Responding to Prescription Drug Abuse

Operator: Welcome, and thank you for standing
by. At this time, all participants are in listen-only mode. After presentations, we
will conduct a question-and-answer session. To ask a question on the phone, you may press
*1. This conference is being recorded. If you have any objections, you may disconnect
at this time. I would now like to turn the conference over to Mr. Mike Koscinski. Sir,
you may begin. Mike Koscinski: And welcome to our webcast
on preventing prescription drug abuse. I am so glad that you could join us this afternoon or
this morning, for those of you on the West Coast. This is a very important webcast on
a very significant public health problem that is daunting our United States, and we have
been focusing on this issue for a second time. The first is a more general overview, but
this time on information that could help you, especially those of you working at the local
or state level on specific interventions on preventing prescription drug abuse. Our speaker
today is Dr. Ted Miller. He’s an economist and policy analyst at the Pacific Institute
for Research and Evaluation. He has almost 20 years of experience analyzing poisoning
prevention and control issues, and you may know him for his estimates of the cost of
underage drinking, by state, or the cost savings from substance abuse prevention programs.
He also directs SAMHSA’s Prevention Prescription Abuse in the Workplace Technical Assistance
Center. Now before we begin, I would hope that you
will ask questions. There’s a Q&A on the top there, where you can ask over the Internet, or,
if you would like, the operator will be happy to take your calls, and there will be breaks
when Dr. Miller is presenting his material for you to ask questions either way, through
the Internet or through the phone. If you’re watching this live, not on the replay but live, you
can download the slides as we speak. If you see the word “feedback,” and to the left,
there’s a yellow icon, but that’s not the one. To the left of the yellow icon, there’s a white icon.
If you touch it very gently with your mouse, you’ll see the word “handouts”;
just click on that icon “handouts,” and you’ll see the ability there to download
Dr. Miller’s slides. So without further ado, and I do hope you’ll have questions
for Dr. Miller today, I’m going to switch the program to Calverton, Maryland, and to
Dr. Miller at the Pacific Institute. Dr. Miller. Dr. Ted Miller: Thank you, Mike. Mike told
me to tell you that this is my picture over on the right here, so you know who you are
talking with, and what I’m going to do today is talk very briefly about the prescription
drug abuse problem and then talk in some depth about what we are doing, and we could be
doing, to respond to it. Prescription drug abuse is a longstanding problem. I think someone
needs to put a mute button on. You can see that from 1966 Valley of the Dolls, which
is all about Valium. Valium was a very lethal drug. There were a lot of deaths, and Burt
Reynolds asks, “Does anybody have a Valium?” and 40 people offered him their controlled
prescription substances. When we replace Valium with less-lethal drugs, deaths from poisoning
overdose went down; but with prescription pain killers, they’ve come back of late.
And what you can see here is the prescription painkiller deaths now exceed motor vehicle
traffic deaths, and the drug poisoning overdoses went up again in 2011 (we just got the numbers).
So this is a continuing problem. No wonder it’s a problem when you look at the chemical
composition of oxycodone and heroin. Look at how similar they are; and over on the ends,
they are basically the same drug and very addictive. And we see this huge surge in drug
overdose deaths and, particularly, ones with opioids. And we see a similar surge
in emergency department visits both for the prescription painkillers and for benzodiazepines and generally
for illicit drugs going up much faster than illicits. More teens can get prescription
drugs and marijuana in 1 hour, according to recent study surveys, although that difference does shrink
with age. Prescription opioids have now passed alcohol as the drug of choice in Tennessee.
The reason for that is simple: because your health insurance won’t cover your booze
bill, but it will help cover your opioid bill. This was a slide that really struck me because
it looked like the slide I used for years about alcohol. It turns out that two-thirds
of the prescription opioids are consumed by less than 10 percent (or about 10 percent) of the prescription opioid
users. Now that is similar to alcohol, where most of the alcohol is consumed by a small
percentage to the drinkers. Many of you have probably seen this slide, and the way it is
usually presented is that most people get their opioids eventually from one doctor.
If we think about 10 percent of the people as the problem, 4 percent from a drug dealer,
1.9 percent from doctor shopping, a few from the Internet, some from other (which may be
stealing it), and some bought it from a friend or relative who may have gotten it from a
drug dealer, bought on the Internet or bought from a friend or relative or from more than one
doctor. Notice that more than one doctor is more common than this selling set, more possibly,
so there is a different way to look at that slide that is much more alarming.
If we look at where the risk of death is the greatest, it is among men, among whites, among Native Americans,
and among middle-aged people. Fifty-eight percent of the people who die are over age 40 and
low income, and people living in rural areas are hit hard by this. Fifty-eight percent of those who are
dying are taking multiple abuse-able pharmaceuticals, though it doesn’t mean they were taking
them in more than the doses prescribed. We see quite a few people who are on doses of 100 morphine
equivalents a day who are dying even when taking just their prescribed dose. And twenty-one
percent of those who died mixed prescription and illicit drugs. The cost for this problem is
more than 56 billion dollars, and the biggest piece of that is health care costs. The reason
for that is not only the cost of the prescription drugs, but there is the cost of all the doctor
visits to go get the prescriptions and all the tests that those doctors do and the other
aspects of lost productivity and criminal justice costs.
So how do we respond? How do we respond to the man who is managing his pain with his
prescribed dosage, but the pain gets so bad he takes an extra one or just taking what
he is supposed to, he gets addicted because it’s a very addictive drug. How do we respond to a “pills
party” and kids bring over whatever pills they can grab out of the medicine cabinet?
