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CDC Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999—2008

Tuesday, November 1, 2011 – 12:45pm ET

Operator: Welcome.  At this time, during the question and answer session today, you may press star one to ask a question. Today's conference is being recorded.  At this time, I′ll turn the call over to Mr. Tom skinner.  You may begin, sir. 

Tom Skinner: Thank you, Shirley.  And thank you, everyone, for joining us for the release of another CDC vital signs.  This one on overdoses of opioid pain relievers in the United States for the years 1999 on to 2008.  We're very pleased today to be joined by Mr. Gil Kerlikowske, Director on the Office of National Drug Control Policy.  We also have with us today the Director for the Centers for Disease Control and Prevention, Dr. Thomas Frieden.  And also with us today is health scientist from the CDC, Dr. Chris jones.  Dr. Frieden is going to provide some opening remarks, then Mr. Kerlikowske.  Then we will get to your questions.  So without fur adieu, I′ll turn it over to Dr. Frieden. 

Thomas Frieden: Good afternoon, everybody. Thanks very much for joining us. This is Dr. Frieden, director of the CDC.  The topic today is about prescription pain killer overdose and the unfortunate and, in fact, shocking news is that we are in the midst of an epidemic of prescription drug overdose in this country.  It's an epidemic, but it can be stopped.  15,000 people died from prescription drug [editor′s note: this should be painkiller] overdose last year.  That is about 40 deaths per day from prescription pain killers, also known as prescription opioids and essentially these are narcotics.  Same drug, different word for the same drug. Narcotics prescribed by physicians kill 40 people a day.  The number of deaths has increased threefold in the past decade.  And now there are more people killed by prescription narcotics than from heroin and cocaine combined. 

This reflects a huge increase in the amount of prescription narcotics prescribed by doctors every year.  In fact, enough narcotics are prescribed to give every adult in America one month of prescription narcotics.  As a result of this large number of prescriptions and there are about one out of every 20 adults who have a history of inappropriately using prescription narcotics.  This stems from a few irresponsible doctors and, in fact, now the burden of dangerous drugs is being created more by a few irresponsible doctors than by drug pushers on the street corners.  There is a fivefold difference in the rate of drug abuse deaths between different states. So state policy can make a huge difference in either controlling or allowing this epidemic to proceed.  The costs are substantial.  Not only is it 15,000 deaths a year, it's also tens of thousands of emergency department visits, hospitalizations, drug treatments and an estimated $70 billion a year in health care costs. 

Prescription pain killers are meant to help people who have severe pain.  They are, however, highly addictive.  Palliation of pain is a right and people with chronic pain such as people with cancer whose pain cannot be relieved otherwise can benefit enormously from effective pain relief.  There are specific things that can be done to drastically reduce the number of prescription overdoses, of deaths and people who become addicted.  The first is for states to rigorously monitor who is prescribing and to whom, to identify the doctors and the patients who may have inappropriate patterns of prescription or use and then to take effective action for those doctors or those patients.  One means of taking that effective action is through patient review and restriction policies which identifies problem patients or patients who have had a problem with drugs and limits them to one doctor to prescribe narcotics and one pharmacy to fill those narcotic prescriptions.  States can also take effective action to shut pill mills and reduce doctor shopping by patients.  Boards that are concerned with physician licensure can take appropriate action against physicians who have been inappropriate in providing prescription narcotics outside the bounds of reasonable medical practice.  And the health care profession can do a better job at improving their practices in prescribing, ensuring that appropriate quantities are prescribed, for example, if someone comes in with acute pain three days rather than 30 days should be the standard.  That applies to physicians, dentists and others who prescribe.  For chronic pain, narcotics should be a last resort.  There are many other effective ways of palliation of pain.  Narcotics are highly addictive.  And in emergency departments, more and more emergency department systems around the country are looking at the use of long acting narcotics and saying this may not be an appropriate thing to prescribe from the emergency department.  It's something that someone should get from their source of ongoing care.  For the individuals, it's important to know not to start using drugs inappropriately, not to help others to start and to get help to stop if you are addicted or having trouble with pain killers, narcotics or prescription opioids.  Again, bottom line, we have in the midst of an epidemic of prescription drugs overdose from opioids, prescription narcotics, this epidemic can be stopped and we're optimistic that examples from around the country show that when states get serious about prescription drug overdose, they're able to shut pill mills, they're able to reduce inappropriate prescriptions and they're able to begin turning the tide on this epidemic.  I′m delighted to be joined by director Gil Kerlikowske from the national drug control policy office.  Director Kerlikowske. 

