Preven&ng  Prescrip&on  Drug  Abuse  

R.  Gil  Kerlikowske,  Director  

White  House  Office  of  Na;onal  Drug  Control  Policy  

April  10-­‐12,  2012  Walt  Disney  World  Swan  Resort  

Na;onal  Drug  Control  Strategy  

•  Science-­‐based,  public  health  approach  to  drug  policy  •  Coordinated  federal  effort  on  115  ac&on  items    

–  Special  emphasis  on  ac&ve  duty,  veterans,  and  military  families;  women  and  girls;  individuals  in  the  criminal  jus&ce  system;  and  college  students  

•  Signature  ini&a&ves  –  Prescrip&on  Drug  Abuse  –  Preven&on  –  Drugged  Driving  

Pain  Reliever  Prescrip;ons:  2000-­‐2009  

ER  –  Extended  Release,  LA  –  Long-­‐Ac&ng,  IR  –  Immediate  Release  Source:  SDI,  Vector  One:  Na;onal.    Extracted  June  2010.  

Prevalence of Past Year Drug Use Among 12th graders  2011 Monitoring the Future Study  

* Nonmedical use

Drug Prev. Drug Prev. Alcohol 63.5 OxyContin* 4.9 Marijuana/Hashish 36.4 Sedatives* 4.3 Synthetic Marijuana 11.4 Hall other than LSD 4.3 Amphetamines* 8.2 Inhalants 3.2 Vicodin* 8.1 Cocaine (any form) 2.9 Adderall* 6.5 LSD 2.7 Salvia 5.9 Ritalin* 2.6 Tranquilizers* 5.6 Ketamine 1.7 Cough Medicine* 5.3 Provigil 1.5 MDMA (Ecstasy) 5.3 GHB 1.4 Hallucinogens 5.2 Methamphetamine 1.4

Categories not mutually exclusive

Prescrip;ons  Dispensed  for  select  opioids  in  U.S.  Outpa;ent  Retail  Pharmacies,  2000-­‐2009  

0  

20,000,000  

40,000,000  

60,000,000  

80,000,000  

100,000,000  

120,000,000  

140,000,000  

2000   2001   2002   2003   2004   2005   2006   2007   2008   2009  

Hydrocodone   Oxyocodne   methadone   buprenorphine   tramadol  

Num

ber  of  Prescrip;

ons  

Source:  SDI,  Vector  One:  Na;onal.    Extracted  June  2010.  

Heroin  Cocaine  

27,658  uninten&onal  drug  overdose  deaths  

Uninten&onal  Drug  Overdose  Deaths  United  States,  1970–2007  

Na;onal  Vital  Sta;s;cs  System,  hZp://wonder.cdc.gov  

Year  

Emergency  Department  Visits  

Persons  Classified  with  Substance  Abuse/Dependence  on  Psychotherapeu;cs  

0  

500  

1,000  

1,500  

2,000  

2,500  

2002   2003   2004   2005   2006   2007   2008   2009   2010*  

Results  from  the  2010  Na2onal  Survey  on  Drug  Use  and  Health  (NSDUH):  Na2onal  Findings,  SAMHSA  (2011).    hXp://www.oas.samhsa.gov/nsduhLatest.htm.  

*Number  in  2010  is  sta;s;cally  significantly  higher  than  in  2005.  

Drug-­‐Induced  Deaths  vs.  Other  Injury  Deaths,  1999–2009  

1999   2000   2001   2002   2003   2004   2005   2006   2007   2008   2009  

Injury  by  firearms   28,874   28,663   29,573   30,242   30,136   29,569   30,694   30,896   31,224   31,593   31,347  

Drug-­‐induced   19,128   19,720   21,705   26,040   28,723   30,711   33,541   38,396   38,371   38,649   39,147  

Homicide   16,889   16,765   20,308   17,638   17,732   17,357   18,124   18,573   18,361   17,826   16,799  

Suicide   29,199   29,350   30,622   31,655   31,484   32,439   32,637   33,300   34,598   36,035   36,909  

Motor  vehicle  accidents   42,401   43,356   43,788   45,380   44,757   44,933   45,343   45,316   43,495   39,790   36,216  

0 5,000

10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000

NU

MB

ER O

F D

EATH

S

Causes  of  death  aZributable  to  drugs  include  accidental  or  inten;onal  poisonings  by  drugs  and  deaths  from  medical  condi;ons  resul;ng  from  chronic  drug  use.    Drug-­‐induced  causes  exclude  accidents,  homicides,  and  other  causes  indirectly  related  to  drug  use.    Not  all  injury  cause  categories  are  mutually  exclusive.  

Source:  Na;onal  Center  for  Health  Sta;s;cs,  Centers  for  Disease  Control  and  Preven;on.    Na;onal  Vital  Sta;s;cs  Reports  Deaths:    Final  Data  for  the  years  1999  to  2009  (January  2012).  