They mix them all together in a bowl and you wash them down with booze and when they get
you to the ED nobody has any idea what you just mixed with the alcohol and what they
need to treat. The federal response has been to declare this an epidemic, and the Office of
National Drug Control Policy in 2011 put out a federal plan to respond to the epidemic laying out
federal agency roles and responsibilities, prevention treatment goals, best-practice
guidelines, calling for new medications with lower abuse liability, and calling for more
patient and prescriber-patient programs. That plan expands in the National Drug Control
Strategy, and that strategy in general calls for action in education and monitoring proper
medications disposal and enforcement. They talk a lot about parent, youth, and patient
education, engaging in and enlisting antidrug coalitions and other organizations in public
education campaigns, requiring manufacturers to develop educational materials, developing
a mass media campaign. One thing to realize as you think about this
problem is it is a 3-pronged problem, so it needs a 3-D response. There are people who
are just in therapy with these addictive drugs, and it is not just the opioids, it’s
also some of the other drugs that are used for antidepressants that can be hard to shake.
That is particularly dangerous for the chronic user, but even an acute user of the doctor-prescribed
2 weeks of opioids is going to have withdrawal symptoms. If you stop after a week and then
get withdrawal symptoms, you go back to the bottle because you think you are not ready
to go off of them and you are hooked. Then there are those who are using them recreationally,
and they can get addicted, too. And if the addiction is there, that is a different problem
to deal with because now you have an addict, And what happens if that addict is also in
pain and needs a pain relief? Many of you know the public health approach:
we define the problem, we identify the risk and protective factors, we develop and test
our prevention strategies, and we ensure widespread adoption. And that certainly applies here,
and that is the way the
SPF-SIGs (Strategic Prevention Framework
State Incentive Grants) do things, for example. I wanted to
give you a bit of a different take on it, so I turned to injury prevention, where they
have something called the Haddon Matrix, developed by the first head of the Highway and Traffic
Safety Administration, and he was a public health guy. He said we should think about
responses in terms of: for the event, during the event, and after the event. I thought
about it and said, “What is the event here?” The event here is people who are abusing or
misusing prescription drugs but have not yet been detected in doing so. Before the event
is people who are just in the general public or people who have been prescribed prescription
drugs but aren’t yet misusing them. And after the event is what we do once we detect
that somebody is misusing a drug. And Bill Haddon said, down the other side of the matrix,
we should think of the host, that’s the person, the agent–in this case, that’s
both the drug and the prescription for the drug, the physical environment, and the social
environment. And so that is the conceptual framework I am going to take you through today.
It is important to realize that many of these cells, nothing is settled, and just take the
example of the disposal of prescription drugs, and should we flush the controlled substance,
the opiates, down the toilet, if we’re disposing of them? That is easy, and we can be certain
it is not recoverable, but there are cons to that. One of the major cons is that it can damage
the environment. A second major con is that you don’t want to tell them to flush everything
down the toilet because we don’t want every prescription drug in the world in our water
system. So you get mixed messages between substances; furthermore, we have some states
that went one way. The EPA says flush the opioids. There are some states who said
it was illegal in our state. That is a confusing, mixed message and leaves people not knowing
what to do, so something that seems like it ought to be simple is not. We are seeing prescription
drugs in our tap water right now. So the next step is we say, “If you are not going to
flush it and you don’t take it back and you want to dispose of it yourself, mix it
with coffee grounds or kitty litter, or mix it with sawdust.” I went and read a bunch
of those fact sheets, and I thought about it. The first thing I realized is not everyone
has coffee grounds, and some people drink tea and they have a dog, and then I said to
myself, “Besides, if I take my oxycodone and mix it with kitty litter, these things
are worth $40 a pill on the street, why doesn’t somebody just fish them out and sell them?”
I finally realized that some of the fact sheets, but not all of them, had this critical additional
point: add water, either dissolve the pills in water and then dump them in, or dump them
in and add water. The Connecticut Disposal Fact Sheet is the
one that I think is probably the best done of the group that are out there right now. So, let’s look
at the Haddon Matrix now and look at all the ways we can do things. I am going to start
out by going down pre-event and talking about what we do, and we start with the host, so
we want to educate youth, we want to educate elders and put them through prevention programs just like
we would with any other kind of substance abuse. We want to educate workers because, remember,
a lot of these people are middle aged. Educate patients when they get their prescriptions
and before they get their prescriptions because one of the things to educate them about is
that there are alternatives here. Also, educate pregnant women because we are starting to
see a lot of babies show up in birthing rooms who are addicted to prescription opioids,
and we don’t want that. What do we do with the drug? We can reformulate it to stop tampering.
OxyContin and some of the others, the addicts were grinding them up so that they could either
shoot them or dissolve them in water, and they have changed things so if you try to
do that, it releases something that causes the opioids to go away and not work. It’s
a major change. There is also something called an ARAP combination,
which tends to increase the change of liver damage, and we get rid of those, and it looks
like the FDA is going to ban those we can move opioids to a higher schedule of danger
and put more opioids there so there are more restrictive prescriptions. Some states have
prescriptions that you can easily make yourself on your computer and look like the prescription
pad. There are other states where the prescription pads have the kind of security that dollar
bills now have. There are others where they are actually moving toward an electronic prescription
where there is a secure line between the doctor and the pharmacy and that is the only way
the pharmacy gets prescriptions for controlled substances. The package warnings need to be
rewritten, and package warnings are normally written when a drug is approved. They need
to be changed, and we need the dispenser and the prescriber when they hand out these drugs
to warn people about them and to say, “Hey, these are addictive and this is what you have
to be careful about. And if you have any leftovers, you’ve got to dispose of them, and here
is a sheet on how to do it.” Physical environment: we need to make sure
that our health insurers cover the other things that are as likely to cure pain as an opioid.
Those are things like mindful meditation, massage, acupuncture, and all of these things
are 15 percent effective, and so is non-prescription pain medication, people should start with
those because there is no risk of addiction with those. We have prescription drug monitoring
programs and some of those programs are allowed to do proactive monitoring for providers to
pick up ones who are pill mills because that is important. We need to regulate our internet
and import sales of prescription drugs, and it is hard to do. There are organizations
that have tried drug testing-either random drug testing or pre-employment testing. That is a questionable
issue right now because there are no federal standards yet on testing. There is a thing
called a “medicine cabinet lock box,” and if you have got a prescription opioid-even
if you are the only one in the house, but people occasionally come over-you ought
to keep it locked up. We are getting take-back programs to take back the leftover drugs.
