Salt lake county prescription pain medication DATA

1. Salt lake county prescription pain medication DATA Prepared for Salt Lake County Division of Substance Abuse Services July 2009

2. Overview • The Problem • The Plan • Who we talked to • What we heard • Overall Results • Next Steps

3. The Problem THE NATIONAL PROBLEM • A drop in illicit drug use between 2002 and 2007 • BUT an upswing in non-medical prescription drug use and abuse THE LOCAL PROBLEM • Utah is in the top 10 states for non-medical use of prescription drugs • In 2006: - 485 overdose deaths; of those 307 were from a non-illicit drug - 56% involved a prescription narcotic - 40% had a prescription for the drug that killed them This data shows a clear need for local preventative entities to tackle the problem of prescription drug misuse and abuse

4. The Plan • Salt Lake County Substance Abuse Services and Neighborhood Action Coalition collected data for the Strategic Prevention Framework State Incentive Grant (SPF SIG) requirements. • We conducted focus groups with community members, interviews with key community leaders, and surveys of healthcare professionals. • Objective: Obtain knowledge and understand beliefs about prescription narcotic medication misuse and abuse in different populations in Salt Lake County. • This new knowledge will be used to select strategies for prescription drug misuse/ abuse prevention programs in Salt Lake County. It may also be used to further understanding of this important and emerging issue.

5. Key Informant Interviews Study Design Semi-structured interviews were conducted with 12 knowledgeable experts with a broad understanding of prescription pain medication misuse and abuse. Who We Talked To Key Leaders from: • Project Reality • University Neuropsychiatric Institute (UNI) • Utah Poison Control • Department of Pharmacy Services, University of Utah • Cornerstone Counseling Center (Prevention and Treatment Services) • Cottonwood Heights Police Department

6. General: Increase in unintentional overdose deaths related to prescription drugs in Utah All age groups are affected BUT there are varying themes among ages and population Examples Addiction issues appear in adults and teens following a legitimate prescription Problems can begin with family members/friends sharing with younger siblings/children Group of well-educated and successful individuals addicted to pain meds Addiction issues in mothers who were prescribed pain medications at childbirth; eventually move on to heroin What we learnedKey Informant Interviews

7. What we learnedKey Informant Interviews Attitudes: Everyone shares a piece of the blame in this multi-factorial problem Issues There is a general lack of education among consumers and prescribers The issue is a social norm and does not discriminate based on age, SES, etc. Marketing of prescription drugs appears to be a bigger problem than we think There is a lack of product stewardship Overprescribing is rampant

8. What we learnedKey Informant Interviews Networking: There appears to be a lack of collaboration among invested institutions like DOPL, health care providers, law enforcement, insurance providers, etc. There needs to be more monitoring by physicians with patients with long-term pain medication prescriptions Larger work load for case management with prescription drugs because of the HIPPA and confidentiality concerns Limited # of pain clinics means existing clinics disperse more drugs More addiction specialists or trained pain clinic personnel needed Law Enforcement: “Reactive” instead of a “proactive” approach. Individuals “work the system” (i.e. M.D. shopping, fraud, etc.)

9. What we learnedKey Informant Interviews Prevention: Prevention of prescription drugs is not officially a part of standardized curriculum due to lack of documented research Treatment: All age groups are affected Increase in opiate use without gateway drugs such as alcohol is a new phenomenon One theory is that this new generation has been raised to believe that life should be pain free and therefore they are more vulnerable to seeking relief through pain medications Additional treatment groups for young adults needed to focus on Rx. issue Adults become addicted following a legitimate prescription Start out with opiates but switch to heroin because it’s cheaper Also seeing cross-addictions which include benzodiazepines (large amounts prescribed in Utah)

10. Focus Groups Study Design Selection Criteria - Self or close relative had been prescribed prescription pain in past year Approved by both U of U IRB and State of Utah IRB Designed to target SPF SIG “Causal Factors” - Community Norms, Individual Factors, Availability/Sharing, Knowledge of Proper Use, and Criminal Justice/Enforcement Who We Talked To Total of 7 focus groups : men and women from Salt Lake County 3 with participants age 18-30 2 with participants age 31-55 2 with participants age 56+

