Vital Signs – Prescription Drug Overdose

OPERATOR: Welcome and thank you for standing by.  I'd like to inform all parties that your lines have been placed in a listen-only mode until the question and answer session of today's conference.  Today's conference is also being recorded.  If you have any objections, you may disconnect at this time.  I would now like to turn the meeting over to Mr. Tom Skinner.  Sir, you may begin. 

TOM SKINNER:  Thank you, Calvin.  Thank you all for joining us today for the release of another CDC vital signs report. We're joined today by the director of the CDC, Dr. Tom Frieden who will provide some opening remarks.  Also available today is Dr. Len Paulozzi, a medical officer in CDC’s injury center, who is also going to be available to answer questions.  I'd like to turn the call over to Dr. Frieden. 

TOM FRIEDEN:  Hello, thank you all very much for joining us.  This month we have the latest in our monthly vital signs.  Each month we focus on the latest data about a critical health issue that faces the country and what can be done about it.  This month, the topic is overprescribing of opioid narcotics.  Overdoses from opioid narcotics are a serious problem across the country.  And we know that overdose deaths tend to be higher where opioids get heavier use.  So you can see really two correlations.  One, over time, over the past decade or more, there's been a dramatic increase in the amount of opioids prescribed and, two, across the country, there are dramatic differences.  Now, prescription opiates can be an important tool for doctors to use, and some conditions are best treated with opioids.  But they're not the answer to every time someone has pain.  However, we found that health care providers in 2012 wrote 259 million prescriptions for opioids.  That's enough for every American adult to have their own bottle of pills.  In fact, we found that health care providers in some states prescribed these drugs three times as much as in other states.  The opioid prescriptions ranged from a low of 52 for every 100 people, which is still awfully high in Hawaii, to an extraordinary 143 per 100 people in Alabama.  Southern states had the most prescription per person for painkillers, especially Alabama, Tennessee and West Virginia.  The northeast had the most per-person prescriptions for long-acting painkillers and for high-dose painkillers, especially Maine and New Hampshire.  When you look at specific opioids, the inconsistencies are even larger.  There were nearly 22 times as many as prescriptions written for the opioid Oxymorphone in Tennessee as were written in Minnesota.  Many of the states with high rates are the ones that have the most serious problems with opioid overdoses.  We think opioids are likely to be overprescribed in these states.  It's really important to remember that these medicines can be dangerous.  If we're not careful, the treatment can quickly become the problem.  There are two main reasons why these medicines are so dangerous.  The first is that they are very addictive.  So there's a high risk that if you take these, you may end up addicted to opiates and in fact some recent studies suggest that three out of every four people who are currently using heroin started with prescription opiates.  The second reason they're dangerous is that they're so powerful.  They can suppress your breathing such that you die.  So not only are they addictive, but they are also potentially deadly.  One of the questions is why there are such huge differences in prescribing.  We don't think it's because people in some states have substantially more pain than people in other states.  Previous studies have shown that many contribute to the big variation in the use of overuse of some drugs.  There's not a clear consensus among providers of evidence on when to use a certain type of drug.  And for opioids the high rate may also mean there are many people abusing drugs who are getting multiple prescriptions for their own use or otherwise.  And many states report problems with for-profit, high-volume pain clinics, so called pill mills, that prescribed large quantities of these drugs to people who really don't need them medically.  It is interesting to note that antibiotic prescribing rates are also highest in the southern region.  Some regional health care characteristics may influence the use of prescription drugs in general.  But there is good news.  And we have a second report that I think is really very positive and very exciting.  States can take steps that do reduce overprescribing and that rapidly result in a reduction in deaths.  We today are releasing a report from Florida that shows that in 2010 and 2011, Florida regulated pain clinics and stopped health care providers from dispensing that is, giving out, prescription opioids from their offices.  After implementation, the number of prescriptions dropped dramatically.  For example, oxycodone prescribing dropped by a quarter.  And following that, oxycodone overdose deaths dropped by half.  In fact, overall, after implementation, prescription opioid deaths decreased by more than a quarter, 26 percent.  And the number of drug deaths overall decreased by a sixth.  17 percent in just two years.  These changes may well represent the first well-documented substantial decline in drug overdose mortality in any state during the past ten years.  I'm just going to repeat that because i think it's so important.  These changes may well represent the first documented sustained -- substantial decline in drug overdose mortality in any state over the past decade.  There are lots of things that states can do to improve the prescribing of these potentially dangerous medicines.  They can increase the use of drug monitoring programs, which are state-run databases that track prescriptions for painkillers and can help find problems in overprescribing.  These programs can be more effective if they're real time, universal for all prescribers and all controlled substances and actively managed so that anytime there's an increase, the patient or the physician is contacted.  States can also consider policy options, such as laws and regulations relating to pain clinics to reduce prescribing practices that are risky for patients.  They can evaluate their own programs to consider ways to improve Medicaid, worker compensation programs and other state-run health plans to find and address inappropriate prescribing of painkillers.  And they can identify ways to increase substance abuse treatment and other treatment programs that can be helpful when people have pain.  These can be physical therapy, these can be other modalities.  They can also expand first responder access to naloxone, a drug used when people overdose, that can reverse the overdose.  Health care providers also have an essential role to play.  One of the things these state programs can do is empower health care providers with more information about the drugs that their patients are receiving from other sources and with more tools that they can use to provide services to patients who come in with pain that requires some form of treatment.  Just because someone has pain doesn't mean they need an opiate.  Opiates are potentially dangerous medications.  Health care providers can use prescription drug monitoring programs to identify patients who might be misusing drugs putting them at risk for overdose and use effective treatment, such as methadone, for appropriate patients with substance abuse problems.  They can also discuss with patients the risks and the benefits of pain treatment options, including options that don't include prescription opiates or benzodiazepines.  I have friends and colleagues who have had severe pain and have been very concerned about even short-term use of opiates because of the risk of addiction.  But what we find even more concerning is the use of these addictive and potentially deadly medications for chronic pain because there's very little evidence that they're effective for chronic pain.  The bottom line is that we're not seeing consistent, effective, appropriate prescribing of painkillers across the nation and this is a problem because of the deaths that result.  Every day, 46 people die from an overdose of prescription painkillers in this country.  We need to do important things at every level but change at the state level, I think, has the greatest promise.  All states, but especially those where prescribing rates are highest need to examine whether the drugs are being used appropriately.  What type of pain treatment you get shouldn't depend on where you live but on the condition that you have.  And at CDC, we're here to support those efforts.  And together, I’m optimistic that we can reduce the risk of overdose while making sure that patients in all states have access to safe and effective pain treatment.  So thank you very much.  And we'll turn it over for questions. 

