Transcript : Vital Signs Opioid Prescription Changes

Press Briefing Transcript

Friday, July 7, 2017

• Audio Recording [MP3 – 6 MB]

OPERATOR: Welcome and thank you for standing by. All participants will be able to listen only during the conference. To ask a question press star one. The conference is being recorded if you have objections please disconnect at this time I will turnover now. You may begin.

KATHY HARBEN: Thank you, this is Kathy Harben. I’m Chief of CDC’s News Media Branch. Thank you for joining us for the release of the new CDC vital signs, this one on trends and opioid prescribing and how the amount of opioids prescribed to patients varies widely from county to county in the United States. We’re joined today by CDC’s acting director Dr. Anne Schuchat. We also have Dr. Deborah Dowell, she’s one of the authors of the study and she’ll join during the question and answer period. I will now turn it over to Dr. Schuchat.

ANNE SCHUCHAT: Thank you Kathy and thanks everyone for joining today’s call to discuss CDC’s vital signs report. Each month we focus on the latest data on one of the critical health issues facing our nation and what can be done about it. This month we are looking at the opioid prescribing trends at the county level and across the nation. To start with some good news, half of U.S. counties saw decrease in the amount of opioids prescribed per person from 2010 to 2015. Overall, opioid prescribing in the United States is down 18% since 2010. We measure prescribing in morphine milligram equivalence or MME, we saw a drop from 782 MME’s per person in 2010 to 640 MME’s per person in 2015. But despite these overall declines, the bottom line remains we still have too many people getting opioid prescriptions for too many days at too high a dose. The amount of opioids prescribed in 2015, was still about three times as high as in 1999, and we see tremendous variation between counties. Opioid prescribing varies as much from place to place as the weather. Even neighboring counties could have a major difference in prescribing levels. In 2015, six times more opioid per resident were dispensed in the highest-prescribing counties than in the lowest prescribing counties. Higher prescribing practices place residents in these counties at greater risks of opioid addiction, overdose and death. In addition, the dramatic increases we’ve been seeing in heroin overdose is another tragic consequence of exposing too many people to prescription opioids since most people who use heroin started off misusing prescription opioids. We are now experiencing the highest drug overdose death rates ever recorded in the United States driven by prescription opioids and by illicit opioids like heroin and illicitly manufactured fentanyl. In today’s report among many significant factors we saw higher opioid prescribing in counties with small cities or towns, had a greater percentage of white residents. Were where a higher concentration of primary care physicians or dentists work or where more people were uninsured or unemployed and where more people had diabetes, arthritis or disability. But these factors together only explained about a third of the wide variation of opioid prescribing across the U.S. in 2015. The finding suggests we need more consistency among health care providers on the appropriate use of opioids. The 2016 CDC guideline for prescribing opioids for chronic pain offers providers recommendations to improve opioid prescribing practices. We can think of the high opioid prescribing in three parts: one part of the problem is that too many opioid prescriptions are being written. In 2015, there were 71 opioid prescriptions for every 100 people in America.  Non-opioid therapy is preferred for chronic pain treatment, excluding cancer treatment, palliative or end of life care.  Some options of non-opioid therapy include pain medicines like acetaminophen, ibuprofen and naproxen, physical therapy and exercise, cognitive behavioral therapy. Another part of the problem is that opioid prescriptions are given for too many days. Anyone taking opioids can become addicted to them. After taken them for just a few days a person becomes more likely to take them long term. Taking even a low dose opioid for more than three months, increases the risk of addiction by 15 times .the average day supplied per prescription increased 33% from 13 days to nearly 18 days from 2006 to 2015. Finally, too high a dose is the third aspect of high prescribing. A dose of 50 MME or more per day doubles the risk of opioid overdose death compared to 20 MME or less per day. At 90 MME or more the risk increases ten times. Average daily MME prescription remained steady from 2006 to 2010 and went down 17 percent from 2010 until 2015. But the average remains high. High doses of opioid have not been shown to reduce chronic pain better than low doses. Health care providers have an important role in offering safer and more effective treatment to patients. As a doctor, I’m familiar with the complexities of pain management and how important is to have an ongoing and individualized dialogue with each patient and I’ve been a witness to the very real and devastating impact opioid addiction can have on individuals, families, and communities. As a public health leader, I see the value of data to guide efforts and the importance of consumer and provider education the data we’re releasing today show that we have more work to do to protect Americans from the risk of opioid addiction, overdose and death. What can be done to curb this epidemic? The findings from today’s vital signs provide trends in opioid prescribers and different factors. But no region is exempt. Look at the range of prescribing practices across the country and even with our own states or counties can give insight on where we can make the largest strides in improving care. Everyone has a role to play to help address this issue and become part of the solution from health care providers who can follow the CDC guidelines on appropriate prescribing for chronic pain to consumers who can take medicines as directed and store them safely. To state and local public health who can improve the usability of prescription drug monitoring programs and track hot spots where overdoses are occurring. Community coalitions like ones i met with last week in Kentucky, can give voice to these challenges and help us fill the urgent need to work together toward solutions. The bottom line here is simple – with opioid medications, we’re still seeing too many getting too much for too long. The amount of opioids prescribed in 2015 was enough for every American to be medicated around the clock for three weeks. The opioid overdose epidemic didn’t arise overnight and we won’t be able to resolve it overnight. But changes in annual prescribing from 2006 to 2015 hold promise that prescribing practices can improve. The 2016 CDC guideline’s release was a vital step toward this end. Its recommendations can be used to ensure appropriate use of prescription opioids and improve care for all people. Thank you and let me return to the operator.

