A Multifaceted Approach to Addressing Prescription Drugs in Your Community Jason B. Fields MD Medical Services Manager, DACCO

Floridas Prescription Drug Diversion and Abuse Roundup 2012 to 2015 Pam Bondi, Attorney General Floridas Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2 nd, 2012

Contributors to the Crisis Florida had weak regulatory oversight of pain management practices, Limited oversight of physician dispensing habits No statewide Prescription Drug Monitoring Program (PDMP). Floridas Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2 nd, 2012

The Crisis Most serious public health and safety threat to our state Prescription drug abuse kills more than seven Floridians every day Floridas communities suffer from prescription drug addiction due to increasing health care costs and a growing proportion of prescription drug diversion fueled crime. There are reporting increases in the number of infants suffering from Neonatal Withdrawal Syndrome due to their mothers abuse of opioid painkillers. Floridas Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2 nd, 2012

Goals of the Roadmap This action has led to a dramatic decrease in the number of Florida physicians dispensing the most powerful pain-killing narcotics from their offices. Law enforcement and health regulators are now actively collaborating in regional strike forces to inspect, investigate, and prosecute those who seek to flood our communities with diverted pharmaceuticals. At the end of 2011, Florida successfully launched its PDMP, which is a crucial component in our efforts to combat prescription drug abuse. Floridas Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2 nd, 2012

HB 7095 (June 1 st, 2011) This significant piece of legislation banned dispensing of Schedule II and Schedule III controlled substances by physicians Created a standard of care for all physicians prescribing controlled substances to treat chronic pain Required physicians to either electronically prescribe controlled substances or use counterfeit-proof prescriptions Added several critical criminal violations to support enforcement Improved reporting to the states PDMP from 15 days to 7 days. Floridas Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2 nd, 2012

PDMP HIPAA compliant Prescription Drug Monitoring Program (PDMP) in accordance to F.S Has contributed to the steep decline in the number of Florida doctors dispensing the most oxycodone in a given year. Florida went from 90 of the top 100 prescribers to, as of last count, only 13 of the top 100 now residing in Florida. Floridas Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2 nd, 2012

PDMP The PDMP became operational on September 1, 2011, when it began receiving controlled substance dispensing data from pharmacies and dispensing practitioners Health care practitioners began accessing the data reported to the PDMP on October 17, 2011, and Law Enforcement Agencies began requesting PDMP reports during the course of active investigations on November 14, 2011

PDMP Information collected in the database is available to registered health care practitioners to help guide their decisions in prescribing and dispensing certain highly abused prescription drugs It may also assist health care practitioners in identifying patients who are doctor shopping or trying to obtain multiple prescriptions for the same controlled substance from multiple health care practitioners, which is a felony in the State of Florida.

The Crisis Florida has became the epicenter of pharmaceutical drug diversion Prescription drug overdoses kill on average seven Floridians every single day – a tragic number five times greater than deaths caused by all illicit drugs combined. For every 1 overdose death there are 9 treatment admissions, 35 emergency room visits for misuse or abuse, 161 people with abuse and/or dependence issues and a staggering 461 nonmedical users of prescription drugs. Floridas Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2 nd, 2012

Substance Use in Adolescents There are multiple genetic and environmental risk factors that make adolescents vulnerable to the initiation of substance use. Unfortunately, earlier use of tobacco, alcohol, and drugs is more likely to result in substance use disorders in adulthood. The substance use in the teenage years which begins as minimal or experimental use with minimal consequences can progress in a subset of individuals to more serious substance use disorders like substance abuse or dependence.

Substance Use in Adolescents Substance abuse is regular use that has a negative impact on daily functioning or that is associated with recurrent significant problems. Substance dependence is associated with loss of control over the use of a drug with more serious consequences. There is abundant evidence that the earlier the initiation of use of substances like tobacco, alcohol, or marijuana, the more likely that individual will have significant addiction issues.

MTF Monitoring the Future (MTF) is a long-term study of American adolescents, college students, and adults through age 50. It has been conducted annually by the University of Michigans Institute for Social Research since its inception in 1975 and is supported under a series of investigator- initiated, competing research grants from the National Institute on Drug Abuse.

Narcotics Other than Heroin The use of narcotic drugs other than heroin (most of which are prescription analgesics) increased sharply in recent years, as have emergency room admissions involving these drugs, making this class of drugs of particular concern. Use in 12 th gradethe only grade for which use is reportedshowed some no significant decline in The two major components of this class are Vicodin and OxyContin, and both showed no significant declines in all three grades. However, for the three grades combined, the declines for both Vicodin and OxyContin were significant in 2012, as a result of the greater precision gained with the larger combined sample.

Oxycontin OxyContin use increased some in all grades from 2002 (when it was first measured) through 2011, In 2012 the prevalence rate dropped in all three grades; though no single grade change was significant, the change for the three grades combined was. Annual prevalence in 2012 was 1.6%, 3.0%, and 4.3% in grades 8, 10, and 12, respectively.

Vicodin Use of Vicodin remained fairly steady at somewhat higher levels since 2002, until among 10th and 12th graders its use declined after Use among 8th graders also declined in In 2012 annual prevalence rates were 1.3%, 4.4%, and 7.5% in grades 8, 10, and 12; and the decline in 2012 was significant for the three grades combined.

Marijuana Use Past Year Use and Perception of Risk of Using Regularly

NSDUH: Past Year Non-Medical Use Misuse of prescription drugs is second only to marijuana as the Nations most prevalent illicit drug problem and is a public health concern, with approximately 22 million persons initiating nonmedical pain reliever use since Combined 2010 and 2011 data indicate that the rate of past year nonmedical use of prescription pain relievers among those aged 12 or older was 4.6 percent nationally and ranged from 3.6 percent in Iowa to 6.4 percent in Oregon

NSDUH: Past Year Non-Medical Use The national rate for the total population declined between and (from 4.9 to 4.6 percent).8 This rate also decreased nationally among persons aged 12 to 17 (from 6.4 to 6.1 percent) Among those 18 to 25 (from 11.5 to 10.4 percent); however, the rate remained unchanged for persons aged 26 or older.

Myth: Having an Rx prescription gives a patient license to adjust the dosage, and it is safe to continue taking the medicine after it is no longer needed. Likewise, if the medication is prescribed, it can be shared with family and friends.

Fact: Taking prescription drugs that are not prescribedor taking them in any way other than directed by a doctoris considered misuse or abuse and can lead to dangerous outcomes. Additionally, using another persons medication is against the law. Sharing your prescription medicines with another person is also illegal and could lead to devastating results.

Myth: Because Rx drugs are legal, misuse and abuse of these drugs is less risky than using illegal drugs.

Fact: Rx medications provide many benefits when used correctly under a prescribers care. But when misused or abused, they can be just as dangerous as illicit drugs, especially when taken with alcohol or other drugs.

Myth: Prescription medications are not drugs of typical abuse among teens and young adults.

Fact: Even though the percentages of teens abusing these drugs is relatively low, compared to marijuana, current trends reveal troubling signs that abuse of these medications is acceptable behavior. What makes it more complicated is that parents, other adult caregivers and those prescribing the medications to teens seem to be unaware of the problem.

Myth: Rx medications are more difficult to obtain than illegal drugs.

Fact: Those who abuse Rx medications report that these drugs can be easily obtained from family members and friends. Additional sources include family medicine cabinets and other frequented locations such as kitchen cabinets, night stands and purses.

Myth: Parents believe that because Rx medications are prescribed by healthcare professionals, teens and young adults will not abuse them.

Fact: Many parents are not even aware that commonly prescribed medications are being abused to get high. In fact, some do not consider the possibility that their unused medicines could get into the wrong hands, and many do not know how to properly dispose of old medicines.

NSDUH: Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older:

Developmental Vulnerability There is a 2 to 8 fold increase in substance use problems if use of tobacco, alcohol, and THC begins < 15 There is a 1 in 4 chance of coming into harm if using starts < 15 A narrow window of approximately 2 years for onset of onset of first use makes such a significant difference

New Users in the Past Year of Specific Illicit Drugs among Persons Aged 12 or Older, 2010 Source: SAMHSA, 2009 National Survey on Drug Use and Health (September 2010). * Includes pain relievers, tranquilizers, stimulants, and sedatives Note: The specific drug refers to the drug that was used for the first time in the past year, regardless of whether it was the first drug ever used or not.

Drug-Induced Deaths vs. Other Injury Deaths, 1999–2009* Source: National Center for Health Statistics, Centers for Disease Control and Prevention. National Vital Statistics Reports Deaths: Final Data for the years 1999 to 2007 (2001 to 2009); Deaths: Preliminary Data for the years 2008 and 2009 (2010 and 2011). *Data for 2008 and 2009 are provisional and subject to change. Causes of death attributable to drugs include accidental or intentional poisonings by drugs and deaths from medical conditions resulting 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. 9/2011

Heroin Cocaine 27,658 unintentional drug overdose deaths Unintentional Drug Overdose Deaths United States, 1970–2007 National Vital Statistics System, Year

The Prescription Drug Abuse Problem 478 million prescriptions for controlled- substances dispensed in U.S. in million Americans reported current non- medical use of prescription drugs in in 4 people using drugs for first time in 2010 began by using a prescription drug non-medically 6 of top 10 abused substances among high school seniors are prescription drugs 28,000 unintentional overdose deaths in 2007 – driven by prescription opioids

Commonly Abused Prescription Drugs

Prescriptions Dispensed for select opioids in U.S. Outpatient Retail Pharmacies, Number of Prescriptions Source: SDI, Vector One: National. Extracted June 2010.

56 Treatment Admissions Involving Opioid Analgesics 1 1 Includes admissions where primary, secondary, or tertiary substance was reported as Other opiates/synthetics. Excludes admissions for non-prescription use of methadone. OxyContin introduced SAMHSA 2007

Heroin Cocaine 27,658 unintentional drug overdose deaths Unintentional Drug Overdose Deaths United States, 1970–2007 National Vital Statistics System, Year

8 Signs in Teens Change in sleep habits Change in energy level Change in personal hygiene Change in mood/ personality Sudden change in grades Change of friends Loss of Appetite Constricted eye pupils (pin-point pupils for suspected opiate use)

Prescription Drug Abuse Prevention Plan Coordinated effort across the Federal government 4 focus areas – Education – Prescription Drug Monitoring Programs – Proper Medication Disposal – Enforcement

Resources 2012 Monitoring the Future Survey 2011 NSUDH 2012 Medical Examiners Commission Interim Drug Report CADCA Preventrxabuse.org