In the social environment, we’ve got drug-free policies and programs. We’ve got to train
our providers, put out practice guidelines, mass media campaigns, and targeted media campaigns,
and we need to do surveillance both through surveys and do some research on what to do.
We need to mobilize our communities, and we need to take our Comprehensive Substance Abuse
Prevention programs and make sure that they have prescription drug abuse covered in them,
and we can show that it is effective. So what do we do during the event? We give
people tools to assess whether they have a problem. We build into our wellness programs
self-assessment tools. And it turns out that if you overdose on opioids and someone quickly
sprays Naloxone up your nose, they can save your life. We need to start to co-prescribe
those kits, and there are states that are trying that now. The prescription monitoring
programs, moving to the agent side, serve to check as they prescribe that people are
not getting multiple prescriptions for multiple places that don’t all appear legitimate, and they let
the doctor check and they let the dispenser check. There is also proactive PMP reports
allowed in some states, where they send to a doctor and say, “You have a patient who
is getting high doses of opioids from four sources; make sure that is appropriate.”
There are states, now, that are starting to experiment with putting a case manager in
the emergency department whose job it is to check on everybody who is getting opioids
and do things like make sure that the number of pills in the script are small, that there
are no refills on that script, that that script has to be filled in perhaps 5 days or it can’t
be used, and also checking that the person is not already in trouble.
As we get to the physical environment, there is screening that can be done out there. There
is screening through testing, there are poison control centers out there who can . . . (and
the screening for testing is really for-cause testing, a little questionable but perhaps
a little more common). There are poison control centers that people can call when they are
in trouble, there’s law enforcement that can pick these people up and say, “Ah, there
is a problem,” and get them some place where they can get help. Lesson from nonprescription
opioids: needle exchanges for those recreational users who are crushing something-cut the
harm. Social environment: there are assessments
by family and friends. There’s immunizing 911 callers.
Post-event: there is brief interventions, just like we have with alcohol and drugs, and we
are starting to use those and see them be effective. There is treatment and vocational
rehab, and there is Naltrexone, which causes opioids not to give you joy, and it takes
the addiction away. The problem is, if you are also using it for a painkiller, it no
longer works. There are states where they are starting to say they have caught a person
with a problem, and it is very common in Medicaid in over 30 states that they can limit someone
with a problem to either one prescriber or one dispenser or both.
Moving back to the agent, we’ve got programs to take it back and get rid of it, and we’ve
got disposal. Those take-back programs can be police departments, they can be pharmacies,
or they can be a funeral director who puts on to the list of things to do when somebody
has died and take their prescription drugs, which are dangerous, to a place for disposal.
There are theft safeguards because it is easy to have these drugs stolen. There is the restriction
of prescribers and dispensers. In terms of physical environment, once we’ve caught
somebody, we should trace back the sources of the drugs, perhaps; we need to prosecute
the dealers and the pill mills, and that is how we help find them. There is scheduled
testing, and that is a monitoring thing; that is generally between the patient and the physician
who is monitoring the recovery, and that is essential in monitoring the recovery, perhaps,
but it is a medical thing. Social environment: we need to collect and analyze event data
so we know what is happening so we can monitor it. We need to evaluate the programs that
we have, and as people go into recovery, they need family and peer support. And one thing
that is a big issue is Internet and cell phones as facilitators here. You can buy drugs over
the Internet, and you can use your cell phone or the internet to make appointments with your drug dealer
instead of having to go to an old drug market. It is a very different thing, and I don’t
know that we have figured out how to intervene in that new way of dealing drugs. You get
to the market and you want to make sure it is the right pill, and you take out your cell
phone and use the pill identifier app in the cell phone and say, “That is the pill
I want to buy.” So, let me pause, and you will see on your
screen a poll, “Does Your Coalition or Workplace Address Prescription Abuse?” If you would
either check yes or check no, please, and we will see what the answers look like. We
will come back to the polls. [Skipped over polling] Let me give you some examples of places that are doing something
now that seem to have reasonable programs. One of those is Madison/Dane County, Wisconsin,
where they have a Safe Community for the World Health Organization and they decided that
one of their priority issues would be prescription drug abuse. They mounted a community-wide,
multifaceted effort and started out with a drug poisoning summit, and they brought in
130 professionals, they brought in data, they prioritized action steps. They focused on
six strategy areas, which were reducing access to drugs, reducing inappropriate prescription
use, primary prevention of substance abuse, early intervention treatment and recovery,
mental health care integration (which wasn’t even one on my list), and overdose intervention
and harm reduction. In Berkeley County, West Virginia, their coalition
against substance abuse put out a broad-based program as well. They started out again with
data collection analysis, they put together a logic model and worked for cross-state access
to prescription monitoring programs because they felt people could be on both sides of
the border buying prescription drugs, and they needed to know it. They did training
presentations to parents, youth, and pharmacists about what are the harmful effects, how can
parents monitor, how we can procure and dispose of prescription drugs. They evaluated pharmacists’
experience with prescription monitoring program and the use of coalition materials. They put
together a billboard about prescription abuse with QUITLINE, and they did something that
we thought was great. They went to realtors, and they said, “Hey, when you have an open
house make sure that when you put away the valuables, put away the prescription drugs.”
They are trying to revive medicine cabinets in their community and also put in a feel-good
activity of drug-free skate nights. I would remark that this kind of feel-good activity,
they tend to be a little bit expensive, and we don’t have much evidence that they reduce
substance abuse, generally. We do have some evidence that the night ones may reduce violence.
