Addressing the Substance Abuse Epidemic in Tennessee

1. Addressing the Substance Abuse Epidemic in Tennessee John J. Dreyzehner Commissioner

2. A Rising Tide Near Triplingin Opioid-related Deaths (in parallel with opioid sales and Rx opioid treatment admits) 2011 OD Deaths (U.S.): • 41,340 Any Drug • 22,810 Rx drug • 16,917 Rx opioid • 4,397 Heroin Sources: National Vital Statistics System, DEA Automation of Reports and Consolidated Orders System, SAMHSA TEDS

3. The Numbers in Tennessee Data source: Tennessee Department of Health, Office of Health Statistics, Death Statistical System. Overdose deaths were defined as having underlying cause of death ICD-10 codes X40-X44 (accidental), X60-X64 (intentional suicide), X85 (intentional homicide), and Y10-Y14 (undetermined).

4. The Numbers in Tennessee Data source: Tennessee Department of Health, Office of Health Statistics, Death Statistical System. Overdose deaths were defined as having underlying cause of death ICD-10 codes X40-X44, X60-X64, X85, and Y10-Y14.

5. Deaths by Age Group, TN

6. Opioid Prescription Rates by County • TN, 2007-2011 2007 2008 2009 2010 2011 Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.

7. AMPHETAMINE 1100 1000 900 800 700 600 % of Basal Release 500 400 300 200 100 0 0 1 2 3 4 5 hr Time After Amphetamine Why Do People Abuse Prescription Drugs? These prescription drugs, like other drugs of abuse (cocaine, heroin, marijuana) raise brain dopamine levels Dopamine Neurotransmission FOOD 200 150 100 % of Basal Release 50 Empty Feeding Box 0 0 60 120 180 Di Chiara et al. Time (min)

8. “Ask your doctor if taking a pill to solve all your problems is right for you.”

9. How We got Here “Dr. Portenoy and other pain doctors who promoted the drugs say they erred by overstating the drugs’ benefits and glossing over risks.” “…urged tackling what they called an epidemic of untreated pain…[and]…campaigned to make pain…’the fifth vital sign’ that doctors should monitor, alongside blood pressure, temperature, heartbeat and breathing.” A PAIN-DRUG CHAMPION HAS SECOND THOUGHTS “In 1998, the Federation of State Medical Boards released a recommendation policy reassuring doctors they wouldn’t face regulatory action for prescribing even large amounts of narcotics…In 2004, the group called on state medical boards to make undertreatment of pain punishable for the first time…That policy was drawn up with the help of several people with links to opioid makers…the federation said it received nearly $2 million from opioid makers since 1997.” “In 2001, the Joint Commission, which accredits U.S. hospitals, issued new standards telling hospitals to regularly ask patients about pain and to make treating it a priority…The Joint Commission published a guide sponsored by Purdue Pharma. ‘Some clinicians have inaccurate and exaggerated concerns’ about addiction, tolerance and risk of death, the guide said. ‘This attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain control.’”

10. TN’s Prescription Drug Problem TN: Tied for 1stin country for kilograms of prescription painkillers sold per 100 people Prescription Painkillers Sold By State, 2012 Data source: CDC, Vital Signs: Opioid Painkiller Prescribing. July 2014. Available at: http://www.cdc.gov/vitalsigns/opioid-prescribing/

11. Source of Opiates for Non-Medical Use Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings. SAMHSA

12. Transmission in the substance abuse epidemic- How did we get here?

13. Supply and Demand: The Substance Abuse/Misuse Market Buyers Sellers Potential Buyers

14. Substance Abuse/Misuse: Constraining the Market Control Treatment PDMP Addresses All Three Prevention

15. Prescription Safety & Population Protection • Steady reduction in the number of high-use patients since third quarter of 2012. • Survey of 800 CSMD users found: • 71percent had changed a treatment plan after viewing the patient’s information on the CSMD • 73percent said they are now more likely to discuss substance abuse issues with a patient • 57percent said they are now more likely to • refer a patient for substance abuse treatment • Cumulative milligram morphine equivalent dispensed shows decline in year-to-year comparison since CSMD became mandatory: • 0.7percent in 2013 • 6.7percent thus far in 2014

16. A New Tool To Combat Overdose Deaths: Naloxone Effective July 1, 2014 Licensed practitioner in Tennessee can prescribe

17. The Prescription for Success Plan Plan for the Future: • Decreasethe number of Tennesseans that abuse controlled substances. • Decreasethe number of Tennesseans who overdose on controlled substances. • Decreasethe amount of controlled substances dispensed in Tennessee. • Increaseaccess to drug disposal outlets. • Increaseaccess and quality of early intervention, treatment and recovery services. • Expand collaborations among state agencies. • Expandcollaboration with other states.

18. REMEMBER Doctor shopping is associated with a 5-fold higher risk of death. An MME of 100 or more is associated with an 11-fold higher risk of death. Source: “High-Risk Use by Patients Prescribed Opioids for Pain and Its Role in Overdose Deaths” by Baumbatt, et al, JAMA Internal Medicine, May 2014 Image credit: Naypong, FreeDigitalPhotos.net

19. Thank you for your partnership. There’s a lot more for us to do together.