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Examining the Growing Problems of Prescription Drug and Heroin Abuse

April 29, 2014

Witness: Daniel Sosin, MD, MPH, FACP

Testimony - Testimony before the House Energy and Commerce Subcommittee on Oversight and Investigations

Good morning Chairman Murphy, Ranking Member DeGette and Members of the Subcommittee.  Thank you for the opportunity to testify before you today about the public health issues related to prescription drug overdoses and CDC’s role in the prevention of these overdoses.

My name is Dr. Daniel Sosin, and I am the Acting Director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention(CDC).  In this role, I am responsible for the leadership and implementation of CDC’s programs that prevent violence and injuries and reduce their consequences.  It is a pleasure to be with you today to talk about CDC’s approach to the prevention of prescription drug overdoses-a national epidemic.  We are at an important moment for this public health challenge.  As you will hear today, we know more now than ever before about the burden and who is at risk for prescription drug overdose.  However, there is still much to learn to be able to completely address this epidemic.  My testimony reviews the nature of the epidemic, how preventing prescription drug overdoses has the potential to prevent some heroin overdoses, and CDC’s unique contribution to addressing this public health crisis.

The National Prescription Drug Overdose Epidemic

Drug overdose death rates have climbed sharply and steadily over the past decade and are higher now than they have ever been.  Drug overdose death rates have climbed throughout the country, with some states like New Mexico, West Virginia and Kentucky being among the hardest hit.1

Increases in prescribing opioidpain relievers – drugs like oxycodone, hydrocodone, methadone and fentanyl – are driving the dramatic increase in overdose deaths over the last decade.  Opioid pain reliever overdose deaths have quadrupled since 1999.2  CDC has declared the problem of prescription drug abuse a public health epidemic and addressing it remains a key priority for the Agency.

The prescription drug overdose epidemic is driven by fundamental changes in the way healthcare providers prescribe opioid pain relievers.  Beginning in the 1990s, providers started prescribing more opioid pain relievers in an effort to address what was, at that time, perceived to be a widespread problem of undertreated pain.  As opioid pain reliever prescribing increased, overdose deaths increased simultaneously.3 Today, the supply of opioid pain relievers is larger than ever.4

As the nation's health protection agency, CDC has worked to identify the clear connection between increased inappropriate opioid prescribing and overdose deaths. Certainly, the Agency recognizes and supports the appropriate use of opioid pain relievers as a useful tool for clinicians in controlling certain types of pain, such as pain related to cancer diagnoses.  But, we are concerned with and are working to address the inappropriate prescribing of these drugs-such as when they are prescribed at doses or for durations not clinically-indicated, in combination with other contraindicated drugs like sedative-hypnotics, or for conditions for which other remedies may be indicated.

In addition to the clear human toll of opioid abuse, it also is a tremendous strain on our country’s healthcare system. One study estimated that people who abuse opioids generate over eight times the annual health care costs compared to people who do not abuse these drugs.5

Prescription Opioid Abuse and Dependence Still Greater than Heroin Abuse and Dependence

One of the reasons we are gathered here today is our shared concern over reports that heroin use and overdoses are increasing.  This is true; the number of persons meeting criteria for heroin abuse or dependence more than doubled from 2007 to 2012.6,7  Some states, cities, and counties from across the country have reported recent increases in heroin-related deaths, including Maryland, Kentucky, and New York City. This increase in deaths is alarming.  However, opioid abuse/dependence is still approximately four times greater than heroin abuse/dependence.  In 2012, more than two million people reported opioid abuse/dependence-approximately the population of Houston-compared to about 467,000 people reporting heroin use.8

For CDC, preventing prescription opioid abuse and misuse will help prevent some cases of heroin abuse.  For example, some studies of people who use heroin show that many times prescription opioid abuse precedes heroin use.  CDC’s analysis has found that more than three out of four people who reported both past-year opioid abuse and heroin use said they used opioids non-medically-that is, without a prescription or for the feeling or experience the drugs cause-prior to heroin initiation.9  In addition, more than seven out of ten people who reported past-year heroin use also reported using opioids non-medically in the past year.10 From 2002 to 2011, first-time heroin use was 19 times higher among those reporting prior nonmedical opioid use than among those who did not report using opioids non-medically.11  In short, research suggests that a small portion of people, less than four percent of past year non-medically prescription opioid initiates, began using heroin within five years of prescription opioid initiation.