The Flight Attendants Drug and Alcohol Program is another interesting program. It is broad
based; these are workers who operate heavy machinery every day, and if they are taking
a prescribed drug that says, “Do not operate heavy machinery while on this drug,” they
shouldn’t be in service on an airplane. They take sleeping pills to sleep sometimes
because of irregular work schedules, they often have back pain or other pain and may
be on prescription painkillers, they sometimes get depressed, so they may be on antidepressants.
All of those are issues, so the flight attendants have put together a self-assessment tools
similar to the CAGE to help flight attendants recognize that they had a problem and put
together the EAP consultation referral, they put together a brief intervention and treatment,
and they put together a surveillance survey to find out whether their people are out there
when they shouldn’t be and to make them aware of what the restrictions were that they
needed to pay attention to. Project Lazarus in Wilkes County in North
Carolina that is, again, broad-based and it is evidence-based, and they have managed to
do a fair amount of evaluation of this program. They started out by monitoring their data,
thinking about what to do. They said, “We are going to put together a toolkit and face-to
face meeting to educate primary care providers about managing pain and about safe opioid
prescribing, educate parents and families on opioid safety, on handling overdose emergencies.
We are going to co-prescribe Valtrex and Naloxone.” And they are prescribing it, and they have
started that, and it has moved out. They put together ED case managers and said, “You
don’t prescribe in the county in ED without the case manager talking the time to look
closely at the patient and whether there is an issue with that patient.” They put together
treatment; overdose deaths dropped by 69 percent in 2 years, 28 straight months of decline.
Meanwhile, deaths rose in all other North Carolina counties, and the deaths that were
left in Wilkes County were opioids prescribed elsewhere. At the same time, there was no
change to speak of in how many Wilkes residents received an opioid painkiller, but they weren’t
receiving them in overdose quantities, and they were receiving them with education about
how to use them well. There have been several narrow Naloxone program
replications: Massachusetts state wide, Operation Opioid Safe at Fort Bragg, Eastern Band of
Cherokee Indians were ones that struck me as interesting. Down here at the bottom, you
seen somebody administering Naloxone to somebody-I’d imagine a posed picture, but still, it shows
you how easy it is. Some states are immunizing 911 callers, so that if they call in about
overdose and they were somehow involved in that happening, there is no self-incrimination
worry. Operation Unite in Kentucky, founded by a Congressman-broad based, very well-funded-has
the goal of combating addiction and corruption of prescription drug abuse in southern and
eastern Kentucky. Activities include undercover narcotics investigations, coordinating funding
treatment for substance abusers, providing support to family and friends of abusers,
education awareness, and a lot of feel-good activities.
Another interesting one is the VetCorps that CADCA is running. They have added 100 full-time
VISTA AmeriCorps staff to CADCA community coalitions. What those staff are doing is
supporting veteran and military family needs, with emphasis on serving the needs of National
Guard and Reserve families. Some of them are allowed to deliver direct services but many only
assist coalitions in developing and carrying out strategies to address the service gaps
for returning veterans and their families, and that includes prescription drug abuse
,which is a large issue in that group. We have been with this drug abuse problem for
military families for a long time.
[Operator working to open polls] I want you to ask yourself which of these
four is not a street name for methadone? Is it “fizzies,” “jungle juice,” “Maria,”
or “512?” And the answer is “512,” which is actually Percocet. But it is interesting
to see that these things all have street names, and it tells you that they are purchased on
the street. Live Right Do Right in Baltimore is a host-focused
program and is a youth program, and they took an evidence-based lifeskills curriculum; they
tweaked it to have prescription drug abuse. They added mentoring, family counseling, mental
health evaluations and assessments, and substance abuse treatment referrals. There are a whole
lot of programs out there that are focused on the host pre, and even some of those that
are on NREPP haven’t necessarily been evaluated in terms of the prescription abuse content
that was in them, even when they went on NREPP. Programs like that are Stay on Track, which
is school-based, Team Awareness for Youth in the Workplace. One that has been evaluated
in its prescription drugs, and that I will talk about later, is Healthy Workplace program.
The Get Fit Wellness website that SAMSHA developed has prescription drug content. Pathways Opiate
Overdose Coalition, New Bedford, Massachusetts, is a youth peer-to-peer and social marketing
program that has added this content. San Ramon Valley, California’s, CASA is an adult-guided
peer program that has added prescription abuse. I have listed a few more here, such as We
Are Not Buying It in East Brunswick, New Jersey, fights media misinformation and the media’s
depiction of what happens with substances is not accurate. The Partnership for Substance-Free
Buncombe County does community risk education and take-back, and that is a fairly typical
program, and these are some examples of the kinds of community programs we are seeing.
There are quite a number of programs that SAMHSA has funded through its Practice to Science
Initiative. Something else I wanted to talk to you about
is the National Council on Patient Information and Education, and this is their e-mail address
up here at the top, their web address, and one of the reasons I want to talk about them
is that with SAMHSA, they are just launching a national video challenge, and the details
of that will be out in mid-March on the website. It is for youth ages 17-25 who are invited
to submit a 2-minute video addressing the question, “How can technology be used to
pass forward information about the availability of educational resources to promote prevention
and recovery; what creative strategies can help ensure the college- and community-based
service organizations across the know about these resources and encourage them to reach
out to other people?” They are focusing on five resources. Two of those were developed
with SAMHSA by NCPIE: one is a resource kit to inform college peer educators and leaders
about the dangers of prescription drug misuse, prevention, and treatment; the second one
is an online educational workshop maximizing your role as a teen influencer: what can you
to do help prevent teen prescription abuse? The other three are more general but very applicable
in the prescription abuse area. There is SAMHSA’s Treatment Locator,,
and SAMHSA’s Recovery Month. In Utah, they have got a Use Only as Directed
Campaign and Take-Back Initiatives, and these are host and social-environment focused pre,
plus the take-back post; mass media campaigns; individual education, information and strategies
focusing on safe use, storage, and disposal; and then prescription take-back events. This
shows you the kind of a deposits thing that they use, and this is as lock box which you
can lock up meds if you have taken them back. But the thing about the locked box is that
it is more portable, but you have to worry
00:38:01,809 –> 00:38:08,809,700
about the box getting stolen if it is unattended. There are ways to do that.