Source  of  Prescrip;on  Pain  Relievers  

Source:    SAMHSA,  Center  for  Behavioral  Health  Sta&s&cs  and  Quality,  Na&onal  Survey  on  Drug  Use  and  Health,  2008-­‐2009  

Prescrip;on  Drug  Abuse  Preven;on  Plan  

•  Coordinated  effort  across  the  Federal  government  

•  4  focus  areas  –  Educa;on  –  Prescrip;on  Drug  Monitoring  Programs  

–  Proper  Medica;on  Disposal  

–  Enforcement  

Educa;on  •  Educa;on  Goals  for  healthcare  providers  

–  Knowledge  on  appropriate  prescribing  –  Effec;vely  iden;fying  those  at  risk  for  abuse  –  PDMP  use  in  everyday  clinical  prac;ce  –  Screening,  interven;on,  and  referral  for  those  misusing  or  abusing  

prescrip;on  drugs  •  Main  Ac;ons  

–  Legisla;on  requiring  mandatory  educa;on  for  all  clinicians  who  prescribe  controlled  substances  

–  Increase  substance  abuse  educa;on  in  health  profession  schools,  residency  programs,  and  con;nuing  educa;on  

–  Work  with  the  American  College  of  Emergency  Physicians  to  develop  evidence-­‐based  clinical  guidelines  that  establish  best  prac;ces  for  opioid  prescribing  in  the  Emergency  Department  

–  Expedi;ng  research  on  the  development  of  abuse  deterrent  formula;ons  

Top  10  prescribing  special&es    immediate-­‐release  opioids,  2009    

General  Prac&&oners/Family  Medicine;  26.7%  

Internal  Medicine;  15.4%  

Den&sts;  7.7%  

Nurse  Prac&&oners;  3.5%  

Physicians  Assistants;  4.0%  

Emergency  Medicine;  4.7%  

Other;  20.2%  

Physical  Med  &  Rehab;  2.7%  

Anesthesiologists;  3.2%  

Orthopedist;  7.4%   Unspec.;  4.5%  

SDI, Vector One: National, 2009. Extracted June 2010. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/AnestheticAndLifeSupportDrugsAdvisoryCommittee/UCM217510.pdf

General  Prac&&oners/

Family  Medicine;  27.0%  

Internal  Medicine;  16.8%  

Nurse  Prac&&oners;  5.7%  

Physicians  Assistants;  4.3%  

Hematology;  1.7%  

Orthopedist;  1.9%  

Neurologist;  2.8%  

Unspec.;  4.9%  

Physical  Med  &  Rehab;  9.3%  

Anesthesiologists;  13.8%  

Other;  11.8%  

Top  10  prescribing  special&es    extended-­‐release/long  ac&ng  opioids,  2009    

SDI, Vector One: National. Years 2009. Extracted June 2010. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/AnestheticAndLifeSupportDrugsAdvisoryCommittee/UCM217510.pdf

Educa;on  Gaps  •  Physicians  

–  2000  survey:  56  %  of  residency  programs  required  substance  use  disorder  training,  median  number  of  curricular  hours  ranged  from  3  to  12  hours1  

–  2008  follow-­‐up:  “Although  the  educa;on  of  physicians  on  substance  use  disorders  has  gained  increased  aZen;on,  and  progress  has  been  made  to  improve  medical  school,  residency,  and  postresidency  substance  abuse  educa;on  since  2000,  these  efforts  have  not  been  uniformly  applied.”2  

•  Pharmacists3  –  67.5%  report  receiving  two  hours  or  less  of  addic;on  or  substance  

abuse  educa;on  in  pharmacy  school  –  29.2%  reported  receiving  no  addic;on  educa;on  –  Pharmacists  with  greater  amounts  of  addic;on-­‐specific  educa;on:    

•  Higher  likelihood  of  correctly  answering  ques;ons  rela;ng  to  the  science  of  addic;on  and  substance  abuse  counseling  

•  Counseled  pa;ents  more  frequently  and  felt  more  confident  about  counseling  

1.  Isaacson  JH,  Fleming  M,  Kraus  M,  Kahn  R,  Mundt  M.  A  Na;onal  Survey  of  Training  in  Substance  Use  Disorders  in  Residency  Programs.  J  Stud  Alcohol.  61(6):912-­‐915.  2000.    2.  Polydorou  S,  Gunderson  EW,  Levin  FR.  Training  Physicians  to  Treat  Substance  Use  Disorders.  Curr  Psychiatry  Rep.  10(5):399-­‐404.  2008.  3.  Lafferty  L.  Hunter  TS,  Marsh  WA.  Knowledge,  aktudes  and  prac;ces  of  pharmacists  concerning  prescrip;on  drug  abuse.  J  Psychoac:ve  Drugs.  2006  Sep:38(3):229-­‐232.  

Proper  Medica;on  Disposal  

•  Goals:    –  Easily  accessible,  environmentally  friendly  method  of  drug  disposal  that  reduces  the  amount  of  prescrip;on  drugs  available  for  diversion  and  abuse  

•  Main  Ac;ons  –  Publish  and  implement  regula;ons  allowing  pa;ents  and  caregivers  to  easily  dispose  of  controlled  substance  medica;ons  

– Next  DEA  Take  Back  Day  April  28  – Once  regula;ons  are  in  place,  partner  with  stakeholders  to  promote  proper  medica;on  disposal  programs  

Enforcement  

•  Goals:  – Assist  states  in  addressing  “pill  mills”  and  doctor  shopping  

•  Main  Ac;ons  –  Provide  technical  assistance  to  states  on  model  regula;ons/laws  for  pain  clinics  

–  Encourage  High-­‐Intensity  Drug  Trafficking  Areas  (HIDTAs)  to  work  on  prescrip;on  drug  abuse  issues  

–  Support  prescrip;on  drug  abuse-­‐related  training  programs  for  law  enforcement  

hZp://www.whitehouse.gov/ondcp