TOM SKINNER:  Calvin, we're ready for questions, please. 

OPERATOR:  Thank you.  At this time, if you would like to ask a question, please press star 1 on your keyboard to ask a question.  One moment for our first question.  Our first question comes from Mike Stobbe with the Associated Press. 

MIKE STOBBE:  Thank you for taking -- actually I have two questions if I may.  Dr. Frieden, you mentioned that the antibiotic prescription pattern was also high in the south compared to the rest of the country.  In these numbers you're reporting with opioids, is this just a reflection that the south prescribes all sorts of medication more than other parts of the country?  Are there other types of drug that follow the same pattern? 

TOM FRIEDEN:  These are just two that we've looked at.  We haven't looked at others.  But it is striking that we've seen this pattern in both of those situations that we've looked at.  And in both cases, it's so important to look at both the risks and the benefits of medications.  Every benefit -- every medication has both risks and potential benefits.  So understanding what those are and when the balance tips is important.  I will say that the pattern is not identical.  It's just something of a trend because you also see very high rates of opioid prescription in the mid-Atlantic.  So there are differences there.  But this is something that we could look into further. 

MIKE STOBBE:  And my second question, if I may, do you have state-by-state data on opioid overdoses?  And does that data match the opioid prescription data?  Is it -- does one automatically lead to the other or is the order a little different? 

TOM FRIEDEN:  I’ll ask Dr. Paulozzi to comment further.  As a general trend, they correlate.  But there are many factors at play.  Len? 

LEN PAULOZZI:  Yes, this is Len Paulozzi.  We have looked in the past at a correlation between distribution of these drugs and all drug overdose deaths, that is, overdose death from any kind of drug.  And there is a correlation there.  You question was about opioid analgesic overdose death.  And that's more difficult to study because some states don't record the specific drugs involved in the overdoses very well.  So we can't do the same kind of correlation for an individual type of drug. 