The National Coalition Against Prescription Abuse is pre-event host and social environment.
It is a major education website, and I put the web address here as well, and the reason
because is that I like their screening and self-assessment tools and I like the stories they
had up from people. They also have parent and student education in there and initiate
and support legislative action and they’re building wide-ranging coalition partnerships
to push legislation and push enforcement where political action is needed. Another project
that is out there that is a broad-reaching one is the Medicine Abuse Project (youth)
and to prevent host and social environment again. It has resources for educators, a curriculum
called Prescription for Understanding developed by the National Education Association and
Health Information Network. I have not been able to find any information on the evaluation
of that curriculum as yet, though. They also work also on education awareness and prescription drug abuse awareness
for parents and grandparents; they provide steps family members can take for prescription
abuse by their children. So, think about which of these is not a street
name of OxyContin: so, is it “blue crack,” “Cotton,” “hillbilly horse,” “killer,”
“Roxi,” or “40-bar?” It turns out that “Roxi” is Percocet again. But think
about the ability of kids to be having a nice talk about “killer” OxyContin, “Man, did you see that ‘hillbilly
horse’ in that movie?” and nobody knows what they are talking about. Or they’re
talking about, “Gee, I’d like to get five ‘hillbilly horses’ myself. I wonder how
expensive they’d be?” This is that program for the workplace that’s
an extension of Healthy Work Life, and it’s been evaluated with an NIH grant. It’s called
SmartRX, Your Prescription for Good Health. It is a 1- to 2-hour, self-directed, online
tool designed to prevent misuse of prescription drugs among adult women. It covers use of
analgesics and anxiety drugs, sedatives, and stimulants, and it is part of a wellness website,
and that makes it less threatening, which the research shows. It increases knowledge
of proper prescription medication administration and increases the ability to manage their
own medications or concerns about medication administration. Users describe the program
as comprehensive, clear, informative, and useful. They are currently extending this program
to add content more tailored to men and male workers. Another program that is out there
that is on NRAPP that is a prescription drug abuse program that has been evaluated is Enhance
Wellness, and it is for older adults, and it is participant-centered motivational intervention
that complements formal health care. It addresses wellness including managing prescription drug
use and reducing use of psychoactive drugs. It has been evaluated and reduced length of
hospital stays and lowered the use of psychoactive drugs, it alleviated symptoms of mood disorders
among participants. I thought it was useful to put a reminder up here of what a pill manager looks like,
which could be one way to reduce your chance of taking too many drugs at one time or forgetting
you took them and taking them again. Another one that has been evaluated with NIDA
funding is called Mobilizing the Community to Reduce Teen Prescription Drug Abuse Use
operated in Rural Tennessee. It is a pre-event physical and social environment modeled on
an Alaska inhalant prevention program. They did a lot of community mobilization, home
and environmental strategies, parent education, and safer disposal and storage. This over
here is a medicine cabinet locked shelf, and they are about $20 and not expensive. Then
the medical environment they promoted using the Prescription Monitoring Program and have
educated physicians about the problems and contribution of prescribing practices. They
are improving pharmacy practices and looking at where over-the-counter medications can
interact with the opioids are kept and the ones that can be abused are kept and they
are saying, “Get those off shelves where kids can just grab a bunch or steal them.”
In Oregon, they have put together a whole action plan and is medically oriented. They
are working on communication with media packet templates, so they actually give the doctors
something they can use to write, say, an op-ed to their local community paper about the issue.
They are assessing needs for opioid prescriber education, they are enhancing the detox model
throughout the state-funded treatment system to align with the medically monitored model,
including medication-assisted treatment. They are looking at clinical system coordination
there, so it is a very different thing. They are now approaching that environment and the
medical environment. In Aroostook, Maine, there is a Diversion
Alert Program from their ASAP Coalition that is focusing, very heavily, based on having
gone and collected and having analyzed local data and said, “What is our problem, and
what do we do?” They have modeled themselves on a responsible beverage service training;
they’ve got providers out educating other health care providers about the problem, and
then they are providing those providers with monthly lists of names of residents who have
newly been charged by the police with pharmaceutical crimes, either buyers or sellers. With ongoing
access to the names of those that are being convicted so it is a complement to the prescription
abuse, and they are saying, “Hey, this is law enforcement data, but let’s try to use
it for a public health use.” The last quiz that I get to do (or don’t
get to do) is, “Which of these is not a street name for Adderall?” Is it “beans,”
“black beauties,” “Christmas trees,” “double trouble,” or “pineapple?”
It turns out “pineapple” is Ritalin. Another program that is out there in Ohio is Recovery
to Work Vocational Rehab Initiative, and it is post-event and host and physical environment.
It is blending addiction, mental health, and vocational rehabilitation services to address
needs of eligible clients. They have considered social and mental benefits that employment
contributes to recovery, and they are trying to build that in and giving priority to individuals
addicted to opioids, including prescription opioids. The one problem is that the job market
is not very good now in Ohio right now, so they have got a whole lot of people in this
program but haven’t, as yet, found them any jobs. Hopefully the economy will be improving
there, and they will see a lot more success. In Bucky County, Pennsylvania, they have focused
on take-back, and they did that after looking at their data and looking at what was needed
in their community. They built their program around the SAMHSA Strategic Prevention Framework,
and they built it as a take-back program within that framework. They launched a wide range
of actors, and they are using take-back messaging as a way to educate people about the risks
so that the education is what is threatening and is embedded that way. It will be very
interesting to see what happens as that gets evaluated, and I hope it will be. The C.A.R.E.S.