These findings suggest the need for additional strategies to reduce inappropriate opioid prescribing and use so that there are fewer people who become addicted. Reducing inappropriate opioid prescribing is one of the necessary approaches to prevent people from becoming addicted to opioids and keep them from later transitioning to heroin.

CDC Efforts to Reverse the Prescription Drug Overdose Epidemic

CDC is working to reverse the prescription drug overdose epidemic by focusing on three areas that are both central to the CDC mission and complementary to the work of our sister agencies like the Substance Abuse and Mental Health Services Administration, the Food and Drug Administration, the National Institute on Drug Abuse, the Department of Justice, and the Office of National Drug Control Policy.  The first area of focus is on protecting the public’s health by improving data quality and tracking trends to monitor actionable changes in the epidemic, including promoting the use of prescription drug monitoring program data for safer prescribing.  Prescription drug monitoring programs, or PDMPs, are a promising tool to directly help prescribers reduce unwarranted prescribing.  They also will allow CDC and states to better understand more quickly what populations are being prescribed these drugs to inform where and how to implement prevention strategies.  The second area of focus is strengthening state efforts by scaling up effective public health interventions. Through our technical assistance and direct funding to be awarded later this year, CDC is helping states implement tailored, state-specific prevention strategies and evaluate their own policies and programs aimed at addressing the epidemic.  Third, we are focused on improving patient safety by supplying health care providers with data, tools, and guidance for evidence-based decision making that improves population health, for instance by identifying effective insurer mechanisms for preventing over-prescribing of opioids. One example includes Patient Review and Restriction Programs(PRRs) where insurers direct patients whose claims are flagged for potential overutilization or abuse (such as a single patient receiving opioid prescriptions from multiple prescribers and/or pharmacies) to a single provider, pharmacy, or both.  In 2012, CDC convened expert representatives from state Medicaid agencies, managed care organizations, and private insurers to share experiences using PRRs as one method to prevent prescription drug abuse, diversion and overdose.

In addition, the Fiscal Year2015 President’s Budget includes $15.6 million in new funding to expand CDC’s Core Violence and Injury Prevention Program (VIPP) to include additional states with high burdens of prescription drug overdose. The increased investment will equip more states to prevent injuries and violence, with the requirement that, each state that is funded  selecting prescription drug overdose as one of the state's four injury-prevention focus areas. Sixteen of the currently-funded States through the Core VIPP have prioritized prescription drug overdose within the State public health department.

By applying these strategies, CDC is focusing on one of the “upstream” drivers of the epidemic-that is, the prescribing behaviors that created and continue to fuel this crisis-to impact this epidemic on a national scale and break the cycle of abuse, addiction, and overdose.

Conclusion

Prescription drug abuse and overdose is a serious public health issue in the United States.  The burden of prescription drug abuse and overdose not only impacts individuals and families but 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.  CDC is committed to tracking and understanding the epidemic, supporting states working on the front lines of this crisis, and rigorously evaluating what works to prevent overdoses and save lives.

Thank you again for the opportunity to be here with you today and for your continued support of CDC’s essential public health work.

Footnotes

1 Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999--2008, Morbidity and Mortality Weekly Report, November 4, 2011.

2 QuickStats: Number of Deaths From Poisoning,* Drug Poisoning,† and Drug Poisoning Involving Opioid Analgesics - United States, 1999–2010, Morbidity and Mortality Weekly Report, March 29, 2013.

3 Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999--2008, Morbidity and Mortality Weekly Report, November 4, 2011.

4 Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999--2008, Morbidity and Mortality Weekly Report, November 4, 2011.

5 White AG, Birnbaum, HG, Mareva MN, et al. Direct Costs of Opioid Abuse in an Insured Population in the United States. J  Manag Care Pharm. 11(6):469-479. 2005.

6 Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD.

7 Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.

8 Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.

9 Jones, C.M., Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002–2004 and 2008–2010. Drug Alcohol Depend. (2013).

10 Jones, C.M., Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002–2004 and 2008–2010. Drug Alcohol Depend. (2013).

11 Muhuri PK, Gfroerer JC, Davies MC. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. SAMHSA CBHSQ Data Review. 2013 (accessed April 23, 2014).

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