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Death by Prescription NEHOUA Betsy Sears, MSM, MT(ASCP) EVP Sales Support ExamOne ExamOne Old news ExamOne Confidential – Do not copy or distribute | 2 More recent ExamOne Confidential – Do not copy or distribute | 3 No one is immune. . . 1 in 20 using Rx painkiller for non-medical use ExamOne Confidential – Do not copy or distribute | 4 Outline • History of prescription drug abuse • Definition of “misuse” • Statistics • Demographics • Who is at risk • Drug culprits • Quest Diagnostics studies • Costs • Protective solutions ExamOne Confidential – Do not copy or distribute | 5 History of Rx drug abuse • Laudanum – 1800’s; opium and alcohol (women) • Morphine – 1827; Germany; painkiller of choice Civil War • Cocaine – post Civil War; coca cola • Heroin – 1898; Bayer Company Germany – remedy for morphine addiction • Called “patent” medicines – secret ingredients • Food and Drug Act – 1906; label ingredients • Harrison Narcotic Tax Act – 1914; Rx needed ExamOne Confidential – Do not copy or distribute | 6 Prescription drug misuse • What is it? Use of a medication without a prescription in a way other than as prescribed for the experience or feelings elicited Sell or give away medications Combine prescribed and illicit drugs Forgetfulness to take meds as directed • Each pattern – potential for risk • Is equivalent to the term "nonmedical use," used by many of the national surveys or data collection systems www.drugabuse.gov ExamOne Confidential – Do not copy or distribute | 7 Sobering statistics • 116 million Americans suffer from chronic pain – more than the number of people affected by diabetes, heart disease, and cancer combined • 475,000 ER visits in 2009 • Drug fatalities increased 3% in 2010 • Prescription painkillers kill more people than heroin and cocaine • Sales of oxycodone, hydrocodone and methadone up 300%: ’98–’08 • In 2010, 12 million using Rx painkillers non-medically; 2 million people reported using for the first time within the last year • Narcotic pain relievers now cause or contribute to nearly 3 out of 4 prescription drug overdoses and about 20,000 deaths (2012) Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). (2012) [cited 2012 Feb 1]. ExamOne Confidential – Do not copy or distribute | 8 In 2008, there were 14,800 prescription painkiller deaths CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers —United States, 1999-2008. MMWR 2011; 60: 1-6 ExamOne Confidential – Do not copy or distribute | 9 Death rates – >100/day http://www.cdc.gov/HomeandRecreationalSafety/pdf/PolicyImpact-PrescriptionPainkillerOD.pdf ExamOne Confidential – Do not copy or distribute | 10 Where and how much – 300 million Rx/year! Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), 2010 ExamOne Confidential – Do not copy or distribute | 11 Source of prescription drugs How nonmedical users of prescription pain relievers obtained the drugs > One Doctor 1.9% Other 5.0% Internet 0.3% Drug Dealer Stranger 3.9% One Doctor 18.1% Free From Friend/Relative 55% ExamOne Took from Friend/Relative 4.4% Bought from Friend/Relative 12.2% Confidential – Do not copy or distribute | 12 Death rate by state - 2010 National Vital Statistics System. Drug overdose death rates by state. 2010 ExamOne Confidential – Do not copy or distribute | 13 Who is most at risk? Good to know! • Those who obtain multiple controlled substance prescriptions from multiple providers • Those who take high daily dosages of Rx painkillers • Those who misuse multiple commonly misused Rx drugs • Those with history of substance misuse • Those on Medicaid Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). (2012) [cited 2012 Feb 1]. ExamOne Wizbangblue.com (Image) Confidential – Do not copy or distribute | 14 Commonly misused medications • Opioids – derived from opioid poppy (or synthetic version) used for pain relief Hydrocodone (Vicodin™) Oxycodone (Oxycontin™, Percocet™) Fentanyl ( Duragesic™, Fentora™) Methadone Codeine • Benzodiazepines – CNS depressants used as sedatives Alprazolam (Xanax™) Diazepam (Valium™) Lorazepam (Ativan™) • Amphetamine-like – CNS stimulant used to treat attention deficit hyperactivity disorder (ADHD) Dextroamphetamine/Amphetamine (Adderall™, Adderall XR™) Methylphenidate (Ritalin™, Concerta™) ExamOne Confidential – Do not copy or distribute | 15 Prescription opiate dispensing 160 140 Total Rx (millions) 120 100 80 60 40 20 0 2005 2006 