Alliance, funded by the industry, has picked up on that. They actually have things like
a pain management toolbox, pharmacist toolkit, and prescriber education on the website. The
reason I put their web address up here is because they have a toolkit that basically
builds on that Bucks County experience. It is 15 pages of details on how do you set up
and run a take-back program in your community. CADCA likes that toolkit; they’re actually
testing it out in seven other communities now. One thing that worried me a little about
that program and perhaps many of these take-back programs is when you have a Take-Back Day,
you are going to get lots of people together in one place bringing back their medications.
You run the risk of developing a marketplace right in the place, of John saying to Mary,
“What are you taking back?” and Mary saying, “Oh, my dentist gave me 30 days of painkillers
when he pulled my tooth, and I have 28 days of them left, so I was bringing it back.”
[John says]”You know, I have been having back pain, so maybe you can give me that bottle, and I’d even
give you $10 for it.” You have added to the problem instead of reducing it. So it’s an issue.
I was just noticing in Q&A there’s 4 questions” Let me talk now some about Prescription Monitoring
Programs and I could give you a whole lecutre on it, but I’ll be very brief about it and we may do a webinar one of these days
just about Prescription Monitoring Programs. We’re planning to do a series of webinars where we will bring in some of
these best programs and let you hear directly from those folks in detail about their programs.
Prescription Monitoring Programs are set up by government; they collect, monitor, and
analyze electronically transmitted prescribing and dispensing data from pharmacies and practitioners.
Some of them are law enforcement-oriented, and some public health oriented, and some
both. Forty-eight states have authorized these; almost 40 have them up and operating now.
The theory here is the prescribers and dispensers can check patient prescription history and
make sure that somebody doesn’t have six prescriptions for high-dose opioids. Some
states are allowed to send proactive reports about patients that a provider might need
to check on. Some states can scan and say, “Here are people who are issuing sixty 100
mg opioid/oxycodone/OxyContin prescriptions an hour-that might be a pill mill, somebody
needs to check on it.” And, depending on the state, they may be able to say to law
enforcement, “You can check on it,” and they may be able to say to the medical association,
more in a public health mode, “Maybe you need to check on this prescriber.”
Something that’s ironic is that, in some states, Medicaid may have access so that Medicaid
can check a Medicaid recipient and see all the prescriptions they are getting, but there
are no states where private health plan case managers, pharmacy managers, or fraud control
people can have access or where medical review officers at companies have access to prescription
monitoring programs. That means that we are saying, “OK, doctor who is a pill mill,
your job is to detect that this person is abusing drugs;” dispensers that is being
used by all the pill mills, “Your job is to check;” but payer, whose pharmacy manager
has financial incentives to catch up with this person who has gotten hooked, “You
are not allowed to have access to the data.” There is a lot of policy discussion going
around right now that takes the position I just took, and we think we may see changes
in legislation in some states; there are model laws are being written right now. There are
also a series of federal prescription drug monitoring program priorities, and one of
these is to integrate the electronic health record right in with the Prescription Monitoring
Program so that when the doctor goes to prescribe, the Prescription Monitoring Program kicks
up without taking extra time and says, “This person has three other prescriptions for this
same drug.” Increasing interstate compatibility and communication:
currently, these systems are home-grown state things. There is not a standard set of data
collected in a standard way. There are some of them where it comes in the same day; there
are some of them where, once a month, they upload the data. Evaluating the effectiveness
of these programs: and we started to show that they have some effect, but they vary
so much from state to state that we need to evaluate more about what works best. Exploring
the feasibility of reimbursing prescribers who check the monitoring programs before writing
a substance controlled through prescription. Evaluating those Medicaid programs that limit
doctor shoppers and that limit people abusing prescription drugs to one doctor and one pharmacy;
those are all the things that the feds are working towards. There is technical assistance
about prescription drug monitoring programs from Brandeis, they’ve got their Monitoring
Program Training Technical Assistance Center and their Center of Excellence working in
this area. Chris Jones and Len Paulozzi at CDC have also done a lot of work in this area,
as has Jinhee Lee at CSAT, so there is a lot of available support in that area. The National
Governor’s Association and AASTHO are both out there; they are identifying best practices
in the states, and with funding that they got from pharmaceutical industry, they have
been funding planning efforts in several states. Finally, the National Safety Council has launched
their Preventing Deaths from Prescription Drug Overdose Initiatives-this is a big
deal. The National Safety Council had two initiatives, workplace/ occupational injury
and illness, and motor vehicle crash; and for many, many years, those have been their
two big priorities. They were so alarmed by the number of deaths from prescription death
overdoses, and a number of them were people whose prescriptions in part came from worker’s
compensation and, in many cases, were only what came from worker’s compensation. They
said this is a third area we have to be in and have a major presence in for a while.
They have launched a series of large expert meetings to plan strategies and get commitments,
and the next one will be in Atlanta in late March. It is open to the public, and they
are trying to change employer, purchaser, and payer practices around prescription opioids
and their impact on the workplace. They are trying to educate the public about safe use
and storage, changing opioid prescriber behavior, supporting efforts to reduce misuse, looking
at regulatory and legislative policy changes. They have got some interesting fact sheets
that we have given them some advice on, around things like how do you modify your health plan to
incorporate prescription drug abuse, considerations Considerations for what an EAP needs to know about prescription
drug abuse and how to integrate that in there. What to do in terms of how to modify your
drug-free workplace policy to incorporate workplace drug abuse, and what to do with
respect to return to work, and I believe those fact sheets will be out shortly.