Gil Kerlikowske: Let me thank Dr. Frieden for inviting me here to Atlanta and to the CDC today and for his commitment in raising awareness in the public health community about this challenge.  And more importantly, to raising America′s awareness because of the great credibility and trust that people in this country have for the CDC.  I also want to take a moment to commend the incredible staff here at CDC, who have worked so hard on this.  This is truly been a partnership that is going to result in turning this epidemic around.  Well, prescription drug abuse is our nation's fastest growing drug problem.  And according to my colleagues here, and you've heard Dr. Frieden call it an epidemic, and that's not a word that I or the nation's public health community use lightly.  Well, the facts as outlined by Dr. Frieden are truly devastating.  He has outlined the troubling trends in the data.  I′d like to talk for a few minutes about what we're doing together to address this challenge.  And when I talked about working together, I′m not talking about just among the federal partners.  But, really, among state and local agencies, which is where a lot of the work is getting done.  From day one, the Obama administration has been laser focused on responding to this crisis.  And the CDC couldn't be a better partner in these efforts.  Earlier this year with the help of our federal partners, it was actually in April.  The first comprehensive action plan to combat the national prescription drug abuse epidemic.  The plan provides a national framework for prescription drug aversion and reduce by supporting the expansion of the state–based prescription drug monitoring programs, recommending more convenient and environmentally responsible disposal methods to remove unused or unneeded medications from the home.  Supporting education for patients and health care providers.  And reducing the prevalence of the pill mills and the doctor shopping efforts through enforcement.  We have set a goal of reducing prescription drug abuse by 15% by 2015.  We're also working with congress to pursue legislative actions that will reduce this epidemic.  Already, the president signed into law bipartisan legislation that will make easier for communities to collect dangerous, unneeded or expired prescription drugs on their own.  And we're working closely as DEA finalizes these rules.  To build on the progress, we're working with congress on legislation that will require those who prescribe certain pain killers to receive education regarding the proper prescribing.  Let me close by saying that America′s prescription drug abuse epidemic is not a problem that's going to be solved overnight.  But at the same time, we are clearly not powerless about this.  All of us have a role to play in the most important work clearly happens at the local level.  And as we work on an aggressive federal response, I urge every parent to take time today to properly dispose of unneeded or expired medications from their homes, to take time to talk to their kids about the significant harm caused by prescription drug abuse.  And with that, I think we're turning it back to tom.  

Tom Skinner: Okay.  Shirley, I believe we're ready for questions, please. 

Operator: Thank you.  We will now begin the question and answer session.  If you would like to ask a question, please press star 137 you will be prompted to record your name.  To withdraw your quarterback, you may press star 2.  Our first question comes from Miriam Falco with CNN Medical News.  You may ask your question. 

Miriam Falco: Hi.  Thanks for taking questions.  Mr. Kerlikowske –– this isn't the first time, as you mentioned, that we've been hearing about this epidemic.  And what's even changed, if anything, since April since you made your big announcement?  There was another report that came out a couple months later.  How exactly do you get doctors to not prescribe to multiple –– or how do you coordinate so that one doctor is only prescribing these pain killers as oppose to multiple doctors and only one pharmacy dispensing this?  How is this happening in reality?  It seems like there's a lot of stuff happening in Washington, but how is it happening in the field? 