11. What we learned FOCUS GROUPS The drug misuse-abuse continuum is not well understood Most common definition of misuse was taking too much OR not using as prescribed or to treat a different pain that what the prescription was originally given for Another term that was used was “accidentally/unknowingly not using as prescribed” Most common definition of abuse was using it to get high or for recreation purposes Participants also identified evidence of abuse was when the use of the drug interferes with your life or when you become addicted where the medication is something you need (dependence) They also described it as “knowingly taking more than prescribed”

12. What we learned FOCUS GROUPS Many save ‘em, store ‘em, or give ‘em away Most participants report they don’t discard unused (or oftentimes expired) medications and they indicate they don’t know how to properly dispose of them. In fact, many believe they can take them back to a pharmacy. Most indicated they would not use a dropbox. Those reporting they would use a dropbox suggested the best location would be the pharmacy. Many report storing their medications in the kitchen, bedroom, medicine cabinet, and even their vehicles, purses, and pockets. Some participants say it is common to share prescriptions, but mostly among family members. There is a financial motivation for all of this – saving money on co-pays, new prescriptions, and saving money for family members and friends.

13. What we learned FOCUS GROUPS Healthcare professionals provide a wide variety of prescription pain med use information Many report that their physicians do not discuss the risks associated with taking prescription pain medications, while some report they do have a conversation with their physician. Physicians who DO explain medications with their patients seemed to be the exception. Some report the pharmacist just asks if you have questions regarding the medication or asks if you have taken it before. The pharmacist is also credited with asking more frequently about general risks and the specific risk of combining alcohol use with the medication. Much of the information about interactions and risks comes from the information sheet patients receive from the pharmacy. Patients rely heavily on the information contained therein. Participants surmise the reason physicians are less likely to discuss these risks are due to their detailed knowledge of the patient.

14. Surveys Study Design A survey based on a SPF SIG data collection document was mailed with a self-return stamped envelope to 668 healthcare professionals. The survey was anonymous and would have taken less than 10 minutes to complete. Who We Talked To Family practice physicians, pharmacists, and dentists in Salt Lake County.

15. What we learned Survey Responses • A total of 192 surveys were returned for analysis (29% response rate) • Dentists (N = 32), Pharmacists (N= 54), and Physicians (N=106) • Zip code 84107 had the most returned surveys (N=17)

16. What We Learned

17. What We Learned

18. What We Learned

19. What We Learned

20. What We Learned

21. What We Learned

22. What We Learned

23. What We Learned

24. What We Learned

25. What We Learned

26. What We Learned

27. What We Learned

28. What We Learned

29. What We Learned

30. What We Learned

31. OTHER HIGHLIGHTS Physicians & dentists participated in prescription drug training more so than pharmacists Dentists generally have been trained in prescription drug misuse – less recently than physicians and pharmacists Pharmacists suspect “fraudulent prescriptions” less frequently than physicians and dentists suspect “doctor shopping” Physicians were more likely “not to report” doctor shopping than dentists or pharmacists Of those who would report: dentists would report to physicians and pharmacists would report to law enforcement

32. OTHER HIGHLIGHTS Physicians & dentists more frequently reported they didn’t know who they would report suspected “doctor shopping” to than pharmacists Most common reason given for not reporting was “they weren’t sure it was doctor shopping or a fraudulent prescription” When asked how often they discuss other medication use, all three groups indicate “they do it all or most of the time” but only physicians report discussing alcohol use interactions with medications regularly. When asked about discussing issues related to dosage and timing, and potential interactions with other medications, all three groups report doing it all or most of the time

33. OTHER HIGHLIGHTS Pharmacist Comments: Not aware of any trainings. Not sure when/where training is offered. Very frustrating as a "witness" dealing with the court system (rx. fraud case). Takes too much of my time in a hectic work environment and for what? The police/authorities don't have resources to do much against them. They typically still get away with it and go right back to doing it again (rx. fraud comment). Co. policy - we don't notify police. But I would report to MD still. I would be very interested in attending a training. Also, I worked in Rutland, VT as an intern where they currently have a narcotics Abuse Prevention plan including special rx. pads for controlled substances. Might be a good idea in Utah.