Let me turn now to telling you a little bit about our resource center. Our resource center
is called Preventing Prescription Drug Abuse in the Workplace (PAW) Technical Assistance,
but the people who wrote that said community coalitions include-or, if they don’t,
should include-workplaces because workplaces are important partners. So one of your jobs
is to support preventing prescription drug abuse by community coalitions and help them
with that, too. So we assist workplaces and their community partners, particularly SAMHSA
grantees, with resources, networking, strategies, and evaluation efforts. The reason for workplaces
is that is where we reach adult abusers and the parents of young abusers. And the most
deaths here are in adult abusers, so we took the main focus in part to where they are at.
We developed resources; our website is [email protected], and if you e-mail [email protected], that is
one way to request technical Assistance or the resources. If you are a SAMHSA grantee,
you can go to your project officer and request our services that way (and that is probably
the most appropriate). Our project officer is Deborah Galvin, and her phone number is
here; and her e mail address I will give you later. My staff is Rekaya Gibson, and this
is her phone number, and she is easier to get on than I am, and my e-mail address is
here, and I will give you Rekaya’s later. One of the things that we have done is that
we have put out a weekly summary now of new reports and resources that have come out on
prescription drug abuse, so everything that comes out in journals or important in the
newspaper, reports that come out, we are putting it out as a weekly e-mail. If you want to
subscribe to that, it is [email protected] It is free, and if you don’t like it, it’s
really easy to get off, you just click on something at the bottom. Past issues of it
are now archived by our partners at West Virginia University Injury Control Research Center,
and we use CDC funds to put up that archive because they thought these were important
for people. The archive link is on their home page on the left-hand side.
We have a lot of fact sheets that we are starting to be able to release, “Prescription Drug
Abuse Awareness: Information for Employers” and “Monitoring Prescription Drug Use in
the Workplace: What Can Employers Ask?” These are legal drugs, so what can you legally
ask your employee (who has the right to privacy about their health with respect to their use
of these drugs)? “Opioid and Narcotic Painkillers: Know the Benefits, Understand the Dangers”
is designed for people to hand out to large numbers of people who may be using these and
give them some specific education about them. “Five Reasons Not to Share Prescription
Drugs at Work,” this is one I am really particularly proud of because it is so important
when you look at most of these fact sheets, they never really explain clearly to people,
well, why it is that if your wife has pain because she hurt her back, give her one of
your pain pills. That means you are playing doctor, and you may not know about something
else in her medical history that means that the painkiller can be dangerous for her even
though it is not dangerous for you. We have a whole series of fact sheets that we have
put together on theft, “Realtors, Warn Your Clients;” “Pharmacists, Warn Your Customers,”
particularly in grocery stores; “Attention Shoppers, Don’t Let Your Prescription Drugs
Get Stolen Out of Your Shopping Cart.” If your drugs come by mail, watch out that they
don’t get stolen, and we are probably about to do one of those for people in hotels saying, “Hey, when
you are in the hotel, don’t leave your prescription opioids sitting out in the room unless you
would leave your money sitting out in the room;” those things are worth $40 a pill on
the street. “How to handle left over medication, why throw it away, and how do you dispose
of it” is another one. There are how to dispose of it and take-back programs all on one sheet.
We put together for community groups and technical assistance providers a fact sheet and resource
guide. It says, here are all the fact sheets, and we can find out they are on the Web and
from people’s materials, and we have reviewed them all. We have looked at the reading level,
we looked at the content, and if you want one to distribute to your coalition or workplace
on this topic, here is what looks like probably the ones you should choose from. We can narrow
it down to one, or two, or three-and, in some cases, there are half a dozen good ones-but
it tells you that they are for preventing unintentional prescription abuse, for abuse
risk due to drug interaction, for proper disposal of prescription and over the counter drugs,
for recognizing that you have a problem, and there are some of those that are generic and
some of those for specific drugs. Different fact sheets of recognizing you have a problem
and getting help; recognizing someone else has a problem and getting help. There is some
stuff for workplaces that we found that were generic supervisor guidance or employer education
about the issue that we felt worked for prescription drug abuse.
There are some other resources that we have listed, and the fact sheets we put together
were based on gaps that we saw when we finished that review. We have other fact sheets nearing
completion, and there is one that should be released any time now that’s for employers
that explains to them what they need to know about prescription drug monitoring programs,
that those can be a cost-saving tool for them, and they should be telling their health plans
if they are basically a large provider, a large company. They should be telling their
health plans that they want their physicians using the programs and that that will save
them money because they won’t have any of their patients who are doctor shopping and
they are paying for them to get their medication of abuse, who they are paying not only for
the meds but paying for all those doctor visits and all those tests to get the prescriptions
for those meds. I already mentioned the National Safety Council
fact sheets that we have been working with them on, and we are working on a series of
fact sheets that are alternatives to prescription drugs for pain management explaining to people
that alternatives are out there: one that is sort of an overview, and specific ones
so that they can get more details if they are considering a specific intervention. We
have one coming out on prescription abuse statistics and trends; what is hard about
that one is every time you think you have it in clearance, the trends come out again,
and new studies come out because this is a very rapidly evolving target. We have been
working on one on Native Americans and prescription abuse as well. And, as I said, TA from your
SAMHSA project officer or Deborah Galvin’s e-mail address is here, Rekaya Gibson’s
address from my staff is here, and mine is here. [Mike: Is it time for questions?]
Dr. Miller: We are up to the summary first.[Mike: okay] In summary, the evidence-base is weak but is starting
to improve. We are addressing prescription abuse for therapeutic effect is hardest, and
our ability to prevent and treat other abuses is growing, though. The reason the therapeutic
effect is hardest is if the person is still in pain, they may need painkillers, and yet
we know they got addicted to them, so we have to have a very tight control schedule so that
they get enough to control their pain but we keep them from tipping back over into addiction.