KATHY HARBEN: Okay. Thank you we’re now ready for questions.

OPERATOR: Thank you. If you would like to ask a question please press star one. You’ll be prompted to give your name and company name. To withdraw your request press star 2. One moment please. Our first question comes from Dennis Thompson with Health Day. Your line is open.

DENNIS THOMPSON: Thank you for taking my question Dr. Schuchat. You said county by county there’s a lot of variation are there any particular regions of the United States where prescription opioids seem to be more freely prescribed than others?

ANNE SCHUCHAT: We have been tracking geographic trend both in the prescribing and the overdose problems, and the Appalachian region has been really hard hit. They’ve taken that to heart and are really, have quite a few programs trying to address this but in our map of today’s data for 2015 we still see the Appalachian area hard-hit. I think a key issue is no part of the country is spared. We see within every state, some high-prescribing counties. There’s parts of the western U.S. that have very high prescribing and parts of the mid-west as well. And so we know that today there are very few towns, cities or even families that don’t have some connection with the opioid problem and we think there’s a lot more we can do working together.

OPERATOR: Our next question is from Heidi Splete with Internal Medicine News. Your line is open.

HEIDI SPLETE: Hi. Thank you for doing the conference and for taking my call. I realize this was breaking down the data mainly by county but do you have any data by condition or by clinical specialty for this particular report?

ANNE SCHUCHAT: Not in today’s analysis. We really looked at the characteristics of the counties. Counties that have a higher prevalence with diabetes, or arthritis or disabilities have higher rates of prescribing, and that makes sense in terms of those conditions directly or indirectly being associated with greater pain issues, but this was an epidemiology analysis not an individual analysis. We know internist and other primary care physicians prescribe large proportions of the opioids in the country and it’s important for the internal medicine audience to be aware of the guidelines for better prescribing and some of the tools that we’ve made available. We have a checklist that people can download I’m told 25,000 downloads of that checklist for safer prescribing have occurred. We also have a mobile app and quite a few thousand downloads of the mobile app have been made, so we really encourage clinicians to look for the new guidelines and some of the tools to make it easier to implement in your practice.

OPERATOR: Okay. Thank you so much. Our next question comes from Sarah Karlin-Smith smith from politico. Your line is open.

SARAH KARLIN-SMITH: Hi, you mentioned in your talk that there were a number of factors associated higher opioid prescribing counties, can you give a better sense of what’s correlated or whether there’s any causation. You mentioned where there’s more people uninsured or unemployed, more primary care physicians or dentists, it’s just hard to get a sense of which of those factors may really be driving prescribing and how it is effecting the dynamics here.

