PRESCRIPTION DRUG ABUSE:PROBLEMS IN IDAHO AND IMPACT

ON WOMEN AND BABIES

REX W. FORCE, BS(PHARM), PHARMDASSOCIATE DEAN FOR CLINICAL RESEARCH

DIVISION OF HEALTH SCIENCESIDAHO STATE UNIVERSITY

Email: Force@fmed.isu.edu

• In 2010, 16,651 died in the US due to prescription drug overdoses– Since 9/11/2001, 2,215 Americans have died in

Afghanistan• One death every 19 minutes due to Rx drug abuse• 1,244 people died from drug-induced causes in

Idaho from 2000-09– Deaths each year increased from 69 in 2000 to 184 in

2009

HOW MANY OTHERS?

• Discuss the scope of the problem of prescription drug abuse…with a focus on opioids

• Evaluate different approaches to preventing the problem of prescription drug abuse on the “supply side”– Prescription monitoring programs– Prescribing guidelines– Legal interventions– Patient-based interventions (contracts, etc.)

• Examine the epidemic of prescription drug abuse and its effect on women and babies

TODAY’S GOALS

NOT IN MY TOWN….? UH, WE’RE #4

• The US accounts for 5% of world’s population and 80% of prescription opioid use; 99% of world’s hydrocodone use

• Hydrocodone (Vicodin, Lortab) has been #1 drug dispensed in the US since 2002

• Idaho is routinely in the US top 5 of per capita hydrocodone use

• 80% of new heroin users used prescription opioids in the month prior

THE PROBLEM

SCOPE OF PROBLEM

Figure 3. Number of Drug-Related Emergency Department (ED) Visits, by Type of Visit: 2004 to 2010

SCOPE OF PROBLEM

OPIOID SALES, TREATMENT ADMISSION, & DEATHS BY YEAR

SCOPE OF PROBLEM

IDAHO STATESMAN – NOV. 7, 2012

…a sign with instructions on how to mix prescription medi-cation with alcohol and a sign advertising drinks like lattes mixed with Xanax (an anti-anxiety medication that is alsoused as a drug of abuse) and vodka…

JUST LAST WEEK…

http://journalnet. com

JUST THIS WEEK…

http://journalnet. com

SCOPE OF PROBLEM

SCOPE OF PROBLEM• Cost of prescription drug abuse (including opioids like

OxyContin, Vicodin, Norco, and Lortab): $53 billion– Opioid abusers cost $16,000/year– Legit users of opioids: $1,800/year

• Additional societal costs:– Children at risk– Lost worker productivity – Increases in health care and Medicaid costs – Escalation of crime to support the habit– Destruction of families– Decreased life expectancy

HOW DID WE GET HERE?• Many years of inadequate treatment of pain – continues

today• Little evidence for optimal use of pain medicines• Reduced patient satisfaction – pain as 5th vital sign• Perceived as ‘safe’• Focus on pain rather than function• (Illegal) promotional efforts to assess and use opioids

– Oxycontin introduced in 1996– 2007 Purdue Pharma fined $634,000,000 for misleading claims about

risk of dependence and addiction• 70% of abused opioids were prescribed (to someone)• A call for judicious use – see Juurlink et al. JAMA March 6,

2013 and Zgierska et al. JAMA April 4, 2012.

• Nevada pioneered proactive reporting in 1997• By June 2012, 41 states had operating PDMPs, 49

have legislative mandates• Majority have secure on-line portal for prescribers

and pharmacists to look up patient histories• Allows for identification of doctor/pharmacy

shopping, excessive prescribing, etc.• In Idaho ½ of providers are signed up and only ½

of those access it with any regularity.