Gil Kerlikowske: Well, first, I don't think we're recommending that patients only be limited to one individual physician, nor do I think we should be in the position of saying that limiting it to a particular pharmacy.  And I think that's the beauty of the PDMP, the prescription drug monitoring programs.  We still have two states that have not passed them.  We still have a number of states that even though the law has been passed recently, and the example would be Florida in which they're not up and running.  We also have in those states, even in the states where they are up and running, physicians who are not using them as robustly as we would like to see.  And we need to make sure that we are doing everything we can to improve these PDMPs.  That will reduce the doctor shopping.  That will allow which the states have the responsibility in regulating the practice of medicine.  That will allow the states to identify potential abusers in the medical field.  And so I think what we've also seen is the drug take backs and it was recently concluded on Saturday by the drug enforcement administration.  So literally what I suspect will be, again, hundreds of thousands of pounds of unused and unneeded prescriptions.  So the problem is continuing and we're hearing a lot about it.  But to be joined at the hip today with the CDC on this issue is important for all of us.  And those are the things that I see where we're making some progress. 

Thomas Frieden: And just to fine tune that a little bit, we think there are specific instances, for example, patients who have a history of inappropriate use of prescription opioids where a patient review and restriction policies can be cost saving and lifesaving and Medicaid programs, prescription benefit managers, insurers and other payers of health care can implement those programs to both save money and save lives. 

Miriam Falco: But, Dr. Frieden, didn't –– Dr. Frieden, didn't you suggest that single physicians, single pharmacy dispensing or are you only talking about those patients who have that history? 

Thomas Frieden: For selected patients, we think that can be a very effective intervention. 

Miriam Falco: And how do you find those, then, if they're doctor shopping?  Do you find them through the health insurance companies not paying for it or how –– how do you do this in reality. 

Thomas Frieden: Through prescription drug monitoring programs, through Medicaid programs, through prescription benefits managers.  So all of these entities have data on what patients have getting, unless they're self–pay.  But most patients are billing the drugs that they're abusing to some insurance system, public or private.  So identifying through that and then limiting them for their own good as well as to save money is the right kind of policy. 

Operator: Our next question comes from Timothy Martin with Wall Street Journal.  You may ask your question. 

Timothy Martin: Hi.  Thanks for taking my call.  Can you tell me how you came to the 72.5 billion annual health care cost figure? 

Thomas Frieden: That's a figure that comes from the insurance industry.  There are several different estimates to come up with the health care costs.  You have to include a small part of it, which is the drug.  But a much larger part, which is the emergency department visit, hospitalizations, as well as drug treatment admissions and care.  Dr. Jones, anything more on that? 

Chris Jones: Sure.  That figure comes specifically from a report that came out in 2007 from the Coalition Against Insurance Fraud.  There have been two journal articles that looked at cost related to prescription opioids in the past year and they estimate close to 55 billion.  So we're in the right ballpark of capturing what we assume is the expenditure from the health care costs on this issue. 

Tom Skinner: And that last speaker was Dr. Chris jones, health scientist here at CDC.  Do you have a follow–up question?  

Timothy Martin: Yeah.  Just a housekeeping one.  So if I heard correctly, I think Dr. Frieden mentioned all but two states have PDMP programs? That's 48 of the 50 states have them for now? 

Gil Kerlikowske: This is Gil Kerlikowske, I mentioned it. Missouri and New Hampshire do not have them.  I was in New Hampshire last month.  There is legislation proposed and I met with state senators and the state representative.  They had several hundred people at an all–day prescription drug summit. 

Thomas Frieden: I would also comment that even where there are PDMPs, states are still figuring out how to use them optimally. So the state of Oklahoma, for example, is going to a real–time system so that when opioids are prescription, they're in the system within five minutes.  There are other states that are ensuring that doctors see the prescription history as automatically as possible, going to a push rather than a pull technology so that they can know easily if patients are using inappropriately.  And other states that are ensuring that pharmacists and not only physicians have access so that they can ensure that that's another window of inappropriate use to close. 

Tom Skinner: Shirley, next question, please. 

Operator: Thank you.  Next question comes from Stephanie Nano, with Associated Press.  You may ask your question. 

Stephanie Nano: Hi.  The last questioner just asked my question.  I′m sorry, was it Missouri and New Hampshire that do not have this legislation? 

Gil Kerlikowske: You are correct. 

Stephanie Nano: And are they all the same systems so that they can cross–reference over state lines or how does that work? 

