 13, 2012; 61(01):10-13. Colorado Rx Abuse Task Force data SAMSHA/NSDUH 2009 survey . • In 2010, 38,329 people died from a drug overdose in the U.S. • One every 14 minutes • Nearly 60% of those deaths involved prescription drugs • Painkillers (opioids) were involved in 75% of those deaths • In Colorado, drug overdose deaths range from 250-500/year • Since 2003, more overdose deaths have involved opioidsthan heroin and cocaine combined • Rates of misuse and overdose death are highest among men, persons aged 20-64, non-Hispanic whites, and poor and rural • Two main at-risk populations: long term medical users (>10 million) and nonmedical users in past month (>6 million)

  5. Drug Overdose Mortality in the U.S. (2010) CDC/NCHS National Vital Statistics System, CDC Wonder. Updated 2010..

  6. Drug Overdose Mortality Trends (1979-2010) CDC/NCHS National Vital Statistics System, CDC Wonder. Updated 2010..

  7. Drug Overdose Death Rates in the US NCHS Data Brief, December, 2011, Updated with 2009 and 2010 mortality data

  8. Opioid and Benzodiazepine Trends Different thanHeroin and Cocaine in the US (1999-2010) CDC/NCHS National Vital Statistics System, CDC Wonder. Updated 2010..

  9. Prescription Drugs: primary driver of Overdose Deaths in US (2010) Jones et al. JAMA 2013; and CDC/NCHS 2010.

  10. Opioids more likely to be involved in single drug class deaths (US, 2010) Jones et al. JAMA 2013

  11. Deaths are the Tip of the Iceberg…For every opioid overdose death in 2011 SAMHSA NSDUH, DAWN, TEDS data sets Coalition Against Insurance Fraud. Prescription for Peril. http://www.insurancefraud.org/downloads/drugDiversion.pdf 2007.

  12. Cost of Prescription Drug Abuse on theU.S. Economy (2006) Hansen et al. Clin J Pain 2011; 27(3): 194-202.

  13. How did we get into this mess? CDC/MMWR Jan 13, 2012; 61(01):10-13. SAMHSA/NSDUH 2009 survey . CDC/MMWR Jan 13, 2012; 61(01):10-13. SAMHSA/NSDUH 2009 survey . • An enormous amount of opioids moves through U.S. channels • 1997: 96mg “morphine equivalents” dispensed per person (in the U.S.) • 2007: 700mg per person (in the US) – an increase of >600% • That 700mg per person is enough for every person in the U.S. to takea typical 5mg dose of Vicodin every 4 hours for 3 weeks • While accounting for about 5 percent of the world’s population, the U.S. now consumes 99 percent of the world’s Vicodin and 84 percent of its Oxycontin • Causes of the increase? There are many, including… • Increased recognition of pain, undertreatment of pain • Pain as the “fifth vital sign”, JCAHO quality measure, etc. • Drug company advertising and promotion • Practitioners are not well trained in opioid pharmacology, addiction • Drugs are very powerful, highly addictive if not used properly • Scamming, doctor/pharmacy shopping, black market for opioids

  14. Sales of Opioid Pain Relievers and Nonmedical Opioid Use (2010-11) #37 in U.S.

  15. Sales of Opioid Pain Relievers and Nonmedical Opioid Use (2010-11) #2 in U.S.(Oregon = 6.4)

  16. Scene #1 Nonmedical Use: The Beginnings

  17. A Typical Patient: Aaron Aaron is a 22 year old male, who started using prescription opioidswhen he was in high school He was a typical high school student, from an upper middle class family, played sports, was looked up to by siblings and friends Aaron started experimenting with prescription drugs at a “pharming” party, where students raid their (parents’) medicine cabinets, bring anyRx drugs they can find to the party, dump them all into a bowl, stir them around, and “pick one or two and chase them with a beer” This led to further nonmedical use: trying one or two of his parents’ Vicodin, then one or two more; getting more from friends; and gradually falling into the spiral of increased use, leading to tolerance, leading to increased use, leading to dependence, and ultimately addiction

  18. Other Paths to Nonmedical Use From 1967…Valley of the Dolls http://youtu.be/t054GSzRywg

  19. Other Paths to Nonmedical Use From 2014…in your own home https://www.youtube.com/watch?v=0bZOgj5HEAE

  20. Sources of Opioids among Nonmedical Users CDC/MMWR Jan 13, 2012; 61(01):10-13. SAMHSA/NSDUH 2009 survey .

  21. Scene #2 Getting Worse: Scamming and Stealing

  22. Aaron: Spiraling Downward As his addiction became stronger, Aaron started to scam doctors for opioid medications (later described it as easy: “Google ‘how to get opioids from a doctor’ and you’ll get lots of ideas”) He estimated that he visited between 40 and 50 doctors over an 18 month period, and went to about an equal number of pharmacies, to “spread myself around and stay beneath the radar” Most of the doctors gave him at least an initial Rx for Vicodin (his drug of choice due to the ability to request and get refills from doctors, their weekend colleagues covering for them, etc.) He finally started running into difficulty when the Vicodin “didn’t do it for me”, and he progressed to OxyContin (oxycodone)