ANNE SCHUCHAT: Yes, the factors likely are important but only explain about one-third of all of the variation. So we think the most important point about the county level analysis is how wide that variation is. A six-fold difference for high-prescribing and low-prescribing counties and we could not explain two-thirds of the difference other than more accessibility to doctors to give opioids or more people with those conditions that may require pain medication. I think there’s probably some nuances about each of the factors whether directly or indirectly linked with greater pain use at the individual level but the key point here is clinical practice is really all over the place. Which is usually a sign that you need better standards. These data are from 2015 before CDC released the guideline for prescribing opioids for chronic pain and we hope the 2016 guidelines are a turning point in more consistent and safer prescribing.

SARAH KARLIN-SMITH: One quick follow up when would you expect to see if those 2016 guidelines make a deference, how many years down the line do you think?

ANNE SCHUCHAT: You know it could take a while to change practices but I think there’s some heartening news in today’s report. We saw a reduction in high-dose prescribing starting in 2010 and in 2009 and 2010 two guidelines came out warning about very high dose prescribing and it was heartening to see as quickly as 2011 and 2012 we started to see an improvement in that very high dose prescribing. That said, clinicians are very used to how they’ve been practicing and it helps to have reinforcements like prescription drug monitoring programs you can look up whether a person already got an opioid before you describe them or academic detailing that can help visit office practice and enforce best ways to manage pain. We are optimistic that some changes might occur quickly but we have so much room for improvement that we think it will take time. The other important point, is that changing prescribing can help prevent people from getting addicted but there’s a very large population of people that are already addicted to opioid medications or to elicit drugs and we know that it’s important for there to be better access to treatment to help them with that addiction as well as broader availability to naloxone to help reverse overdoses that may occur.

SARAH KARLIN-SMITH: Thank you so much.

OPERATOR: The next question comes from Rich Lord with the Pittsburgh Post-Gazette. Your line is open.

RICH LORD: In the vital signs piece you singled out Kentucky, Ohio, Florida as taking vigorous approaches and seeing reductions in most counties can you describe the strength of the correlation between prescribing patterns and state-level prescribing regulations and tell us which regulatory measures seem to correlate best to reductions and finally whether they’ve been taken universally by the states.

ANNE SCHUCHAT: You know, one thing to say about Kentucky, Ohio, and Florida was they had extremely high levels of prescribing. The situation in Florida was quite different because instead of picking up your prescription from the pharmacy they had physicians directly providing the opioid so their state bill doesn’t allow the practice anymore to require providers to put their prescriptions into a drug monitoring program, had a pretty rapid effect. There is good data including a meta analysis in health affairs which talks about the relationship between mandated prescription drug monitoring use and the effect on prescribing as well as pain clinic regulations have had an effect so there’s good data on several state policies, there’s also emerging data about innovative interventions like internet-based physical therapy or internet-based behavioral therapy as potentially safer approaches to pain management even in places with limited access to onsite care.

RICH LORD: Are there things states have not yet done that seem to work or has everybody pretty much adopted the best practices nationally.

ANNE SCHUCHAT: There’s quite a bit more room for improvement. I believe Kentucky, Ohio, and Florida were some of the earliest states to put in place policies but we’re seeing statewide policies in more states and there’s more to do. Even in states with policies, the prescription drug-monitoring program themselves can become more useful or usable for clinicians. When I visited Kentucky I learned about interstate access to data so clinicians could look up not only prescribing from clinicians within their state but states bordering other states they worked out agreements with neighboring states. I would say there’s incremental improvements in places ahead of the curve getting the policies in place. This epidemic is bigger than all of us so those best practices that we identified in Kentucky or Florida we’re trying to make sure to share. CDC has been supporting more than 40 states to strengthen their prevention of prescription drug opioid programs and we’re now supporting a number of states in tackling the illicit drug problem as well. We know we all need to work together.

RICH LORD: Thank you.

OPERATOR: Next question from Dan Vergano with Buzzfeed news, your line is open.