TOM SKINNER:  Next question, Calvin? 

OPERATOR:  Next question comes from Maggie Fox with NBC News.  Your line is open. 

MAGGIE FOX:  I'm interested in knowing what you can do to educate doctors more in the states where it looks like they're overprescribing some of these painkillers. 

TOM FRIEDEN:  One thing is that states have sometimes joined together across the state to come up with statewide prescribing guidelines.  For example, Washington State did this.  And I think this was very helpful for doctors as a way of having guidelines that they can point to and learn from.  It's also really important to you, the prescription drug monitor programs, because that can provide feedback to doctors that may indicate that their prescribing pattern is inconsistent with that of their colleagues.  So that can be quite helpful.  Dr. Paulozzi? 

LEN PAULOZZI:  Yes. Len Paulozzi again, some states have actually -- an increasing number of them are now requiring physicians to check the state prescription drugs monitoring programs before they prescribe these type drugs. 

MAGGIE FOX:  So are you suggesting legislation to require this, because it does vary so much by state?  And do you actually think that's a realistic thing to hope for? 

TOM FRIEDEN:  One thing that we want to see is more effective prescription drug monitoring programs and rigorous evaluation of what works in these.  The states of Kentucky and New York have in the past year or so implemented mandatory checks.  That's one thing we're looking forward to seeing the evaluation of.  But ultimately we want to empower physicians with more information.  We want them to have information about both the guidelines and information about their patients.  There were some pilot projects done that integrated electronic health records with prescription drug monitoring programs so that the doctor didn't have to go into a different system.  And those resulted in dramatic improvements in prescribing practices.  But i think one of the key concepts is that we want to empower physicians so that they can provide safer effective care.  Fundamentally, we think among the over prescription of opioids is that tiny number of doctors who are doing this really as a way of selling drugs using their license.  And for them, legal and medical board action is appropriate.  And, in fact, Florida outlined the dramatic reduction in a number of doctors who seem to fall into that category, following their activities.  But the larger numbers are doctors who are just not fully aware of the risks of these medications and/or may not have access to other modalities of treatment such as physical therapy that play be helpful.  So it's really a question for each state to see what they can do to make as rapid progress as possible.  But what's striking is that Florida shows that policy and enforcements matter, that when you take serious action you get encouraging results.  They still have, as they would say themselves, I’m sure, too many drug overdose deaths but they've made substantial progress in a short period of time.  And if you turn to one of the graphics that we sent out with this press materials that has the title "new laws and enforcement reverse trends in oxycodone prescribing and related deaths in Florida," it's really quite striking.  Prescriptions go up, the deaths go up.  Prescriptions go down, deaths go down.  So this is something where we can make even more progress. 

MAGGIE FOX:  Thank you. 

TOM SKINNER: Next question? 

OPERATOR:  Next question comes from David Lewkowict with Fox News.  Your line is open. 

DAVID LEWKOWICT: Good afternoon, Dr. Frieden.  Thanks so much for taking this call.  I was curious how the problem of overprescribing of these opiates is impacted by the approval of the FDA by such drugs as Zohydro and MoxDuo, which increase the abuse -- potential abuse since they lack some of the safeguards for extended release, et cetera? 

TOM FRIEDEN:  This is really an FDA decision.  So we would defer the issue to them.  I would comment that there's a lot that we still have so understand about the different formulations of drugs.  And while some of the formulations make it more difficult for the drugs to be melted down and then injected, it's not entirely clear how effective that is.  I think to look at any one intervention and suggest that that’s going to resolve the problem is probably overly simplistic.  That we really do have to have a comprehensive approach that gets people involved at the state level, at the federal level, at the prescriber level and health systems level and at the patient level.  But one thing that we have heard from FDA is that they'll be looking at some of the new medications that are coming out to the market very carefully.  And if there are problems, they would take appropriate action.  I don't know, Dr. Paulozzi, if you want to say something more. 

LEONARD PAULOZZI: I would just add that Zohydro and MoxDuo weren't on the market yet at the time of the data.  We showed data through 2012 in these reports. 

DAVID LEWKOWICT: Thank you. 

