Prescription Drug Abuse in Indiana Deaths from Prescription painkillers have reached epidemic proportions. In 2009, over 6,000 persons per day abused prescription pain relievers for the first time. And 2,500 of those were teens. Between 2005-2009, Quest diagnostics reported a 40% increase in employees testing positive for prescription narcotics. A 2010 report found 8% full time and 11.5% part time employees were current drug abusers. Joan Duwve, M.D., M.P.H. Indiana Rural Health Association June 10, 2014

In 2007, 27,658 unintentional drug overdose deaths occurred in the United States. = 1 death every 19 minutes. That number increased to 36,500 in 2008. Rates have increased roughly five-fold since 1990.

Drug Overdose Death Rates Versus Motor Vehicle Accidents Now have more deaths from drug overdose than mva Years 1980-2010 NCHS Data Brief, December, 2011, updated with 2009 and 2010 mortality data

CDC. Death rates for drug poisoning, by state of residence, United States, 2010. Available at http://www.cdc.gov/nchs/pressroom/states/drug_deaths_2010.pdf

Opioid sales, opioid-related deaths and opioid treatment admissions, U Opioid sales, opioid-related deaths and opioid treatment admissions, U.S. Source: Warner et al. 2011

Percent Change in Ten Leading Causes of Injury Death Percent Change in Ten Leading Causes of Injury Death* Indiana, 2000–2010 In Indiana, there was a >350% increase in unintentional poisoning injury deaths from 2000-2010. It is important to note these are the ten leading causes of injury deaths from 2000-2010, not just randomly selected causes of injury deaths. Source: WISQARS *Age-adjusted rates 6

Source: Indiana State Department of Health, Epidemiology Resource Center, Data Analysis Team

Unintentional Poisoning Death Rates, Age-Specific, Indiana, 2005 – 2010 * Rates based on 20 or fewer deaths may be unstable. Use with caution. * Rates based on 20 or fewer deaths may be unstable. Use with caution. Source: Centers for Disease Control and Prevention, WISQARS Database 8

Geographic Variation in Opioid Prescribing in the U.S. Journal of Pain, Volume 13, Issue 10, October 2012, Pages 988–996

Number of Prescription Drug Overdose Deaths in Indiana, 2002-2011 Oxycodone Distribution to Indiana Retail Registrants, January 2007 through June 2008 Indiana Center for Health Policy If the unintentional poisoning death rate stays the same as it was in 2007, about as many Americans will die from unintentional drug poisoning deaths over the next decade as live in cities the size of Newark, New Jersey; Anchorage, Alaska; or St. Paul, Minnesota.” Dr. Len Paulozzi, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention 280,000 people, roughly Source: U.S. Drug Enforcement Administration, 2008

Indiana State Department of Health Mortality Data; Average Annual Accidental Poisoning by and Exposure to Drugs, Medicaments, and Biological Substances by Indiana County (2009 and 2010) – Rates per 100,000 ICD‐10 Codes X40 – X44 Indiana State Department of Health Mortality Data;

Other Adverse Outcomes Other important adverse outcomes http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

Copyright © 2012 American Medical Association. All rights reserved. Neonatal Abstinence Syndrome and Associated Health Care Expenditures:  United States, 2000-2009 2009 NAS vs. Other LOS 16.4 d vs. 3.3d Costs $53,400 vs. $9,500 Marked increase in neonatal abstinence syndrome Figure Legend: NAS indicates neonatal abstinence syndrome. Error bars indicate 95% CI. P for trend < .001 over the study period. The unweighted sample sizes for rates of NAS and for all other US hospital births are 2920 and 784 191 in 2000; 3761 and 890 582 in 2003; 5200 and 1 000 203 in 2006; and 9674 and 1 113 123 in 2009; respectively. JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951 Date of download: 1/6/2013 Copyright © 2012 American Medical Association. All rights reserved.

Percentage of College Students Reporting Rx Misuse in the Past Six Months in Indiana, 2013 Rx Drug Prevalence Adderall 10.1% Vicodin 3.6% Xanax 3.5% Codeine 2.7% Ritalin 1.7% Lortab 1.5% Percocet 0.9% Oxycontin 1.3% Morphine 0.4% Methadone 0.2% Steroids 0.1% Key: Opioid Stimulant CNS Depressant Other * Indiana College Substance Use Survey, 2011 * Most widely misused Rx is Adderall, a stimulant (used/abused by one in ten college students) Source: Indiana College Substance Use Survey, 2013. Indiana Prevention Resource Center.

