CDC’s Role in the Federal Approach to Opioid Overdose Prevention

May 1, 2015

Witness: Dr. Debra Houry

Testimony - House Energy and Commerce Committee, Subcommittee on Oversight and Investigations

Chairman Murphy, Ranking Member DeGette, I would like to thank you for inviting me here today to discuss this very important issue. I’d like to also thank the committee for your continued interest in the prevention of opioid abuse and overdose. My name is Dr. Debra Houry and I am the Director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention (CDC). The activities related to the prevention of prescription drug overdose at the agency are under my leadership. As a trained emergency room physician, I have seen firsthand the devastating impact of opioid addiction on individuals and their families. Other centers at CDC are also working to address the many health impacts of this unprecedented epidemic. As I testify today, CDC staff are in southern Indiana to help stem a large HIV outbreak caused by injection drug use of prescription opioids. The outbreak is only the most recent manifestation of a deadly epidemic unfolding in states and communities across the country.

Deaths from drug overdoses have been rising steadily over the past two decades and have become the leading cause of injury death in the United States¹. This growth in drug overdose deaths consists in large part of a quadrupling in the number of deaths involving prescription opioid pain relievers. As the nation's health protection agency, CDC has applied public health principles to identify the connection between inappropriate opioid prescribing and overdose deaths. The prescription drug overdose epidemic is driven in large part by fundamental changes in the way healthcare providers prescribe opioid pain relievers: 259 million prescriptions were written for opioids in 2012², enough for every American adult to have his or her own bottle of pills. As the amount of opioids prescribed has increased, so has the number of overdose deaths.

CDC is working to reverse the prescription drug overdose epidemic by focusing on three areas that are central to CDC’s mission and complement the work of our sister agencies who join me here today. The first is to protect the public’s health by tracking overdose and prescribing trends and by improving the quality of the data collected. These data can be used to identify those at highest risk and to target interventions. The second is to strengthen state efforts by helping states to scale up effective strategies to combat the epidemic. The third is to supply healthcare providers with the data, tools, and guidance needed to improve patient safety, including through appropriate prescribing of opioids. This approach leverages CDC’s unique scientific and programmatic expertise. Our activities are conducted in coordination with other Federal agencies and departments, are aligned with the Department’s initiative to address opioid-drug related overdose, death, and dependence, and would be expanded by the critical investments in combating opioid abuse and overdose that the President included in his Fiscal Year 2016 Budget.

This initiative focuses on three broader priority areas—improving opioid prescribing practices, expanding use of naloxone, and increasing access to medication-assisted treatment. I want to highlight CDC’s central role in the first of these priority areas by focusing on two activities at CDC that are key pieces of this initiative—developing evidence-informed opioid prescribing guidelines for chronic pain and providing direct support to states to implement robust, multi-sector prevention programs.

CDC’s Opioid Prescribing Guidelines for Chronic Pain

CDC is developing guidelines for the prescribing of opioids for chronic pain outside of the end-of-life care setting. This undertaking is responsive to a critical need in the field. There is a lack of high-quality guidelines on opioid prescribing³. And among those that do exist, many have key limitations, in that they may be outdated and fail to account for the most recent evidence about risks related to dosage or technological advances (such as the enhancement of prescription drug monitoring programs).

CDC’s guidelines will include input from national experts, be responsive to the most recent scientific evidence, and will proceed through a development process carefully tailored to minimize any risk of conflicts of interest. These new guidelines will articulate best practices around opioid prescribing for chronic pain and make important advances in protecting patients. The audience for these guidelines is primary care practitioners, who account for the greatest number of opioid prescriptions compared to other specialties. Primary evidence informing the guideline development comes from the Agency for Healthcare Research and Quality’s 2014 systematic review on The Effectiveness and Risks of Long-term Opioid Treatment of Chronic Pain⁴. This review rigorously addressed the effectiveness of long-term opioid therapy for outcomes related to pain, function, and quality of life and the harms and adverse events associated with opioids.

The process of developing these guidelines is comprehensive and CDC is working diligently to publish the guidelines next year. Informing the process is an expert panel comprised of individuals carefully vetted as subject matter experts, representatives of key primary care specialties, and representatives of state agencies that have developed opioid prescribing guidelines with broad stakeholder input. Our federal partners, many of whom join me on the panel here today, will also be engaged and will be able to provide input on the process. Our goal is to share draft guidelines for public comment by the end of this year.

While release of the guidelines will be an important contribution, of equal importance is the need to widely disseminate and encourage uptake and usage of the guidelines among providers. In addition to development of the guidelines themselves, CDC also is planning activities to promote wide dissemination and to encourage use among providers following their release. CDC is developing a plan to leverage existing partnerships, federal and otherwise, to promote uptake of the guidelines.