DAN VERGANO: Thanks very much. How much caution should we have about reporting 2015 statistics a year and half later your guidelines came out last year and they probably did effect practice so are we giving people an inaccurate snapshot by recording this now, is there any way to get more up-to-date information.

ANNE SCHUCHAT: Timely and complete data is very important. I think a number of innovative approaches are being used to get more recent data. The analysis that we reported today we view as a baseline, pre-guidelines. And we look forward to analyzing data for 2017 and beyond to see what kind of impact the 2016 guidelines have had. We know that some programs insurers and others are looking at their own data to see what kind of effect has happened. I’ve seen a report from Cigna about their own covered patients and a decline in prescribing that they’ve seen since the 2016 guidelines came out. But we look forward to updating this report with more timely information following the guideline report. It’s barely a year since the release and we know the tools we’ve released to make it more accessible to people are still coming out. We are also looking forward to releasing some public service announcements later this year that we hope will reach consumers and help drive down demand for opioids for chronic pain since they really seem to have an excessive harm-to-benefit ratio. Next question.

OPERATOR: Comes from Justin Mattingly Bloomberg news your line is open.

JUSTIN MATTINGLY: Thanks for taking my call. I wonder if you could speak to how much so many opioids being given out has put a strain on hospitals and medical centers that are then treating the overdoses.

ANNE SCHUCHAT: You know, the challenge for emergency departments and for hospitals as well as the limited availability of treatment facilities or treatment access is a huge challenge. You know, as we’ve looked at prescribing practices by type of clinicians, one of the earliest groups we saw improvements in as I’m told was in emergency department clinicians because those probably are the people who have been seeing the negative effects of opioids up close. I know we’ve seen spot shortages of the naloxone, the drug that reverses overdoses in some areas. You’ve seen reports of the medical examiners and coroner’s offices and they don’t have space to store the bodies. This is just a tragic outbreak in so many levels. Improvements in prescribing are beginning but we have so much more work to do.

OPERATOR: Thank you. Your next question from Mike Stobbe from the Associated Press your line is open.

MIKE STOBBE: Hi thank you for taking my call. The question i logged in with has been answered but i do want to ask one other which is, is there data available at the county level also on the number of providers in each county that were prescribing opioids. Maybe some pill mills were shut down, a geographic shift from one county to another, is there any more data available on that that could help explain some of the trends in the county?

ANNE SCHUCHAT: Well let me begin and see if Dr. Dowell wants to add anything. you know Florida took a pretty tough stand against the pill mills with the state wide regulation that went into effect. If you look at the MMWR at counties that saw improvements from 2010 to 2015 it’s fairly impressive how much improvement there was throughout the state of Florida. It’s actually the most decreased state that you can find. Although there’s still some high-prescribing counties they did have quite a big impact, but in terms of the subtleties of ability for us to look at pill mills or shifting practices I will let Dr. Dowell respond.

DEBORAH DOWELL: Yes, for this analysis we didn’t have provider and patient level data to look at specifics who exactly was prescribing in each county but we did use other data sources such as the number of primary care providers and dentists per capita from Dartmouth Atlas’s healthcare to try to get a handle on some of the factors but in this particular analysis we were not able to get to those factors at a granular level.

ANNE SCHUCHAT: One of the things we encourage for health plans or other programs that have access to different providers in their system, academic detailing or feedback to clinicians about their practices compared to others can be helpful. We found that helpful for antibiotic use prescribing and we think that kind of approach may be helpful for this as well. As Dr. Dowell described, this particular database didn’t allow for that kind of analysis. Next question.

OPERATOR: Your next call comes from J.T. Lain with AZ News. Your line is open.

 J.T. LAIN: Hi good afternoon. The Arizona governor recently declared state emergency over the opioid epidemic. How do you see Arizona affected and do you know any particular county with high number of prescription?