Gil Kerlikowske: Well, no.  They're not all the same systems.  I think that's actually one of the important distinctions.  It's not a national program.  The states that regulate the practice of medicine are able to put into place the laws and the restrictions around patient confidentiality, privacy, etcetera.  But we do recommend that the systems be interoperable so that the physician who is –– or the physician's assistant who may be accessing it in Kentucky in where we are in Appalachia, you have West Virginia, you have Tennessee, and they don't want to –– you know, you don't want to burden them with having to make, as Dr. Frieden said, a system in which they have to pull from multiple resources.  So, you know, there's a lot of improvement and a lot of work being done from real–time to others.  But we like the beauty –– or I like the beauty, I think, of the system in which the states take responsibility and accountability for this. 

Thomas Frieden: There are a lot of differences between states.  I′ll come back to that in a moment.  But Dr. Jones may want to mention an initiative just getting under way on this. 

Chris Jones: Sure.  CDC is involved with the Office of National Drug Control Policy, the Office of the National Coordinator at HHS as well as SAMHSA in a set of pilot projects that were initiated this past summer where we're looking at incorporating prescription drug monitoring program data into real–time practice.  And we believe that they will help set up best practices to address some of the differences between the states.  But it will also make it where within the physician's daily practice and within the pharmacists and the emergency department, the information is right there at their hand.  This he don't have to go to a separate database to access the information.  We think by incorporating it into their normal work flow we'll greatly incorporate the use of the data. 

Thomas Frieden: And there's a five–fold difference in drug abuse deaths between the lowest and the highest states.  And it's –– if you look at the map, it's quite striking.  West Virginia is the second highest in the country at 25.8 opioid deaths per 100,000 population.  Right next door in Virginia, the rate is 9.1, one–third the rate just miles away.  So I think this highlights the importance of states getting policies right on prescription drug abuse. 

Tom Skinner: Next question, Shirley. 

Operator: Thank you.  Next question comes from Joette Giovinco with WVTV.  You may ask your question. 

Joette Giovinco: Thank you so much.  I′m in Tampa, Florida, so I think we are the center of this epidemic and we've seen so much over the years.  But there are a couple of questions that I have.  I′ve recently talked to a judge who does drug court.  She says law enforcement is working here, we're starting to see decreases in the number of prescription drugs that are out there but she's seen a shift to heroin use.  And I′ve been told because of the prescription drugs here, the people that are cutting to heroine have had to make it much purer because they needed to compete with them.  Now there's a concern that we're going to start seeing overdoses from heroine.  Is that on your radar screen at all there or is this just something highways happening here locally with us? 

Thomas Frieden: Yes, it is.  And I will say that from the standpoint of the Centers for Disease Control, we see the ramifications of prescription drug abuse in many, many different ways.  So ranging from infants born to mothers who are on opioids and may be at risk of congenital heart disease to infants born to mothers on opioids who are born addicted to opioid medications to increased risky driving in people who are drugged to increases in hepatitis c and potentially HIV among people who started using prescription opioids and then shifted to heroine, either because it cost less or because they needed to get stronger drugs.  And so we're seeing where we had seen, for more than a decade, steady declines in illnesses associated with injection drug use in several different parts of the country we're beginning to go hear reports of resurgences in the use of injection drug use, specifically heroin, as a continuation of the opioid crisis.  So these are serious side effects, serious implications of the epidemic of prescription opioids and another important argument for why we need to take action now. 

Gil Kerlikowske: And there are two things –– this is Gil Kerlikowske that I had mentioned on the heroine.  Anecdotally across the country, I′m hearing a lot of that same message that people that either because of the cost of those prescription opioids or because of the fact that availability is being restricted, that they're turning to heroine.  The other part is that it is really cd credibly dangerous about is that young people don't have that awareness about, one, prescription drugs, but then, two, they have a belief and I′ve heard this again anecdotally, that if they just inhale or smoke the heroine, that they won't, in fact, become addicted to that.  And, of course, it doesn't turn out to be that much longer before they're actually injecting heroine. 

Joette Giovinco: If I may, I have one more question.  I was an occupational medical physician, so I oversaw some of the different drug testing programs in the different industries.  Synthetic opioids, generally speaking they're not picked up and most of the drug testing in workplace communities.  Has that ever been a point of discussion, whether or not to add something like that to a panel? 

Chris Jones: This is Chris Jones.  We have seen within the Department of Defense and some other employer drug screening programs a move to include synthetic opioids, predominantly hydrocodone and oxycodone as well as some of the benzodiazepines.  The valium gateway is typically the one picked up.  To the most commonly used diazepams are not included. 

Operator: If you have a question, press star one.  Next question, Letitia Stein with St. Petersburg Times. 

Leticia Stein: Thank you so much.  You've been highlighting some of the role that states can play, but what about the federal government, which is ultimately responsible for overseeing the manufacture of some of these prescription opioids through the DEA?  What could you, working with the CDC and the administration be doing to address some of these increases that we're seeing? 

Gil Kerlikowske: I didn't catch all of the last part of the question, but let me tell you that I think the federal government's response is that particularly the White House Office of National Drug Control Policy has an incredible bully pulpit, the White House.  And so by bringing the interagency groups together to talk about this, recognizing it's not just a DEA law enforcement problem, recognizing it's not just a prescriber type of problem, we can convened a number of meetings early on.  And I′ll tell you how I came to this.  I have the job a little on it over two years.  And at the time I was being prepared for my confirmation hearing, they said, well, you know more people are dying as a result of drug overdoses, driven by prescription drugs that are dying from gunshot wounds.  And in 17 states, of course, greater than car crash deaths [editor′s note: drug–induced deaths are greater than car crash deaths in 17 states].  And I said, well, I′m a police chief and I actually pay attention to what harms people in my community.  And you know what?  I′m unaware of that.  And I said, I bet if I′m unaware, I bet there's a lot of other people unaware.  That's exactly the case.  One, we've been shouting this from the rooftops and the administration has been focused on it.  The other part is when we released the strategy, the national strategy on prescription drugs, the initial funding for these prescription drug monitoring programs is federal funding.  There is a center of excellence for the prescription drug monitoring programs where people share their best practices and what makes these things effective.  And I think in this strategy, you find a huge role and an important role for the federal government.  But so much of what will occur to make this problem less of a problem will occur at the state and local level and that's, again, part of our job.  And maybe Dr. Frieden wants to comment. 

Thomas Frieden: I′ll just say from our perspective at the CDC, we document the nature and extent and risks for the problem.  We help educate health care providers in appropriate use of pain release.  We identify and analyze best practices so that communities, localities and states can determine what path to take.  And we support state and local governments in their efforts to implement effective control measures. Obviously, many other parts of the federal government are involved, as well.  SAMHSA in the treatment aspect as well as other aspects of drug abuse policy and care.  The Drug Enforcement Administration, the Food and Drug Administration and there is a strong commitment to do what we can do to reduce this as a national problem. 

Leticia Stein: But doesn't the federal government, through the DEA, authorize how much of these drugs are produced every year so that they can reach the marketplace in the first place? 

Gil Kerlikowske: We can talk about the quota system, etcetera, but I think there's a clear understanding that just in one particular drug or one particular group of drugs, reducing the total amount that may be reduced is not going to be an effective answer to the problem.  And the reason is that we don't want to turn the clock back to see the people that are in need of these numbers not get them.  And, of course, the potential in reducing the amount of drugs available could end up resulting in people who would become addicted working the system to get them and the people that actually need them in the proper medication and under the proper supervision would not.  So it sounds like a fairly quick answer that could have –– you know, we'll just reduce the amount being produced.  But we don't really think, given the complexity of the problem, that that's an answer.  Shirley, we have time for questions from two more callers, please. 

Operator: Thank you.  Lisa Girion with the LA Times, you may ask your question. 

Lisa Girion: Hi.  I heard some talk today about the problem of these drugs and kids and, you know, cleaning out the medicine cabinets and parents talking to their kids about this problem.  And, yet, the data shows that the overdose deaths is a bigger problem among people in middle age.  Middle ages.  Can you talk about what you're doing to address that part of the problem? 

Thomas Frieden: Well, it's a wide group of society.  But as you know, the highest risk is in the middle aged population.  I think one of the risks that we're seeing is that as more people in that age group have kids, their kids are at risk.  As I mentioned earlier, we're already seeing infants born opioid addicted or opioid induced birth defects.  But the programs we're recommending would benefit all who use and potentially abuse opioid drugs by ensuring that when they're necessary, they are provided.  And when they're not necessary, they're not provided.  Right now, the system is awash in opioids, dangerous drugs that got people hooked and keep them hooked.  And by working with states, with provider organizations, with health care systems and insurers and others, we can reduce the inappropriate prescription of medications which will benefit all who are addicted or at risk of being addicted. 

Chris Jones: Yeah.  This is Chris jones.  I just wanted to add that there simple steps that are recommended in evidence–based guidelines to help identify those patients who may be at risk and understanding that the 35 to 54 age group is a group that's at risk, we believe that it's important for health care provider to screen for substance abuse or mental health history to use the prescription drug monitoring programs to determine if they're receiving drugs from other providers, to monitor when patients are on chronic opioid therapy.  And to use the quantity that's appropriate for the treatment, for the condition being treated. 

Tom Skinner: Okay.  One more question, Shirley. 

Operator: Our final question comes from Christine Moyer with American Medical News.  You may ask your question. 

Christine Moyer: Hi.  Thanks for taking my question.  You started answering at the end of your previous answer.  It seems that in some ways the epidemic puts doctors in a difficult position when they're presented with a patient who does have chronic pain, who does need pain relief, it's almost a challenge of what should I be doing now?  And you started to touch upon that in your previous answer, but can you offer physicians any other recommendations on how to handle those situations? 

Chris Jones: I think our overall goal here is to make sure if we improve how the drugs are prescribed, we can really achieve that balance of making sure that patients have access to effective pain treatment.  But also reducing the number of people who are abusing it and overdosing.  And this is Chris jones.  Sorry.  But like I –– as I was saying before, it's critical.  We know that people with a history of substance abuse disorder, even if it wasn't specific to prescription pain disorder, people who have mental health disorder are at an increased risk.  So screening that.  There are simple screening tools that physicians and other subscribers can use.  We believe if you start a patient on a small amount that seems appropriate for the condition being treated and continue to monitor that patient, you're less likely to have them end up on chronic opioid therapy.  Studies show patients who end up on opioid therapy many years later continue to be on it.  We want to make sure we're continuing to be on it. Patient provider agreements, setting the expectation for the pain treatment and understand if they're not improving in their functioning or their quality of life, it makes sense to discontinue the opioids. Those are some of the recommendations and you'll find those in our materials today.  

Thomas Frieden: I think what Dr. Jones points out is that there are a series of tools that physicians can use to maximize palliation without resorting to narcotics and that ranging from addressing mood disorders to physical therapy to pain relief that does not include narcotics, there are many things that can be done to increased patients' comfort and functionality without risking a lifetime of addiction.  I want to thank everyone for joining us today and recap that we are in the midst of an epidemic of prescription narcotic overdose.  The number of overdose deaths now is more than that of heroin and cocaine combined and that nonmedical use of prescription pain killers costs the health care system an estimated $70 billion a year.  And there are effective measures that can be taken, particularly by states where we have a huge variation in the rate of prescriptions that are provided and the right of prescription overdoses and overdose deaths.  By monitoring better, by taking appropriate action for patients and providers, by cracking down on pill mills and, doctor shopping and, doctors who are prescribing inappropriately, and by promoting good medical practice so that patients who need pain relief get it and patients who don't need narcotics don't get them by reducing the quantities prescribed, the patients for whom they're prescribed and the places that they're prescribed in.  It's possible to make a big difference and reduce this epidemic and bring it back into a controllable levels.  So thank you very much also to Mr. Kerlikowske for your participation.  We greatly value the partnership we have. And thanks to all of the staff who worked on this report for an excellent –– an important piece of research.  Thank you, Shirley.  This concludes our call. 

Operator: Thank you.  This does conclude today's conference.  We thank you for your participation.  At this time, you may disconnect your line. 

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