1. Noah Aleshire National Center for Injury Prevention and Control Centers for Disease Control and Prevention Epidemiologic Basis for Pain Clinic Laws National Center for Injury Prevention and Control Division of Unintentional Injury Prevention, JD

2. Outline of Presentation  Pill Mills and Pain Clinics  Key Facts About the Epidemic  Florida’s Experience

3. Pill Mill A doctor, clinic, or pharmacy that is prescribing or dispensing controlled prescription drugs inappropriately Pain Clinic A privately-owned facility providing pain management services to patients, often including the prescription of controlled substances

4. What’s “inappropriate” prescribing?

5. #1 a small number of opioid prescribers vast majority of opioid prescribing

6. Just 3% of California workers compensation opioid prescribers… Swedlow et al. Prescribing patterns of schedule II opioids in California Workers’ Compensation, CWCI Institute, 2011

7. 55% of all CSII opioid Rx 3% of prescribers Swedlow et al. Prescribing patterns of schedule II opioids in California Workers’ Compensation, CWCI Institute, 2011

8. 62% of all morphine equivalents 3% of prescribers Swedlow et al. Prescribing patterns of schedule II opioids in California Workers’ Compensation, CWCI Institute, 2011

9. 65% of all associated payments 3% of prescribers Swedlow et al. Prescribing patterns of schedule II opioids in California Workers’ Compensation, CWCI Institute, 2011

10. 1% of prescribers Swedlow et al. Prescribing patterns of schedule II opioids in California Workers’ Compensation, CWCI Institute, 2011 33% of all CSII opioid Rx 41% of all morphine equivalents 42% of all associated payments

11. Oregon PDMP Report 2012: http://www.orpdmp.com/orpdmpfiles/PDF_Files/Reports/Statewide_10.01.11_to_03.31.12.pdfhttp://www.orpdmp.com/orpdmpfiles/PDF_Files/Reports/Statewide_10.01.11_to_03.31.12.pdf Oregon PDMP report top 8.1% of providers prescribe 79% of CII-CIV drugs

12. Top 20% of prescribers account for 63% of overdose deaths Ontario Public Drug Program, 2006 Adapted from data from Dhalla et al. Can Fam Physician 2011;57:e92-e96

13. Percent of CS II-V prescriptions prescribed by prescriber decile by year, KY, 2009 Blumenschein, K, et al. Independent Evaluation of the Impact and Effectiveness of the Kentucky All Schedule Prescription Electronic Reporting Program (KASPER) Institute for Pharmaceutical Outcomes and Policy, Univ of Kentucky, 2010

14. CS II-V controlled substance prescriptions per hour by prescriber rank by year, KY Calculated from Blumenschein et al. Independent Evaluation of the Impact and Effectiveness of the Kentucky All Schedule Prescription Electronic Reporting Program. Institute for Pharmaceutical Outcomes and Policy, Univ of Kentucky, 2010

15. Pill Mills = High Volume Prescribers “You just walk in, they ask you what hurts, they take your blood pressure, they weigh you, and they say actually – literally sometimes, ‘What do you want?’ … ‘How many do you take a day?’ You could be ridiculous and say 40. I mean, I could get 200 of each, Roxi's and Oxy's at the same time, which makes no sense, and Xanny bars (Xanax) at the same time. They just ask you what you want.” --White female, 41, street based/illicit drug user Rigg KK, March SJ, Inciardi JA. Prescription drug abuse and diversion: role of the pain clinic. J Drug Issues. 2010 ; 40(3): 681–702.

16. #2 taking high doses of opioids higher risk of overdose

17. Most opioids consumed by small percentage of patients at high dosage levels, NM, 2007-2008 Unpubliished data from New Mexico case-control study.

18. Average MME per Rx (Ca. Workers Comp. Study) Swedlow et al. Prescribing patterns of schedule II opioids in California Workers’ Compensation, CWCI Institute, 2011

19. Dunn et al, Opioid prescriptions for chronic pain and overdose. Ann Int Med 2010;152:85-92. Overdose risk highest among small percentage of patients at high dosage, Group Health, 1997-2005

20. Pill Mills = High Dosage Prescribing Rigg KK, March SJ, Inciardi JA. Prescription drug abuse and diversion: role of the pain clinic. J Drug Issues. 2010 ; 40(3): 681– 702. “Every three weeks he would give me 60 Xanax, 25 Trazapans, 300 thirties (30 mg) of Roxicodone, the little blue ones. He would give me 120 Percocets to go in between the blue ones, which makes no sense to me but I'm not going to fight it – plus another 120 wafers, which are the 40 milligram methadone. And then later on he added in Dilaudid, like 30 of those and the Oxy eighties. He put those in place of the Percocets, which made no sense but again whatever. Okay so now he's giving me eight times the amount, and that was every three weeks.” --White male, 39, drug treatment enrollee

21. #3 doctor shopping higher risk of overdose

22. People Prescribed CS II-IV, WV 2005-2007 Peirce LP, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 50(6): June 2012.

23. 7x more likely to doctor shop than control group Peirce LP, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 50(6): June 2012. People who overdosed were… and 13x more likely to pharmacy shop

24. Cepeda et al Characteristics of prescribers whose patients shop for opioid: results from a cohort study. J Opioid Manag. 2013.

25. CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. 2012. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm Distribution of Patients and Overdoses by Risk Group

26. Florida & Pill Mills

27. Florida and the Epidemic  2003-2009 (CDC MMWR)  84% increase in prescription drug overdoses  264% increase in oxycodone overdoses  In 2009, 8 people died of overdoses every day MMWR. Drug overdose deaths — Florida, 2003–2009. 869-72. 60(26). July 8 2011.  2010:  90 of the top 100 oxycodone purchasing physicians in US were in Florida  900+ pain clinics  2011: Revised pill mill law enacted

29. Drug-caused deaths by drug type, Florida, 2007-2011 Source: Florida Medical Examiners Commission Annual Reports

30. Rigg KK, March SJ, Inciardi JA. Prescription drug abuse and diversion: role of the pain clinic. J Drug Issues. 2010 ; 40(3): 681– 702. “They knew it was being abused, but nothing is ever spoken. I weighed about 90 pounds. I was so sick, and my blood pressure was so low it was bottoming out. I was having seizures. My physical health just deteriorated. I mean, it’s obvious if you walk in, you can tell if someone is an active crack head or actively abusing pills.” --Hispanic female, 41, drug treatment enrollee

31. The findings and conclusions in this report are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention. National Center for Injury Prevention and Control Division of Unintentional Injury Prevention