ANNE SCHUCHAT: For the county level data on Arizona, if you follow up with our media office they will get you all the specifics for that. That may be the best way to go. For all of the reporters, if you contact our media office we can get you the data of county-specific results. We know for the local and state papers those are really important and we encourage authorities and communities and the health departments to use those data as spot maps before the 2016 guidelines of how prescribing was spread across the state. I should caution people the county is where the prescription was picked up – basically the pharmacy – not where the person lived. People in rural areas have higher risk of opioid-related overdose than other areas and we didn’t find rural counties associated with high prescribing in this analysis. That’s probably because of lack of pharmacies in rural areas and people who reside in rural areas may be traveling to larger towns or small cities near them. So there’s some cautions around the county maps but we’re happy to make those data available to each of you.

OPERATOR: Our next question comes from Don Saptkin from the Philadelphia Inquirer. Your line is open.

DON SAPTKIN: Didn’t get a link or a file, should I have gotten something?”

ANNE SCHUCHAT: About the county level data?

DON SAPTKIN: or even something broader?

ANNE SCHUCHAT: They’ll be giving out the phone number for that at the end of the call, but yes, you should be able…you may not have gotten it yet, unless you already asked for it, but we are happy to provide to those who are interested.

DON SAPTKIN: Thank you.

ANNE SCHUCHAT: I think we have time for one more question…

OPERATOR: Your last question from Lynne Peterson with Trends in Medicine. Your line is open.

LYNNE PETERSON: Hi. I have a combination question. Let me throw them all out and you can answer them in order however you want. Are there particular opioids that stand out as a problem? Is my first question. And is there any break down between overdose deaths between heroin and prescription opioids and lastly, do you see any impact of abuse of current opioids.

ANNE SCHUCHAT: What’s the last one?

LYNNE PETERSON: Do you see any impact from abuse to current opioids.

ANNE SCHUCHAT: Okay let me try to do these quickly and let Dr. Dowell help. The break down – Let me do your second question first. In 2015 overall, there were about 52,000 deaths from drug overdose. Almost two-thirds or 33,000 of them had an opioid involved, 15,000 involved a prescription opioid and the others were either elicit opioid or potentially some of those that were not counted as opioid-associated probably had opioids, but the drugs were not specified. We know there’s a lot of overlap between prescription and elicit opioids on board and between opioids and other drugs on board. There are challenges in the toxicology testing and back logs in the testing as well as the final results from some of the coroners and medical examiner’s offices. In terms of prescription medicines and which ones stood out. I’ll let Dr. Dowell handle that and the deterrent drug question.

DEBORAH DOWELL: Sure. So in this analysis we didn’t present results on individual opioids but we did look at a number of different individual opioids just to make sure that what we were seeing was not a result of any one of them in particular and what we found was that the patterns we’re describing seem to hold true, the changes from 2010 to 2015 across the whole range of opioids. We do know from other studies in the past, that long-acting opioids seem to be associated with greater overdose risk especially when first started and particularly methadone seems to be associated with higher overdose risk but we didn’t report that with this particular analysis. In terms of the impact of abuse to current opioids we didn’t present this in the findings with this report but we did attempt to look at that. Again, we didn’t see anything in particular related to abuse deterrent use opioids and the research in this field in general there’s very little evidence about the impact of abuse to current opioids on risk like opioid use disorder and overdose. I should clarify, because even clinicians tend to misunderstand this, a lot of people think that use of deterrent means this formulation somehow prevents addiction and that is not true. They just prevent manipulation of the opioid to use it for like an injection that is not intended and people can and still do develop opioid use disorder and overdose orally and we think that orally is the main route for both opioid use disorder and for overdose and overdose deaths.

ANNE SCHUCHAT: I want to thank everybody for calling in to today’s report. Before
I turn things back to Kathy, I want to remind folks that the story here is that we’re seeing too many get too much for too long, in terms of opioid medications. We have three times as high use of opioid today in America as in 1999 and nearly four times as high as Europe and we’re really seeing the toll on the families and neighborhoods around the country. Thanks for calling in. Kathy will share how to follow up.

KATHY HARBEN: Sure. Thank you Dr. Schuchat and Dr. Dowell for joining us today. Also thank you to the reporters who have joined us. If you would like the data behind the map in the MMWR, call 404-639-3286. You can also e-mail us at media@cdc.gov. Thank you again for joining us. This concludes our call.