  23. Majority of opioids consumed by small percentage of patients(Arkansas Medicaid, 2005) Edlund et al. J Pain Symp Manage 2010;40:279-289

  24. Top 8.1% of providers prescribe 79% of CII-CIV drugs (Oregon PDMP, 2011-12) Oregon PDMP Report 2012: http://www.orpdmp.com/orpdmpfiles/PDF_Files/Reports/Statewide_10.01.11_to_03.31.12.pdf

  25. Top 20% of prescribers account for63% of Overdose Deaths(Ontario Public Drug Program, 2006) Dhallaet al. Can Fam Physician 2011;57:e92-e96.

  26. Overdose risk highest among small percentage of patients at high dosage(Group Health, 1997-2005) Dunn et al, Ann Int Med 2010;152:85-92.

  27. More patients on opioids = more doctor shoppers 100% of patients are doctor shoppers Cepeda et al. J Opioid Manag. 2013.

  28. Stealing Can Turn to Robbery…and Worse From 1989…Drugstore Cowboy http://youtu.be/puXEHhZgXaY

  29. Scene #3 Rock Bottom: Heroin and Overdose

  30. Aaron: Spiraling Downward AD eventually started using OxyContin at very high doses, mixed it with Xanax and often alcohol, and overdosed at age 21 AD had a difficult stay in the ICU, and while there had two myocardial infarctions, seizures, a staph infection and pneumonia, and underwent extreme withdrawal symptoms Doctors were preparing AD’s parents for his death, which appeared imminent and very likely Surprisingly, AD regained consciousness, and eventually recovered well enough to be discharged home with his parents The disposition of AD’s case will be shown at the end of the talk; his is certainly not the only example of the downward spiral…

  31. Frequent Nonmedical Users of Opioids more likely to Engage in Risky Use Behaviors (US, 2008-2010) Jones, CM. Drug Alcohol Depend2013.

  32. Majority of Heroin users in past year reported Nonmedical use of Opioids before heroin initiation(US, 2002-2004 and 2008-2010) Jones, C.M. Drug Alcohol Depend 2013.

  33. The Heroin Lifestyle From 1996…Trainspotting http://www.youtube.com/watch?v=Naf_WiEb9Qs&list=PLBA06889EA057B4C0&feature=share

  34. Scene #4The Way Out: Treatment and Recovery

  35. Rates of opioid overdose deaths, sales and treatment admissions increased in parallel (US, 1999-2010) CDC/National Vital Statistics System DEA ARCOS System SAMHSA’s TEDS System

  36. Substance Abuse Treatment Gap (2011) SAMHSA/NSDUH 2011 survey

  37. Physicians Authorized to Treat Addiction (Buprenorphine/Methadone) SAMHSA. National Expenditures for MH Services and Substance Abuse Treatment, 1986-2009. Pub SMA-13-4740.

  38. Scene #5The Way Forward: Coordinated Responses

  39. Federal Initiatives (alphabet soup warning) FDA: REMS programs, stricter regulation on DTC advertising, support of rescheduling certain drugs (hydrocodone) to C-II CDC: Increased surveillance, grant funding, elevate topic in national discussion DEA: Takeback events (2X/year), new rules on returning unused controlled substances (pending), rescheduling ONDCP: Federal strategic plan, elevate topic in national discussion DOJ: Promote PDMP programs, interstate data sharing CMS: Pharmacy/provider restrictions, quantity restrictions NIH: Research funding (basic science, clinical science, policy, collaborative mechanisms/center grants)

  40. Other States and Policy Examples Tougher Pill Mill Laws, Doctor Shopping Laws Physical Exam Requirements Tamper Resistant Form Requirements Prescription Limits Patient ID Requirements Immunity from Prosecution Naloxone Laws Prospective Reports from PDMP programs (and other enhancements)

  41. Pill Mill Laws CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013. .

  42. Doctor Shopping Laws CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013. .

  43. Physical Exam Requirements CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013. .

  44. Tamper Resistant Forms CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013. .

  45. Prescription Limits CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013. .

  46. Patient ID Requirements CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013. .

  47. Immunity from Prosecution CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013. .

  48. PDMP Proactive Reporting Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013. .

  49. Here in Colorado…

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