TOM SKINNER: Next question, please? 

OPERATOR: Our next question comes from Kim Painter with USA Today.  Your line is open. 

KIM PAINTER: Hello.  Today's report gives prescribing numbers for 2012 nationally and state by state.  Do we have any previous comparable numbers either for the country as a whole or state by state that showed there's been this big increase over time? 

TOM FRIEDEN: Over time, we know that prescriptions have increased 400 percent in a decade, a fourfold increase.  Dr. Paulozzi, anything more to add? 

LEONARD PAULOZZI: That’s correct.  In the past, a number of our reports have shown a steady increase.  Those are based on a different data set, the DEA data.  These are the first trends we're showing for a different data source called IMS. 

TOM SKINNER: Next question, please. 

OPERATOR: David Beasley with Reuters, your line is open. 

DAVID BEASLEY: Yes, do you have any idea how much of this is recreational use of these painkillers?  That has absolutely no link to any kind of medical issue?  And also are these drugs being resold on the market, on the black market. 

TOM FRIEDEN: Dr. Paulozzi, I’ll let you start and I may make additional comments.  

LEONARD PAULOZZI: Thank you.  We don't really have a quantitative sense of how much of this volume might be non-medical use, as it's called.  We know there are millions of people in the United States, however, who regularly report non-medical use in the past month of these classes of drugs.  So it's probably a substantial portion.  But we can't quantify it. 

TOM SKINNER: Next question, please? 

OPERATOR: Our next --

TOM FRIEDEN: I would just reiterate that many of those people who are using -- without a medical indication may have started using because they had a health problem that was treated with a prescription opiate and then they became addicted. 

OPERATOR: Our next question comes from Dan Childs.  Your line is open.  With ABC News. 

DAN CHILDS: Thank you very much for taking my question.  Just a quick question.  How many states are there still in the U.S. that are like how Florida once was, with regard to the regulatory environment towards opioids?  And sort of a related question, if there are states out there that already have these programs that really keep an eye on how many opioids are prescribed, how can we really improve on top of that rather than focusing just on the prescribers? 

TOM FRIEDEN: Well, as we indicate in the report, the number of states with painkiller laws increased from three in 2010 to 11 in 2013.  There are other states that have laws that address some parts of the pill mill or pain clinic law legislation.  But I think that there are programs at the state level that can make a really big difference.  One of them is prescription drug monitoring programs, which are actively monitored and capture all patients in real time.  Those programs can identify doctors and patients who need further intervention.  And each of those kind of fall into two groups -- doctors, that tiny group using their medical license to sell drugs and need enforcement action.  And the larger group may not have a full sense of the risks and benefits of prescription opiates.  Similarly with patients, there may be a large number of people who are addicted or who don't know how dangerous the medications are and may need treatment or services, and a small number of patients who may be using their insurance to get and sell drugs.  That is one effective action at the state level.  Another are what are called patient review and restriction programs, sometimes called lock-in programs, where if there is a patient who has problematic prescribing, then what the insurer or Medicaid program can do is say, well, from now on for any opiates or other drugs of dangerous classes, that patient needs to go just to this one doctor and just to this one pharmacy.  And that greatly reduces the risk of further problems. 

DAN CHILDS: Thank you. 

TOM SKINNER: Next question, Calvin? 

OPERATOR: Our next question comes from Nadia Kounang with CNN. 

NADIA KOUNANG: Hi, thanks so much for taking my question.  I wonder, in the example of Florida that you point out because obviously there's been a decrease in the use of pain pills, has there -- and I don't know if there is a quantitative measure for this -- but has there been an increase in other therapies like physical therapy or other therapies to target pain management?  Do we also know in terms of pain from the patient perspective in a state like Florida where there's been a decrease in the use of pain pills, is pain management being met or maybe perhaps this issue in Florida showed that this is really probably a larger issue of abuse versus actual pain needs from patients? 

TOM FRIEDEN: We don't have all of the information on that.  We do know that even at the decreased rate, Florida’s use is far above the national average.  So though we don't have the evidence that might suggest that pain is being inadequately managed there, that is something that could be a topic for a future investigation.  Dr. Paulozzi? 