34. OTHER HIGHLIGHTS Pharmacist Comments: It can be very difficult to decide when to call the police. We had a situation where we called the physician and they just said that they wouldn't see that patient anymore, but we wanted them to do more, but we just left it as it was. Yes, I would like MD's to follow the 80% law and not give new rx.'s unless almost 100% is gone except when a patient is going on vacation or under difficult circumstances like they lose their medication. Also, patients seem to be abusing the 80% law by filling rx.'s nearly every month, so 80% law should be modified to 80% gone they fill once every few months instead of 80% gone every fill. Often difficult to distinguish between use, misuse, and abuse. Pain is very subjective and no therapeutic ceiling for narcotics. It is getting worse almost by the month! We pharmacists are now always in fear of being robbed - possibly of losing our lives! All pain clinics need to be closely checked. Their prescribing habits are getting out of hand.

35. OTHER HIGHLIGHTS Pharmacist Comments: It's obvious you have no idea what goes on in an average pharmacy. Script fraud is an every day, all day experience. Knowledge of all aspects of the problem is an integral part of every pharmacist's life. It is do gooder liberal politicians that need training. Make all controls be e-scripted, sent over secured network w/electronic signatures and finger scanners. Finger scanners are fairly inexpensive in comparison to the hassles of fraud. We fill only 2 days early on narcotics. Many pharmacies fill at 80%, which allows too much misuse/abuse because it is usually 4-6 tabs per day therefore 6 days early is 24-36 extra tabs.

36. OTHER HIGHLIGHTS Dentist Comments: We query the database and we confront the patient. There is a real problem in the state and there are not a whole lot of guidelines for rx. schedule II narcotics. I use the drug database for suspected misuse, but have never had an agency nor a clinic to report to. I do share info with referred specialists. Internet seminars "webinars" specifically on narcotic abuse would be convenient. They can be watched anytime without affecting busy schedules.

37. OTHER HIGHLIGHTS Physician Comments: Unaware that there are trainings. I've read the book on this subject by Dr. L Webster. I get a heck of a lot of real world training in misuse and abuse. I've not seen many programs that appear reputable or interesting. Report to DOPL (mentioned in 16 comments) if needed, otherwise none. Not sure. Sometimes I contact insurance fraud investigator. DOPL: But usually discuss with patient first, report if high number of visits. DOPL, and confront the patient with info and inform them of illegal act. Hadn't thought about counseling re: risk of sharing rx. I can't think of any good reasons not to warn a patient.

38. OTHER HIGHLIGHTS Physician Comments: We all need more education in this area. We need better resources to refer patients to for prescription medication abuse treatment/withdrawal/evaluation. Thank you for DOPL online. Need to hire more drug criminal investigators. Make it easier to report abuse. Review DOPL records of controlled rx.'s filled and enforce. Go after them please. Big problem, especially for young doctors, orthopedics, and providers seeking new patients.

39. OTHER HIGHLIGHTS Physician Comments: One big one; lots of people are interested in making rules, and fixing punitive, even criminal punishments onto providers trying to care for patients with chronic pain/opioid dependence. I see lots of Medicaid patients. NO chronic pain centers accept patients. We're told to refer them on, it is simply not an option available to many of us, I wish it were. Easier access to DOPL records would be helpful. Legal protection as a result of reporting suspicious unproven misuse needs to be clarified. Being able to check DOPL's csdb web site is very helpful, although it still has a 2-4 week lag time it is helpful to check patients credibility and recent drug use patterns.

40. Next Steps Community Coalition Building Midvale Salt Lake City South Salt Lake

41. Questions?