Youth and Controlled Substances 50% of teens believe that prescription drugs are much safer than illegal street drugs. 60-70% say that home medicine cabinets are their source of drugs.

Narcotic Sources National Survey on Drug Use and Health 2011. More than half of nonmedical users get their prescription drugs from family or friends free National Survey on Drug Use and Health 2011.

Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2010-2011 Source: SAMHSA, National Survey of Drug Use and Health, 2011

ONDCP's Prescription Drug Abuse Prevention Plan Education Parents, youth, patients Prescribers Monitoring (INSPECT) Discourage “Doctor Shopping” and Diversion Interstate monitoring Proper Medication Disposal Take back programs Enforcement Identify and eliminate “Pill Mills” and unethical prescribing practices 1. Educate parent, youth and patients about dangers of abusing prescription drugs, and prescribers on appropriate and safe us, proper storage and disposal. 2. Implement monitoring programs in every state, capable of sharing data with other states. For use by healthcare providers and law enforcement. Reduce doctor shopping and diversion. 3. Develop convenient and environmentally responsible prescription drug disposal programs to decrease supply of unused meds in home. 4. Provide law enforcement with necessary tools to eliminate improper prescribing practices and stop pill mills.

Indiana’s Prescription Drug Abuse Prevention Plan Education Parents, youth, patients Prescribers Neonatal Abstinence Syndrome Monitoring (INSPECT) Discourage “Doctor Shopping” and Diversion Interstate monitoring Proper Medication Disposal Take back programs Enforcement Identify and eliminate “Pill Mills” and unethical prescribing practices Treatment and Recovery Addiction treatment services Naloxone Rescue 1. Educate parent, youth and patients about dangers of abusing prescription drugs, and prescribers on appropriate and safe us, proper storage and disposal. 2. Implement monitoring programs in every state, capable of sharing data with other states. For use by healthcare providers and law enforcement. Reduce doctor shopping and diversion. 3. Develop convenient and environmentally responsible prescription drug disposal programs to decrease supply of unused meds in home. 4. Provide law enforcement with necessary tools to eliminate improper prescribing practices and stop pill mills.

The Indiana Prescription Drug Abuse Prevention Task Force Chair: Greg Zoeller, Indiana Attorney General Co-chair: Joan Duwve, Indiana State Department of Health Committees Education: Dr. Deb McMahan, LHO, Allen County INSPECT: Greg Pachmayr, Director, Pharmacy Board Take-Back: Representative Steve Davisson, Pharmacist Enforcement: Tim McClure, OAG Treatment and Recovery: Steve McCaffrey, MHA Committees modeled after ONDCP Natalie Robinson, Michelle Sybesma, Kristen Kelley, many more

Awareness

Accomplishments to Date Education Committee Provider Education Provider Toolkit for management of chronic, non-terminal pain Emergency rules for opioid prescribing for chronic non-terminal pain Annual symposium Public speaking Public Education Bitterpill.in.gov Pills of Peril PBS documentary Adult and adolescent education http://www.in.gov/bitterpill/voices.html - meghan

“First Do No Harm” Indiana’s Safe Prescribing Recommendations

Accomplishments to Date NAS Committee formed to better support families during pregnancy and after delivery Formalized as IPN committee by legislature make recommendations for screening pregnant women for substance use identify and report infants with NAS to understand incidence and improve newborn care

Accomplishments to Date INSPECT Legislature authorized 100% of CSR fees to be used to maintain and operate INSPECT Working with Health Information Exchange and Indiana Network for Patient Care to integrate into EHR systems Decreased reporting interval to INSPECT phased in beginning July 2015

Accomplishments to Date Take-Back State-wide take-back days Indiana law permits pharmacy-based take-back (waiting for federal DEA rule revision to be published) Working with large pharmacy in central Indiana to develop a pilot take-back program

Accomplishments to Date Enforcement Indiana Code now requires owners of clinics dispensing controlled substances to have a Controlled Substance Registration with Indiana Professional Licensing Agency

Accomplishments to Date Treatment and Recovery Loan repayment programs for addiction treatment training Naloxone rescue liability protection for first responders and expansion of life-line law Working with Indiana Medicaid to ensure appropriate formulary coverage for addiction treatment medications

Joan Duwve, M.D., M.P.H. Associate Dean for Public Health Practice IU Richard M. Fairbanks School of Public Health Chief Medical Consultant Indiana State Department of Health jduwve@iu.edu 317-278-0754