LEONARD PAULOZZI: Well, we don't have data on use of other ways to treat pain.  But there is a pattern in Florida where we see much greater declines in the overdose deaths than we see in the decline of the use of the drugs.  And that suggests that a lot of the decline is coming because the people who are more likely to die from an overdose are no longer using as many of these medications.  So it suggests that we're having a major impact on the population that is at greatest risk and lesser impact on the other parts of the population. 

TOM SKINNER: Next question, Calvin? 

OPERATOR: Our next question comes from Dennis Thompson with Health Day. Your line is open. 

DENNIS THOMPSON: Good morning.  I'm wondering if the federal government doesn't also have a role to play in prescription monitoring.  I'm thinking about docs who operate in a state like New York who most of their patients may live in Connecticut or neighboring states and they're unable to track the prescriptions in those states because they don't have access to the state level database. 

TOM FRIEDEN: Actually, there's been good progress on many states, particularly states in regions sharing information across the prescription monitoring programs.  And while it's not national or universal or real time yet, it's much further along than it was.  Most states are now connected in some way or other.  Dr. Paulozzi, can you say more about that? 

LEONARD PAULOZZI: Yes, I would agree there's an accelerating trend towards interoperability is what they call it when the states share data.  Some of them share already with their neighbors and that's rapidly increasing. 

DENNIS THOMPSON: Thank you. 

TOM SKINNER: Next question, Calvin? 

OPERATOR: Our next question comes from John Tozzi with Bloomberg Business Week. 

JOHN TOZZI: I wonder if you can characterize the national trend to compare what happened in Florida since 2010.  I don't believe we've seen the data on opioid overdose deaths in the past two or three years.  Nationally, do the numbers just sort of keep going up along the trend line that you see in Florida prior to 2010? 

TOM FRIEDEN: We're just finalizing the 2011 data because of a glitch in some of the data systems and the 2011 data will be out in September.  Dr. Paulozzi, do you want to say anything? 

LEONARD PAULOZZI: It does appear that between 2010 and 2011 we have only a very small increase nationally in the rate of deaths involving these opioid pain relievers.  So it's hard to know whether that stabilization or even the decline occurred in 2012 or 2013.  But it is a hopeful indication. 

JOHN TOZZI: What we're saying is we don't quite know whether the trend you identified in Florida might be sort of echoed in other states or nationally. 

TOM FRIEDEN: We think it's very unlikely that we see anything like this kind of large increase elsewhere.  I would say.  Dr. Paulozzi, do you agree with that? 

LEONARD PAULOZZI: I do.  Several states have put out reports; some of them have reported declines in the past five years.  Most of those states have seen their rates start to go back up.  Or have in some cases seen prescriptions go down but no change in the total number of drug overdose deaths. 

TOM FRIEDEN: The last point is one I’d like to address for a minute because it's a very important point.  In at least one other state we saw a decrease but it was counterbalanced by an increase in heroin deaths, almost completely.  And we don't know that that's causal because we're seeing an increase in heroin deaths in many states, including states that have decreased prescription opioid deaths or use or increased it or where it hasn't changed.  But what's striking about Florida is that although heroin deaths did increase somewhat, they're at a much, much lower level.  And that increase in heroin deaths was less than a tenth of the decrease in other deaths.  So Florida is important for several reasons.  Florida's experience is important for several reasons.  First, that it shows that there was a real decline in not just prescription opiate deaths but all drug overdose deaths, including illicit drugs.  And secondly, they have a strong information system.  So we have information there that we may not have in other places, which may or may not be seeing progress but which, to your knowledge, has not been documented. 

TOM SKINNER: Next question, Calvin? 

OPERATOR: Our next question comes from Lynn Arditi with The Providence Journal. 

LYNN ARDITI: Hi, thank you.  First of all, do you have a state-by-state ranking somewhere on your website of how states rank in terms of overprescribing?  And my second question is, to what extent in some states has heroin overridden the overdose, what you were just talking about -- in Rhode Island, we've had a huge increase in heroin death spikes in the last six months.  So I’m wondering to what extent has that sort of driven the overdose deaths where even as painkiller-related deaths have dropped.