We know that, as in other areas of substance abuse, environmental strategies can be potent
here. The existing coalition models appear to be applicable that assess your problems;
make your plan around the SPF-SIG framework; think about the Haddon Matrix and what it tells
you about the things you could do and the different areas you want to cover; decide
which parts of the event you want to target, whether you are targeting just the host and
the social environment, which is a comfort zone in many cases, for SAMHSA programs, or
whether you are also going to try to affect the medical providers, the physical environment,
or even the agents. We know that work cases are key here because there’s an adult problem
that’s major, unlike with some substance abuse, where our work has been largely with
youths. And we know that the Internet and apps for the cell phones can be major facilitators,
and we don’t quite know how to intervene on those. Let me turn back to Mike now for questions.
I’ll leave on the screen contact information for our Technical Assistance centers.
Thank you. [Operator provides instructions for participant’s who want to ask questions.]
Our first question comes from Nan Miller:
“How do we watch a repeat of this webinar, where, and how, and when?”
Mike: We will actually have recorded this and send out a link, and you can just send me an e-mail
to me, and I will send the link out, or I can send a link over to Ted at PIRE, and he
will send the link to you. I will show a slide with my e-mail address for reference.
Dr. Miller: One easy way is to email Rekaya Gibson. Operator: Our next question comes from Donna Patterson:
“Can I get the presentation?”
Mike: For those of you who do not have the presentation, you can get it while this meeting is still
live. Do you see the word “feedback” there, on the top, on the gray bar, the gray-bluish
bar? There’s a little yellow icon-that’s not the one-but the white icon next to the
very left of the yellow icon, that is the icon for the slides.
Dr. Miller: Your mouse will say it’s “handouts.” Operator: Our next question comes from Lisa Coleman:
“I had a question-When you were talking about Naloxone and how it works with opiates, does that include heroin addiction
as well?”
Dr. Miller: Yes it does, I believe. Lisa Coleman: “You also said the data showed a decreasein drug overdoses,
but, then, did it also show a decrease in actual opiate use in that community?” Dr. Miller: No–the number of people who have opiate
prescriptions in that community did not drop. I think probably the total quantity of opiates
prescribed dropped substantially, and it’s mining country, there is lots of back pain
out there, and there’s lots of legitimate, mostly work related, opiate prescription in
that part of Kentucky, in that part of the country. (I just confused myself-it’s
not mining country.) There’s a lot of legitimate prescription use because of work and pain.
What they have done is they have gotten it so that people are using their painkillers more responsibly
and are being prescribed more responsibly. They have educated them that this kills people, and a lot of people have died
in our community before we learned how to handle it. Operator: At this time, there are no other phone questions.
Mike: Ted, there’s a few on the internet. [Internet question: What is immunizing 911 callers?] Dr. Miller: Immunizing 911 callers is when you call 911
and you say, “I am calling because John just passed out, and he was taking oxycodone
at the time.” If you were his oxycodone dealer, you could be prosecuted. What some
states decided was that they thought that it was a lot better to have John live than to prosecute you.
So they said, “Okay-we’ll say that there is no prosecutability.” If you call 911 and tell them that, “Somebody has overdosed
on something,” that does not expose you to our saying, “That the cell phone belonged to Mary.”
And going after Mary as to why are you involved in this overdose. Dr. Miller: Next [internet] question
“Is there an appropriate pill-identifying app that we can share with local police and rural
communities to use when they come across pills?” The answer to that is that there’s
probably a dozen of them, and they are very helpful to the police when they come
across pills. Unfortunately, at the same time, they are very helpful in the bigger market
to people who are buying pills on the street or stealing pills out of somebody else’s
medicine cabinet. [Internet Question] “Where do we stand with health insurance
covering alternative pain control such as acupuncture?” It is a great question; the answer is, there
are some places that do, there are some places that don’t, and we need to increase how
many do, in my opinion. Someone says she tries to open and print slides after
downloading them, she can not because they are corrupt. If you will e-mail Rekaya, we will send you
a set of the slides that has not been through the system, and hopefully your system will
like that better. [Internet Question] “How long does the Naloxone last? Does it work
to bring the person back, and then they need to get to the hospital?”
Dr. Miller: I actually don’t know the answer to that-I am not a doctor-and I’m going to say that
the safest thing for me to say is that we could probably find that out on the internet. [Internet Question] “Where can we access the Fact Sheets?” If you e-mail Rekaya, she can e-mail them to
you, as yet, we don’t have them available on the Web yet because of the way
processes work of approval and clearance, but we are allowed to e-mail you the Fact Sheets
that we showed you in the seminar/webinar. Mike: Last call for questions-any others?
[Operator provides instructions for participant’s who want to ask questions.] Operator: There are no questions on the phone.
Mike: Well, if there are no questions, I want to thank Ted Miller
at PIRE for his great content. We do hope that it’s been helpful to you. If you would like the slides, we’re going to leave the meeting open to you for a few more minutes so that you can download those. Dr. Miller: Hold on, Mike. Somebody just gave me an answer-
Naloxone lasts 30 minutes, so you need to get the person to the hospital. Mike: There you go. There’s the answer. I’m going to show Rekaya’s email
for those who want to see the link of the replay. or get the slides if they have not had the
opportunity to download them during the meeting. That’s about it. We hope you’ll join us again.
Keep an eye out for the listserv Ted had mentioned. Ted, you want to go back to the slide with the
address of the listserv you created. If people want to sign up for that, I think it’s a
great resource for folks to be subscribed to. Dr. Miller: We’ve had over 800 people sign up and
we’ve only had about 20 people drop back off. Some of those 800 sign-ups were ones that we started
initially as complimentary-to see if you like it. So almost nobody has dropped thet subscription.
If you’re working on this issue, it keeps you up-to-date. Mike: [email protected]
So thank you. We hoped you enjoyed it. We’d like to hear feedback from you,
so if you’d drop us an email, me or Ted, we’d love to get your comments, etc., etc.
on what you thought of today’s webcast. So, best wishes in your work and we will
see you next time. Take care. Operator: This concludes today’s conference call.
You may disconnect your phones at this time.

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