The Arizona Rx Drug Misuse and Abuse Initiative

1. A Multi-Systemic Approach for Addressing Arizona’s “Silent Epidemic” Janeen Dahn, PhD, FNP-C Arizona State Board of Nursing Created in Part by Shana Malone Arizona Criminal Justice Commission Statistical Analysis Center The Arizona Rx Drug Misuse and Abuse Initiative

2. Why Should We Care??

3. 2011 • In 2011, 33,071 (80%) of the 41,340 drug overdose deaths in the United States were unintentional, 5,298 (12.8%) were of suicidal intent, 80 (0.2%) were homicides, and 2,891 (7%) were of undetermined intent • Drug overdose death rates have been rising steadily since 1992 with a 118% increase from 1999 to 2011 alone

4. According to the AZ CSPMP • Approximately 10 million Class II-IV prescriptions written and 524 million pills dispensed each year. (Arizona 2014 Opioid Prescribing Guidelines) • Prescription pain relievers account for over half of the drugs dispensed in the state. • Arizona ranked 6th highest in the nation in 2010 for drug overdose deaths, and had the 5th highest opioid prescribing rate in the U.S. in 2011 (Arizona 2014 Opioid Prescribing Guidelines)

5. A 4 fold increase in the quantity of Rx Pain Relievers sold in the U.S. in the last decade • The United States makes up 4.6% of the world’s population, but consumes 80% of its Rx opioids • ~46 deaths per day!!!!!!!!!! The Opioid Influx

6. Statistics • Prescription drugs are the second most frequently abused drug category after marijuana http://www.painmed.org/advocacy/rems/opioid-risk-evaluation-and-mitigation-strategies-rems-update/ • Data from the National Survey on Drug Use and Health show that nearly 1/3 of people aged 12 and over who used drugs for the first time in 2009 began using a prescription drug non-medically http://www.whitehouse.gov/ondcp/prescription-drug-abuse

7. Nationwide… • Approximately 15,000 people died every year from overdoses involving prescription pain killers, more than those who die from heroin and cocaine combined. Center for Disease Control and prevention (2013). Prescription Painkiller Overdoses in the U.S. Retrieved from http://www.cdc.gov/Features/VitalSigns/PainkillerOverdoses/index.html • 15,000 died in 2008 – more than triple the 4,000 people killed by prescription drugs in 1999 Center for Disease Control and prevention (2013). Prescription Painkiller Overdoses in the U.S. Retrieved from http://www.cdc.gov/Features/VitalSigns/PainkillerOverdoses/index.html

8. http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

9. http://www.dailymail.co.uk/news/article-2314091/The-drugs-kill-Americans-How-80-000-deaths-year-unintentional-medicines.htmlhttp://www.dailymail.co.uk/news/article-2314091/The-drugs-kill-Americans-How-80-000-deaths-year-unintentional-medicines.html

10. The Problem? ~ 579 million Class II-IV pills were prescribed in Arizona in 2014 Pain Relievers had the highest % of scripts, pills and average number of pills per day; accounting for 60.0% of all pills prescribed Hydrocodone and Oxycodone accounted for 81.4% of all pain relievers prescribed in Arizona

11. Methadone accounts for nearly 1 in 3 prescription painkiller overdose deaths in the U.S. (CDC, 2012). About 5,000 people die every year of overdoses related to methadone Six times as many people died of methadone overdoses in 2009 than a decade before. Use and Abuse of Methadone as a Pain Killer

12. Methadone

13. Methadone

14. Volume: Access Ratio Enough Rx pain relievers were dispensed last year to medicate every adult in Arizona around-the-clock for 2 weeks straight

15. Mortality & Morbidity • A 50% increase between 2008-2013 in opioid-related abuse and dependency cases in the ED • Hospitalizations for non-fatal poisonings (Rx drugs are a leading cause) cost Arizona nearly $213 million in 2013. • 1,099 drug-related deaths in AZ in 2013 – 41% involved Opioids/Opiates • Increase in Crime • Narcotic drug possession increased 15% between 2010-2012 • Increase in DUI-D • 4,073 DUI-D arrests in AZ – a 99.4% increase over the past decade What Is It Costing Us?

16. CONTRIBUTING FACTORSi.e., What is Amplifying this Problem and What Can We Change?

17. Opioid-Naïve Individuals • Those who have never taken narcotics and have minimal experience with controlled substances • Chemically Dependent • Individuals who have developed symptoms of tolerance or physiological and/or psychological withdrawal if use of the Rx drug (legitimately or illegally acquired) is reduced or discontinued • Diverters • Individuals seeking controlled substances for the purpose of selling them to others or healthcare professionals engaged in fraudulent prescribing practices 3 Groups to Keep in Mind

18. Prescribers were told over a decade ago that they weren’t accessing pain well enough – Pain became the 5th Vital Sign Unrealistic Expectations of the Health Consumer Uninformed Patients and lack of education tools/resources The Role of the CSPMP Difficult Balancing Act Prescribers struggle with balancing the legitimate pain needs of their patients while ensuring their safety

19. Arizona Revised Statutes (A.R.S) § 36-2606, effective December 31, 2015, requires every Arizona medical practitioner, including Nurse Practitioners & Nurse Midwives who intend to obtain a Drug Enforcement Administration (DEA) number or who hold one or moreDEA registration numberto also hold a Controlled Substances Prescription Monitoring Program (CSPMP) registration issued by the Arizona State Board of Pharmacy. (A.R.S) § 36-2606

20. Percent of prescribers with access to the database as of 10/1/15 is 36.88% 2049 (37%) NPswith an access account as of 10/1/15. CSPMP

21. Article in the September 2015 Regulatory Journal on “Controlled Substance Prescription Monitoring Program” • Announcement about (A.R.S) § 36-2606 requirement in September 2015 Regulatory Journal • Blast Email on November 2, 2014 regarding the new requirement • Safe Prescribing Practice/Scope Presentations • ASU August 2015 • VA July 2015 What Has AZBN Done?

24. Easy Access • 70% of people who abused prescription pain relievers got them from friends or relatives • 77.8% of Chandler Coalition youth who have misused prescription drugs in the past 30 days report getting them from friends, family or right out of the home

26. What Else?

27. Diversion as a Business Oxy and Hydro generate between $20-$80 a pill “on the street” depending on dose and formulation

29. Arizona Controlled Substances Prescription Trend (by Doses) 1/1/2014 - 12/31/2014

30. The Pill Mill

31. The Stereotype Dealer

32. The Kindergarten Teacher????

33. A Call-to-Action What Can WE Do to Help Curb the Rx Drug Misuse Problem in Arizona?

34. The Arizona Rx Drug Misuse and Abuse Initiative Action Plan and ToolkitA Step-by-Step Guide for Implementing the 5 Strategies Reduce Illicit Acquisition and Diversion of Rx Drugs Promote Responsible Prescribing and Dispensing Policies and Practices Enhance Rx Drug Practice and Policies in Law Enforcement Increase Public Awareness and Patient Education about Rx Drug Misuse Enhance Assessment and Referral to Treatment

35. Final Tip: “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.” --Margaret Mead

36. Questions ???