TOM FRIEDEN:  I’ll take the second of those questions on heroin and then ask Dr. Paulozzi to take the first on state rankings and add anything he would like on heroin.  The heroin problem is serious and we see it getting worse in many parts of the country.  Overall, prescription opiates continue to kill more than twice as many people as heroin and cocaine combined.  So it's important to keep them in perspective.  And also as I mentioned earlier in the call, some recent studies suggest that three out of four people who are on heroin started on prescription opiates.  So in some ways, it's a single epidemic.  And there will be some common treatments and some things that should be done specifically.  But we know there's effective action that can be taken, first to improve prescribing, second to provide treatment for people who are addicted -- and that includes methadone or drug-free approaches -- and third to provide greater access to Naloxone for overdose reversal, among other programs. So I think, as I said earlier, though we are seeing an increase in heroin use, it is not clear that that is a result of tightening up prescription opiate use.  We've heard from parts of the country where both are going up or one is going down and the other is going up.  What we have heard is that money matters and heroin in some parts of the country has been getting less expensive and more accessible.  And that's obviously a huge problem.  Dr. Paulozzi? 

LEONARD PAULOZZI: I would just add that I think the heroin problem is really a problem of the last few years.  And, again, we only have national mortality data through 2011.  It showed a heroin increase but we really don't know what's happened nationally there.  And we look forward to seeing more years of national data come out soon.  The other question was about the ranking of the states.  And this report, this MMWR released today has those ranks included in the first table in the report. 

TOM SKINNER: Next question, please? 

OPERATOR:  Our next question comes from Francie Diep with Popular Science. Your line is open. 

FRANCIE DIEP: Hi, thank you.  Could you tell me more about what studies or evidence is out there that relates prescription rates with abuse rates? 

TOM FRIEDEN: Dr. Paulozzi? 

LEONARD PAULOZZI: Well, there's a variety of different kinds of evidence.  First we see correlations between the trends in both, abuse going up, as prescribing is going up.  We've also talked about the overdose rates being correlated with -- geographically with places where there are higher prescription rates.  And then there are a lot of other studies done on individuals rather than on whole states which show that the rates of abuse are greater when people are -- have larger numbers of prescriptions, get prescriptions from larger numbers of prescribers and are taking higher daily doses with respect to these opioid painkillers.  So there's a variety of different kinds of evidence that associate use of prescriptions and abuse. 

TOM SKINNER: Calvin, we'll take one more question and then we'll have Dr.  Frieden conclude our call. 

OPERATOR: Our last question comes from Abby Hagledge with The Daily Beast. Your line is open. 

ABBY HAGLEDGE: Hi, thank you for allowing me to ask a question.  I'm wondering if this class of drugs -- this is sort of from 30,000 feet question.  If this class of drugs is having such a negative and deadly effect on our population, why aren't we looking for alternate drug therapy options?  And specifically, cannabis I know has been shown to be effective in treating chronic pain.  In your education of these physicians on the danger of opioids, are you recommending that they try any of these alternate drug therapies? 

TOM FRIEDEN: There’s active research on medications that would alleviate pain without having the risk of either addiction or suppressing respirations and resulting in death.  So far, that has not yet yielded new products on the market that are proven to do this.  So that concludes the questions.  If I could just wrap up with a simple summary here.  We've released two pieces of data here, two new articles.  One shows a remarkable variability in state-to-state prescribing of prescription painkillers. And that variability suggests to us that there's a lot of overprescribing going on.  And that's been related -- that overall over time, the increase in prescription opiate prescribing has been tightly correlated with the increase in deaths from prescription opiates and with the number of people who are addicted and seeking treatment.  On a more positive note, Florida today is reporting with us a dramatic reduction in opiate overdose deaths after state policy changes that show really substantial declines in prescribing and associate them with substantial declines in deaths.  I think this really is the key message for today, that this is an epidemic that was largely caused by poor prescribing practices and that can be, at least in significant part, reversed by improving prescribing practices.  So thank you all very much for joining us today. 

TOM SKINNER: Thank you all.  Thanks, Calvin, for joining us today.  Reporters having additional questions or needing additional information can call the CDC press office at 404-639-3286.  Or they may visit the CDC vital signs web page at www.CDC.gov/vitalsigns.  Thank you all once again for participating in this call. 

OPERATOR: That concludes today's conference.  You may disconnect at this time.  Thank you for your participation. 

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES