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CDC Telebriefing on Deaths from Prescription Painkiller Overdoses Rise Sharply Among Women

Tuesday, July 02, 2013 at 12 p.m. ET

CDC Telebriefing on CDC Vital Signs: Prescription Painkiller Epidemic Among Women
Tuesday, July 2, 2013 at Noon ET

OPERATOR: I would like to remind all parties the call is being recorded. If you have any objections, please disconnect at this time and I would like to turn the call over to Tom Skinner, thank you, you may begin.

TOM SKINNER: Thanks for joining us today for the release of another CDC vital signs report. This report on overdoses of prescription opioid pain relievers and other drugs among women in United States, 1999 to 2010. We're joined by the director of the CDC, TOM FRIEDEN who will provide opening remarks and we'll be joined by Dr. Chris Jones, a health scientist here at CDC and Dr. Karin Mack, a behavioral scientist at CDC, who will help out with questions, if necessary. Dr. Frieden.

TOM FRIEDEN: Good morning thanks for joining us. Each month we focus on a specific issue of critical health importance to the country and what we can do to address this. This month we're focusing on one of the very few things in our health status getting worse and getting worse quickly. That's the growing problem of prescription drug overdoses and this month we're focusing on women. Prescription drug overdose deaths have skyrocketed in women. Mothers, wives, sisters and daughters are dying from overdoses at rates that we have never seen before. We are also seeing not only deaths but a great increase in the number of emergency department visits for drug misuse or drug abuse, including opiate overdose or misuse. These are troubling numbers, when i look across all of the different health problems we track at CDC, there are very few getting worse and even fewer affecting so many different parts of the population and age groups of population. The increase in opiate overdoses and deaths is directly proportional to the increase in prescribing of painkillers, opioids are increasing to an extent that we would not have anticipated and that could not possibly be clinically indicated. These are dangerous medications and they should be reserved for situations like severe cancer pain where they can provide extremely important and essential palliation. In many other situations, the risks far outweigh the benefits. Prescribing an opiate may be condemning a patient to lifelong addiction and life threatening complications. While men are more likely to die of a prescription opioid overdose, the gap between men and women have been narrowing.

In other words, unfortunately women are catching up in this regard. Since 1999, the percentage of deaths has been greater or percentage increase in deaths has been greater for women, 400 percent and men 265 percent. And the prescription opioid problem affects women in different way than it affects men. Women are more likely to have chronic pain to be prescribed painkillers and other medications and be given higher doses and use them for longer time periods than men. In addition, it may be that this is because some of the most common forms of pain are more prevalent among women, more likely to have abdominal pain and migraine and muscular skeletal pain than men are. And women have particular challenges with prescription opioids. First off because on average women weigh less at the same dose and may be more likely to have adverse events from opioids. And second, women of childbearing age if they are taking opiates and become pregnant, the infant may be born opioid addicted and higher risk of having heart malformations there's a lot we can do about it. More than five times as many women died from prescription painkiller overdoses in 2010 compared to 1999 and more than 6,600 women die from a prescription opioid overdose each year, that is more than twice the number who die from cervical cancer. And there were more than 200,000 emergency room department visits for misuse among women, one every three minutes. Contrary to what we expect, this is not just a problem among young women. The death rate was the highest ages 45 to 54 among all women.

There is good news, there's things we can do to protect women and reduce the burden of prescription opiates, first is to ensure all health care providers women recognize can be at risk for prescription painkiller overdose, it's not just a problem among men, which is how many think of it currently. Health care providers can talk with patients about the risks and benefits of taking prescription painkillers and follow guidelines for responsible opioid painkiller prescribing such as screening and monitoring for substance abuse and mental health problems and prescription drug monitoring programs to identify patients who may be improperly using prescription painkillers. For their part, states can improve and implement prescription drug monitoring programs. These are programs that track when prescriptions are made so if a patient is going to two doctors across the street from each other, the second one can find out that it's happened. These programs are just really getting up and running in many states and they need to do more -- states need to do more to ensure the programs are real time and complete and actively managed so that we identify patients and doctors who need either services to provide drug treatment for patients or information that escapes for doctors or if there's illegal activity going on. States can increase access to substance abuse treatment, including getting immediate treatment help for anyone pregnant and on opiates, women do so much to keep their families healthy but they also need to do things to keep themselves healthy. If you're prescribed prescription pain medicine, use it only as directed as a health care provider and discuss pregnancy plans with your health care provider before taking prescription painkillers and store prescription drugs in a secure place and dispose of them properly. It's important not to keep prescription medications around the house just in case and never share prescription drugs with anyone else.

 The bottom line here is that prescription opioid deaths among women have skyrocketed in the past decade. Stopping the epidemic is everyone's business and can be done. Places like Washington State have driven opioid deaths down by more than 20 percent in just a couple of years. There are important steps that need to be taken at many different levels and CDC is here to support those efforts. Together I'm confident we can reduce the risk of overdose among women and men while making sure that patients who have severe cancer pain and other indications that are clear for opioid painkillers have access to save and effective pain treatment. Thanks and I'll now turn it over for questions.

TOM SKINNER: Thanks Dr. Frieden, we're ready for questions please.

OPERATOR: Thank you, if you would like to ask a question, please press star one. You'll be prompted to record your name and record your name clearly when prompted. Once again, if you would like to ask a question, please press star one. The first question today is from Jonathan Serrie from Fox News.

JONATHAN SERRIE: Thanks for taking my question. Dr. Frieden, you indicated that doctors are prescribing prescription painkillers at higher rates than before. Is this because there are more drugs on the market or more patients needing painkillers? What's driving the trend?

TOM FRIEDEN: I don't think there's any evidence of a big increase in need for prescription opiates, we need to better understand the risks and benefits of these medications. They are dangerous medications. Patients given just a single course may become addicted for life. So I think there's been a trend in the medical profession and we need to work to reverse that trend. I can tell you when I went to medical school, the one thing they told me about pain was if you give a patient in pain an opiate painkiller they will not become addicted and that was completely wrong. We have a real need to better understand and ensure we use these only when necessary. Dr. Jones, would you like to say anything more?

CHRISTOPER JONES: This is Chris Jones. I would add that I think there's been a large push to treat pain and as Dr. Frieden said, not a lot of information around what are the best ways to do that. I think opioids have a place in the treatment of pain. Our goal and work with partners is to make sure they are being used in the right patients and right quantities and right dose.

TOM SKINNER: Next question, please.

OPERATOR: The next question is from Dan Childs, from ABC news.

DAN CHILDS: Thank you for taking our question. One thing that we wanted to check with because you mentioned that women tend to get higher doses than men and this is one of the underlying reasons for the problem. Why exactly would women be getting higher doses of these medications? Are there any underlying problems that would lead to this?

TOM FRIEDEN: We know that women are more likely to have chronic pain. But why women are receiving higher doses when in fact they should be on average receiving lower doses is something we don't fully understand. And this is one of the things that we'd like to work with health care providers to educate more about.

DAN CHILDS: Thank you.

TOM SKINNER: Next question, please.

OPERATOR: Thank you, our next question is from Lisa Girion from L.A. Times.

LISA GIRION: Hi, Dr. Frieden. I had a couple of questions about your comment about what kind of pain should be treated with opioid painkillers. You said that the amount of narcotic painkillers that are being prescribed right now can't be clinically justified. I wanted to know what you base that on.  And I wanted to understand a little bit more about the types of pain that you're saying these drugs should be used for.

TOM FRIEDEN: We've seen a fivefold or more than fivefold increase in prescriptions in the past 10 to 20 years and nothing like that in terms of the conditions that would be clear indications for painkillers. So for opiate painkillers. In addition we know many people have become addicted because of the large numbers of the prescriptions being written and the large numbers of people who have been treated with the prescription painkillers. In fact, today, there are more people dying and going to the emergency department from prescription opiates than from heroin and cocaine combined. There's nothing in the epidemiology of pain addictions in our society that suggests that there's anything like this increase in painful conditions or this kind of a gap between the need for palliative pain relief in situations like chronic cancer pain or severe, acute pain that cannot be controlled by other means that would justify that kind of an increase in prescription opiate use. Dr. Jones, do you want to say anything more on this question?

CHRISTOPER JONES: I think just to add a little bit more information about the particular types of pain. Certainly as Dr. Frieden said cancer related or palliative care, opioids certainly have a role to play there. I think part of what we see is other conditions like fibromyalgia, migraines, other specific types of conditions that may be more common among women, opioids are often used in those settings yet guidelines and other studies looking at the effectively of opioids in those conditions really doesn't support their widespread use.

LISA GIRION: Okay, can I ask a follow-up?

TOM FRIEDEN: Yes.

LISA GIRION: I hear you saying severe pain and palliative care and cancer pain. I'm not hearing you say chronic moderate pain. Are you -- am I right in hearing you're not saying that? You're not saying that on purpose? Do you think the drugs should be reserved for severe pain?

TOM FRIEDEN: In the data that we have reviewed we've not seen there's a clear indication of these drugs for other conditions. What we really want to emphasize the risk and benefit. These are risky drugs and there are often other medications and other therapies like physical therapy, exercise, cognitive therapies, that can be really very important in addressing chronic pain.

TOM SKINNER: Next question, please.

OPERATOR: Thank you. Our next question is from Nadia Kounang from CNN. Nadia, your line is open. Please check your mute feature. We'll move onto the next question. The next question is from Patti Neighmord from NPR.

PATTI NEIGHMORD: Thank you for taking this question. Dr. Frieden, you mentioned Washington State and i just -- what they did to try to manage this problem a little more. Can you elaborate on what they did and was it Washington State? Was I hearing correctly?

TOM FRIEDEN: That was correct. Washington State worked with prescribers and insurers and worked with their worker compensation program and they got a consensus on how treatment should be used, when prescription opiates should be used and what alternative treatments are and what resources were for patients who were addicted. They then enforced those guidelines through regulation and saw I believe 23 percent reduction in opioid deaths in just about three years.

PATTI NEIGHMORD: And were there any penalties if there were problems?

TOM FRIEDEN: Dr. Jones?

CHRISTOPHER JONES: What they did was they had voluntary prescription guidelines issued in 2007 and updated in 2010 and then moved to rule in 2012. They are just now beginning more of the enforcement phase of that but essentially the rules state that positions or other prescribers have to take certain steps when treating patients for chronic non-cancer pain, especially around higher doses of opioids. They are still working through the process of how that would be enforced but again, they even with their voluntary comprehensive approach to addressing the issue, that I have seen success in the last several years.

PATTI NEIGHMORD:  Can I ask a quick follow-up?

DR. CHRISTOPHER JONES: Yes, go ahead.

PATTI NEIGHMORD: What is it though now? I know there's the triplicate form, isn't that part of the effort to manage prescription painkillers nationwide? I mean I know, is this beyond that or --

TOM FRIEDEN: There are various forms of trying to ensure that prescriptions are tracked and tracked appropriately and that fraudulent prescriptions are found. We think probably the most promising approach is to maximize prescription drug monitoring programs or PDMPs and these can be done very effectively by mandating registration and use by all prescribers, by requiring that non –pharmacist providers who dispense from their office also report to the PDMP and implement real time data reporting and access so doctors can look at what's happening and make sure they are not inadvertently giving too much medication and providing reports on high risk providers and patients to the appropriate providers, regulatory boards and law enforcement agencies and certain circumstances and to establish interstate sharing. Because there are state to state challenges as well as integration of the PDMPs with electronic health records. So, there are a lot of things we think will make a big difference with a prescription drug monitoring programs and that we think probably has more promise than some of the other things we've been looking at. Dr. Jones?

CHRISTOPHER JONES: I would say that I think that the triplicate forms are still used in some states and there's some evidence to suggest that those states that use triplicate forms have lower overdose death rates compared to states who didn't. But I think there's something to what Dr. Frieden said, the PDMP and moving towards the electronic prescribing those types of things, may have sort of a lesser need to use triplicate forms and coming in to replace that. But again, it's getting that information in real time to the right people who are making the prescribing decisions.

TOM SKINNER: Next question, please.

OPERATOR: Once again we'll go back to Nadia Kounang, from CNN. Ma'am your line is open.

NADIA KOUNANG: Thank you so much. Sorry about that earlier. I was wondering in the data you reviewed was there any indication of which opioids perhaps were prescribed more frequently amongst women or was there any sense in terms of specificity on those prescription drugs?

TOM FRIEDEN: I didn't hear the question so I'll ask Dr. Jones if he heard it to respond.

CHRISTOPHER JONES: Yes, so this is Chris Jones. So the overdose data from the National Vital Statistics System, we don't have the ability to look at particular opioids other than methadone and we did not do that for this analysis. In the emergency department data there is the ability to look at particular opioids not particular formulations but you can look at things like hydrocodone and oxycodone, and those are the two primary drugs associated with misuse or emergency department visits both among men and women.

NADIA KOUNANG:  Thank you.

TOM SKINNER:  Next question, please.

OPERATOR:  Our next question is from Timothy Martin from Wall Street Journal.

TIMOTHY MARTIN: Thanks for taking my call and questions. I have two questions. Can you go into the underlying reasons behind the description and percentage of suicides involving drug overdoses between men and women? And, my second question, can you go into the reasons behind why minority women have higher rates than white women? Thank you.

TOM FRIEDEN:  I'll answer the first of those and ask Dr. Jones to answer the second. First off, it's important to be clear that the overwhelming majority of these overdose deaths are unintentional. They are not suicides. So more than 70 percent of the deaths among women were unintentional deaths and only about 12 percent were intentional or suicidal. Men are more likely to use a gun to kill themselves and women are more likely to use pills but still, the vast majority of these deaths are not suicides. They are unintentional overdoses. Dr. Jones?

CHRISTOPHER JONES: Sure I would just add that overall, the suicide rates between men and women are comparable but as Dr. Frieden said, the means of accomplishing the suicide may be different between men and women and as stated in our information, 34 percent of the suicides among women were drug related compared to 8 percent among men. As far as your question on race ethnicity, we didn't break that down by intent. What we typically see, especially with prescription drugs and opioids, the Non-Hispanic, white or the white population and American Indian and Alaskan native populations have the highest overdose death rates, which is consistent among males as well. And that's consistent among the many other morbidity measures of prescription drug overdose and abuse such as treatment admission or emergency department visits.

TOM SKINNER: Next question, please.

OPERATOR: Our next question is from David Sell from Philadelphia Inquirer.

DAVID SELL: Thank you for taking the call. The question about pharmaceutical company marketing. Can you attribute any of the increase and what you would describe as the problem to the prevalence of pharmaceutical advertising, whether it be TV or other forms of marketing?

TOM FRIEDEN: I think there's already been a legal settlement with one of the companies that has made a large payment because of misleading or inaccurate marketing directly to physicians. So clearly marketing is part of the reason why we've seen this increase. Dr. Jones may want to comment further and at this point I'm going to have to step off the line so Dr. Jones will answer the remaining questions. Dr. Jones?

CHRISTOPHER JONES: I think that we have to look at all ways that people are provided education around the appropriate use of these medications and figure out what are the best means to make sure people are getting accurate information.

DAVID SELL: Okay, just to follow-up, accuracy, unfortunately sometimes accuracy gets lost in translation. Sometimes the volume of advertising can have an effect. Do you think that's part of the problem?

CHRISTOPHER JONES: For this particular analysis we didn't look at it so I think it would be difficult for us to try to draw conclusions there.

TOM SKINNER:  Next question, please.

OPERATOR: Next question is from Carmen Foreman from The Oklahoman.

CARMEN FOREMAN: Hi, being from Oklahoma, one of the states with the highest rates of abuse, I'm curious, did you find similarities in states with the highest drug overdose death rate?

CHRISTOPHER JONES: We generally see a trend that states that have higher sales or higher nonmedical use rates have the highest rates of drug overdose deaths but for this particular analysis, we didn't really look at that. We just looked at the variation between states and overdose deaths and again, as you can see in our material, there is a pretty wide variation in different state drug overdose death rates.

CARMEN FOREMAN: Okay.

TOM SKINNER:  next question, please.

OPERATOR: our next question is from Judy Foreman from WBUR.

JUDY FOREMAN: Thank you for taking my question. I have a number of questions. In terms of the addiction rate of the government's own figures are 3 to 25 percent rate of addiction but in people with no prior history of alcohol or substance abuse, it's about 3 percent. So it's—I think it's lower than the public and CDC seems to believe. I heard no mention of the recent Institute of Medicine Report saying 100 million Americans are in pain -- chronic pain and a number of those are in severe pain. And you mentioned the state of Washington but i didn't hear any mention of the Pulitzer Prize winning series from the state of Washington showing that the policy of switching people from sort of standard opioids to methadone resulted in a vast increase in deaths among poor people. And I know you mentioned prescription monitoring programs but there's a CDC's own study a couple of years ago showed that these prescription monitoring programs did not reduce overdose and death. And lastly, if I have the right numbers in mind, in 2010, CDC reported 60 thousand I think 651 deaths from opioid overdoses but rarely does it get mentioned that only 29 percent of those were opioids alone. The rest were benzodiazepines and alcohol and other things in addition. My guess the bottom line question is, is this a political statement CDC is making based on information from the group called PROP and is it really an accurate portrayal of the opioid problem in this country?

CHRISTOPHER JONES:  This particular Vital Signs again, we wanted to focus in on women and I think we're representing the data we have an we've analyzed here at CDC. I agree with the comment that certainly the combination of medications is something that is certainly from a clinical perspective needs to be monitored and addressed. As we've noted in our materials, opioids and benzenoids are often prescribed in combination together. We do think it is important that clinicians be aware of that and monitor for checking Prescription Drug Monitoring Programs for the combination of products that may increase risks. One thing that I would say is that generally about 50 percent of all overdose deaths involve at least one other identified drug. As you correctly stated in our JAMA research letter from February, about 30 percent of the overdose deaths actually involved no other drug. Again, alcohol involved in roughly less than 25 percent of the overdose deaths. So again, we're singling out opioids because that's where we see the greatest increase in overdose deaths but we don't want to diminish the impact that combinations of other CNS active drugs may have, especially in women who are more likely to be described opioids and benzodiazepines.

OPERATOR:  Our next question is from Stacy Singer from The Palm Beach Post in Florida.

STACY SINGER: Hi thanks for taking my call. I guess I want to ask you a question from sort of a consumer perspective. We keep seeing these horrendous and alarming numbers about the impact of oxycontin and oxycodone. I can't think of any other drug that would have a safety profile like this allowed to stay on the market. I don't really understand why this is still on the market. I know you're not the FDA. But how is the CDC working with the FDA when it gets data like this or are you guys not talking to each other because that's how it looks here in the states.

CHRISTOPHER JONES:  We routinely work with the FDA to understand the health implications for both substance abuse, drug overdose deaths, as well as pain. And we provide information like our Vital Signs which can help FDA and other people make appropriate regulatory decisions and really trying to strike the balance of appropriate pain management and appropriate interventions to reduce drug overdose deaths.

TOM SKINNER:  We have time for a few more questions, please.

OPERATOR:  As a reminder, to ask a question, please press star one. Our next question is from Misty Crane from the Columbus Dispatch.

MISTY CRANE: Thank you, I was just curious, to what degree do you think lack of insurance coverage is contributing to pain patients not getting referrals for the nonmedical treatments that were mentioned, cognitive therapy, exercise, physical therapy?

CHRISTOPHER JONES:  I think that is certainly an important issue and CDC in our Grand Rounds we did on prescription drug overdose in early 2011, we specifically brought up insurance coverage as an issue that needed to be explored to make sure that people are not being prescribed a cheap drug like methadone simply because that's the most efficient cost -- lowest cost approach to treating a person's pain and that all options should be available and should be provided because the evidence for other types of alternative treatment such as physical therapy or cognitive behavioral therapy show benefit for people in pain. We think it is appropriate a full list of comprehensive services be offered so that people can have appropriate pain management.

MISTY CRANE: Thank you.

TOM SKINNER: One more question, please.

OPERATOR:  Our final question today is from Michelle Merrill, Hospital Employee Health Newsletter.

MICHELLE MERRILL: Hi, thank you so much for taking my question. Dr. Frieden noted that the highest rate of overdose deaths was among women ages 44 to 54. And we kind of tend to think of drug abuse problems being among younger people. I was just wondering what, if you have a theory as to why older women in particular would have a problem? I mean is it a result of more pain and as a secondary question, I'm also wondering if you've done any research relating occupationally related pain and you know, the workers comp system or whatever, to opioid prescriptions?

CHRISTOPHER JONES:  I think there are multiple factors as to why the highest overdose death rates would be seen in the 45 to 54-year-old age group. Part of that is these would be people who have lived a life that potentially would have chronic conditions where they would be more likely to be treated with opioids. I think that it's possible they may have been on opioids for longer so they are receiving higher doses or are receiving them on a more chronic nature. So again, there's evidence to support that would increase the risk. When you look at the emergency department data you see it skew a little bit younger. Do you do see the younger folks 18 to 34-year-olds having emergency department visits, but really it's pretty comparable rates among both the 25 to 34 year olds all the way to the 45 to 54 year olds. I think there are a number of factors at play. What's interesting is that in the data we looked at for the deaths, the largest increases over the time period 1999 to 2010 were seen in the 45 to 54-year-old age group and the 55 and 64-year-old age group, which I think is consistent with the general trend that during the same time the opioid analgesics were the primary driver of the increase. I think there's a connection with the types of pain and types of treatment that age group might be receiving.

MICHELLE MERRILL: What about occupationally related pain? Any information on that that would connect with --

CHRISTOPHER JONES:  We do see -- we didn't do anything specific for this analysis, but many researchers within the worker's comp group have looked at this and there are many issues around work related injuries where people are receiving opioid for an acute injury and end up being on opioids for some time later and having higher rates of overdose deaths in that group. So there are people like Gary Franklin who have looked extensively among opioid prescribing in workers comp, I would suggest that would be a further resource to delve into.

TOM SKINNER:  Okay this concludes our call, thanks to everyone to join us. A transcript of this call will be available on CDC media relations web page later this afternoon. And should individuals have follow-up questions or need additional information, they can call the CDC press office at 404-639-3286. Thanks once again for joining us.

OPERATOR: Thank you, this does conclude today's conference, you may disconnect at this time. 

 

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