CDC’s Direct Support to States to Prevent Prescription Drug Overdose

The second key activity I want to highlight today is our major investment in state-level prevention.

States are at the front lines of this epidemic and CDC is committed to equipping them with the resources and expertise they need to reverse the epidemic and protect their residents, families, and communities. The most impactful state-level approaches to date have tackled the epidemic on multiple fronts—promoting effective Prescription Drug Monitoring Programs, or PDMPs; leveraging the states’ role as a healthcare payer to improve patient safety; and engaging hard-hit communities to focus efforts where the epidemic is the most severe. At CDC, we have seen the effectiveness of this multi-front, multi-sector approach and made it the foundation of our state prevention programs.

In March, we published a new funding opportunity called Prescription Drug Overdose: Prevention for States. This program is funded through the $20 million newly appropriated to CDC in FY 2015 and builds upon existing CDC-funded state programs that address the epidemic. The new Prevention for States program targets states that have a high drug overdose burden and that demonstrate readiness needed to respond to the epidemic. It requires collaboration across sectors, including public health, law enforcement, and substance abuse services agencies, for a truly comprehensive response. Funded states will advance prevention on multiple fronts—including making PDMPs more timely, easier to use, and able to communicate with the PDMPs of other states; implementing interventions that can be integrated within state Medicaid or Worker’s Compensation programs to protect patients at risk; and bringing data-driven prevention to the communities struggling with the highest rates of drug abuse and overdose. Critically, states also will be given the flexibility to use the program to respond to emerging crises and evaluate existing interventions so they know what works best to reduce overdoses and save lives.

This year, CDC will fund approximately 16 states with awards of up to a million dollars per year over the next four years. The President’s FY 2016 Budget proposes a major expansion of this program. The proposed $48 million increase for the new Prevention for States program would ensure CDC’s state-level investment in prevention can reach all 50 states and Washington, D.C. for a truly national response to the epidemic. This funding will also help CDC better understand the role and impact of naloxone in preventing overdose deaths. Of the proposed $48 million increase for FY 2016, $3 million is allocated to apply CDC’s evaluation expertise to assess the impact of a major SAMHSA naloxone initiative to promote more widespread use of this life-saving drug. We will also continue to support SAMHSA’s leading role in advancing access to medication-assisted treatment, for instance, by analyzing gaps between demand for opioid abuse treatment and treatment availability.

In addition to the work we are doing on the prescription drug overdose epidemic, we are examining the increase in heroin use and overdose. Heroin overdose deaths have more than doubled since 2010⁵ and prescription opioid abuse, a key risk factor for heroin use, has contributed significantly to this rise in heroin use and overdose. People who use prescription opioids non-medically—that is, without a prescription or for the feeling the drug causes—are at an increased risk for heroin use. Among new heroin users, approximately three out of four report having abused prescription opioids prior to using heroin.⁶ In addition, data show that people reporting past-year nonmedical use of opioids were 19 times more likely to initiate heroin use than people who did not report past-year nonmedical use of opioids.⁷ There were an estimated 11 million people who used prescription opioids non-medically in 2011⁸. While most people who use prescription opioids nonmedically do not go on to use heroin, the small percentage (about four percent) who do account for a majority of people recently initiating heroin use.⁹

More research is needed to better understand the characteristics of people who use heroin after abusing prescription opioids. CDC will continue our work in addressing heroin overdoses by leveraging our scientific expertise to improve public health surveillance of heroin and evaluate effective strategies to prevent future heroin overdoses. For instance, under our new Prevention for States program, states may use funds to evaluate the impact of state policies on heroin overdose rates and track heroin outcomes in their state. In addition, as part of the President’s FY 2016 Budget, $6 million would be used to collect near real-time emergency department data as well to explore the most economic and efficient way to collect heroin overdose data. The FY 2016 Budget request also includes an increase of $5.0 million for Health Statistics to expand electronic death reporting to provide faster, better quality data on deaths of public health importance, including Prescription Drug Overdose deaths. These efforts to improve the timeliness of jurisdiction reporting and to modernize the national vital statistics infrastructure are contributing to developing a system capable of supporting near real-time surveillance.

In conclusion, prescription drug abuse and overdose is a serious public health issue in the United States. The burden of prescription drug abuse and overdose affects not only individuals and families, but also communities, employers, the healthcare system, and public and private insurers. Addressing this complex problem requires a multi-faceted approach and collaboration between public health, clinical medicine, and public safety at the Federal, state, and local levels. But, it can be accomplished—particularly with the ongoing efforts of all of the entities represented here on this panel and the new investments proposed in the President’s Budget. CDC is committed to tracking and understanding the epidemic, supporting states working on the front lines of this crisis, and providing healthcare providers with the data, tools, and guidance they need to ensure safe patient care.

Thank you again for the opportunity to be here with you today and for your continued support of our work in protecting the public’s health. I look forward to your questions.