PRESCRIPTION DRUG MONITORING PROGRAMS

Clark et al. PDMP COE White Paper. September 2012

PRESCRIBING AND DISPENSING GUIDELINES

• State mandated – Idaho BoM has adopted guidelines for management of pain – Evaluation– Treatment plan– Informed consent and agreement for treatment– Periodic review– Consultation, if necessary– Accurate medical records– Compliance with controlled substance laws/regulations

http://bom.idaho.gov/BOMPortal/BOM/FAQ/Controlled%20Substances%20&%20Treatment%20of%20Pain%20Policy.pdf

• Personal or family hx of substance abuse• Aberrant behavior– Warning signs of manipulation, dishonesty, threats

• Doctor shoppers• Deception about pain severity• Forging or altering Rx’s• Criminal behavior• Patterns of use• Use screening tools, document, be cautious

IDENTIFYING THOSE PATIENTS AT RISK

4D’S OF PRESCRIBER INVOLVEMENT

• Deficient – outdated and under-educated• Duped – co-dependent, assumes the best

about their patients• Deliberate (dealing) – pill factory• Drug dependent – addicted themselves

MEDICATION AGREEMENTS

• Use one practice and one pharmacy• No other substance abuse• Adhere to visit schedule• Prohibit sharing or selling medication• No premature renewals or for ‘lost’ meds• Med renewals only during business hours• Urine tox screens

• Law enforcement • Behavioral Health/Substance Abuse

Professionals• Public Health• Prescribers• Pharmacists• Patients• Societal

WHOSE PROBLEM IS THIS?

THE LINK BETWEEN RX DRUG ABUSE AND MATERNAL AND CHILD HEALTH

• In 2012, analysis of impact of race and educational attainment on life expectancy in the US

• Life expectancy has fallen by 5 years for white women with less than high school education - since 1990

• Unprecedented in modern times: rivals only 7-year drop in men observed with collapse of Soviet Union

• No better life expectancy than those seen in the 1950s• Prescription drug abuse, smoking, obesity, access to

health care are proposed causes

LIFE EXPECTANCY

Health Affairs 2012;31(8): 1803-1813NY Times 9/20/12

LIFE EXPECTANCY

LIFE EXPECTANCY

WOMEN AND OVERDOSE DEATHS

• Centers for Disease Control surveillance study• In 2010, 943,365 visits by women to ED for

drug misuse or abuse• Men more likely to die from Rx drug overdose,

but death rate in women increased by 415% from 1999-2010.

• One or more Rx drugs was involved in 85% of cases and 71% were from opioids in women

MMWR 2013:62(26);537-542

WOMEN AND OVERDOSE DEATHS2009-10

MMWR 2013:62(26);537-542

National Ave: 9.8(range 3.9-18.5)

WOMEN AND OVERDOSE DEATHS2004-10

MMWR 2013:62(26);537-542

• National Birth Defects Prevention Study (1997-2005) – case-control design

• Prescription opioid exposure evaluated from 1 month prior to pregnancy to end of 1st trimester

• Approximately 2-fold greater risk for ASD, VSD, hypoplastic left heart, gastroschisis, and also hydrocephaly, spina bifida, and glaucoma

• Similar rates of neural tube defects observed in other studies (Obstet Gynecol 2013;122(4):838-44) and animal models

BIRTH DEFECTS

Am J Obstet Gynecol 2011;204:314.e1-11

NEONATAL ABSTINENCE SYNDROME

JAMA 2012;307(18):1934-1940

• Large cross-sectional study of newborns with NAS• Between 2000-2009:

– NAS increased from 1.20 to 3.39/1,000 births– Antepartum opioid use increased 1.19 to 5.63/1,000 births

• Babies with NAS had more respiratory complications (30.9% v. 8.9%) and low birth wt – 1500-2400 gm (19.1% v. 7.0%), and longer length of stay (16.4 v. 3.3 d).

• Normalized hospital charges increased from $39,400 to $53,400 between 2000 and 2009. All other births averaged $9,500.

• Prescription opioid use is truly at epidemic levels

• Women and their babies are harmed by this problem

• Resultant health and societal costs are high• Coordinated, interdisciplinary approaches are

necessary

CONCLUSIONS