2007 hydrocodone/acetaminophen 2008 2009 2010 2011 oxycodone/acetaminophen IMS Health, National Prescription Audit™ ExamOne Confidential – Do not copy or distribute | 16 Positivity rates for “expanded” opiates (percentages) 1.6 1.4 1.2 1 Codeine 0.8 Morphine 0.6 Hydrocodone Hydromorphone 0.4 0.2 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Urine Drug Tests, General Workforce ExamOne Confidential – Do not copy or distribute | 17 Hydrocodone • Semi-synthetic opioid derived from codeine • Lortab™, Vicodin™ • Treat moderate to severe pain; cough suppressant • 1.5 x less potent than oxycodone • Side effects: nausea, vomiting, dizziness, constipation, anxiety • High dose: shallow or stopped breathing, slow, stopped heartbeat, loss of consciousness, seizures, death • U.S. consumes 99% of all hydrocodone in world • Estimate of 131.2 million prescriptions written in 2010 ExamOne Confidential – Do not copy or distribute | 18 Hydrocodone overdose en.m.wikipedia.org ExamOne Confidential – Do not copy or distribute | 19 Positivity rates for Hydrocodone by testing reason 4 3.5 3 2.5 Pre-Employment 2 Random 1.5 Post-Accident 1 0.5 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Quest Urine Drug Tests, General Workforce – 8 million/year ExamOne Confidential – Do not copy or distribute | 20 Oxycodone • Synthesized from poppy-derived thebaine; developed 1916 • Oxycontin™, Roxicodone™, Oxecta™ • Prescribed for relief of moderate to severe pain • Stronger than morphine - 1.5-2x; fewer side effects • Side effects: nightmares, memory loss, constipation, dizziness, nausea • High dose: bradycardia, apnea, hypotension, respiratory arrest, death ExamOne Confidential – Do not copy or distribute | 21 Oxycodone side effects – recreational users Commons.wikimedia.org ExamOne Confidential – Do not copy or distribute | 22 Positivity rates from Oxycodone by testing reason 2.5 2 1.5 Pre-Employment Random 1 Post-Accident 0.5 0 2005 2006 2007 2008 2009 2010 2011 2012 Urine Drug Tests, General Workforce ExamOne Confidential – Do not copy or distribute | 23 The effect…. ExamOne Confidential – Do not copy or distribute | 24 Opiate-based prescription drug overdose Source: Centers for Disease Control and Prevention ExamOne Confidential – Do not copy or distribute | 25 Benzodiazepine • CDC analysis of deaths caused by overdose of opioid painkillers - in 30.1% of deaths, benzodiazepines present • Possess sedative, hypnotic, anticonvulsant, muscle relaxant, and amnesic actions; useful in a variety of indications such as alcohol dependence, seizures, anxiety, panic, agitation and insomnia. • Most common: Ativan (lorazepam) Klonopin (clonazepam) Xanax (alprazolam) Valium (diazepam) • Well tolerated-safe but. . . risk of dependence ExamOne Confidential – Do not copy or distribute | 26 Amphetamine-like • Dextroamphetamine/Amphetamine - Adderall® , Adderall® XR • Methylphenidate (Ritalin, Concerta) • CNS stimulant - controls symptoms of attention deficit hyperactivity disorder (ADHD); used to treat narcolepsy • Side effects: nervousness, restlessness, difficulty falling asleep or staying asleep, uncontrollable shaking of a part of the body, headache, changes in sex drive or ability, dry mouth, stomach pain, nausea, vomiting • High dose: fast or pounding heartbeat, shortness of breath, chest pain, excessive tiredness, slow or difficult speech, dizziness or faintness, weakness or numbness of an arm or leg, seizures, sudden death, heart attack, or stroke in adults or children, especially those with heart defects or serious heart problems ExamOne Confidential – Do not copy or distribute | 27 Top 10 in Southern California – L.A. Times ExamOne Confidential – Do not copy or distribute | 28 Physiology of prescription painkillers • Bind receptors in the brain to decrease the perception of pain • Create a feeling of euphoria, cause physical dependence . . .addiction • Cause sedation - slow down breathing • A person who is misusing prescription painkillers might take larger doses to achieve a euphoric effect and reduce withdrawal symptoms; larger doses can cause breathing to slow down so much that breathing stops, resulting in a fatal overdose ExamOne Confidential – Do not copy or distribute | 29 National Vital Statistics - multiple drug deaths - 2011 • 38,329 drug overdose deaths in USA; 58% - more than single drug • Of the pharmaceutical-related deaths from overdose 74.3% were unintentional 17.1% were intentional (suicides) 8.4% were of "undetermined intent“ • Most common medications (in combination or alone) 75.2% - opioids 29.4% - benzodiazepines 17.6% - antidepressants 7.8% - drugs used for epilepsy and Parkinson's disease • Opioids present in many deaths involving other drugs In 77.2% of benzodiazepine deaths In 65.5% of anti-epileptic and anti-parkinsonism drug deaths In 58% of antipsychotic and neuroleptic drug deaths In 57.6% of antidepressant drug deaths In 56.5% other analgesics, anti-pyretics, and anti-rheumatics ExamOne Confidential – Do not copy or distribute | 30 Quest Diagnostics Health Trends™ • Series of analyses on status of nation’s health • Quest database – de-identified data • 1.5 million patient encounters since 2000 • Laboratory information on majority of conditions and diseases • Identify and track diseases and trends ExamOne Confidential – Do not copy or distribute | 31 Quest Diagnostics Health Trends™ Prescription Drug Monitoring Report 2012 • 75,997 de-identified urine specimen results performed in 2011 (no rehab) – Included results of patients of both genders – ranging in age from 10 years old and above – from 45 states and the District of Columbia. • Objective - to assess the scope and demographic drivers of prescription drug misuse in America and impact of laboratory testing on monitoring for prescription drug adherence • Patients tested for presence of up to 26 commonly prescribed medications, including analgesics, and illicit drugs, such as cocaine and marijuana • Laboratory results characterized as “Consistent” or “Inconsistent” Quest Diagnostics 2012 ExamOne Confidential – Do not copy or distribute | 32 Misuse of Drugs • “Consistent:” only prescribed drugs were detected • “Inconsistent:” a) did not take prescribed drugs b) took prescribed drugs plus other unauthorized drugs/substances c) took only unprescribed or unknown drugs/substances Quest Diagnostics 2012 ExamOne Confidential – Do not copy or distribute | 33 Gender breakdown ExamOne Confidential – Do not copy or distribute | 34 Age range differences ExamOne Confidential – Do not copy or distribute | 35 Summary of Quest Diagnostics 2012 study • Majority of patients misused their prescription drugs – across all demographics • “Inconsistent” does not necessarily mean misuse • 6 out of 10 patients showed inconsistencies: - Clinicians may not have asked pertinent questions about all medications - If asked, patients may not have been forthright • Further points on “inconsistent” results - Less affluent may limit or forego - Patients may not know what doctor has prescribed - Can’t be assumed that follow-up testing will be the same ExamOne Confidential – Do not copy or distribute | 36 Marijuana • Cannabis sativa – affects areas of brain: pleasure, memory, thinking, coordinated movement; THC – psychoactive chemical • Health risks – neurological functioning, cardiovascular and mental health risks in adults, carcinogens in smoke (not linked to lung CA) • Some studies show marijuana use precedes use of other potentially dangerous drugs; 2.5x more likely to misuse prescription drugs • 29 million Americans (11.5%) using in 2010 • Eighteen states allow medical marijuana • Colorado and Washington – 2012 legal Fiellin L, Tetrault J, Becker W, Fiellin D, Hoff R. Previous use of alcohol, cigarettes, and marijuana and subsequent abuse of prescription opioids in young adults. Journal of Adolescent Health, August 2012 ExamOne Confidential – Do not copy or distribute | 37 Quest Diagnostics Health Trends™ Prescription Drug Monitoring Report 2013 • Report on marijuana and prescription drugs • Quest Diagnostics medical and health informatics experts analyzed 227,402 de-identified urine specimen results performed in 2011 and 2012 – Included results of patients of both genders – ranging in age from 10 years old and above – from 45 states and the District of Columbia. • Objective- to focus on the role of marijuana in the use, and misuse, of prescription and other illicit drugs • Patients tested for presence of up to 26 commonly prescribed and misused drugs (pain medications, CNS meds, amphetamines) as well as illicit drugs • Laboratory results characterized as “Consistent” or “Inconsistent” ExamOne Confidential – Do not copy or distribute | 38 Key findings • Prescription drug misuse continues to be highly prevalent – 60% • Marijuana was the most misused drug - 26% • Recreational marijuana users more likely than non-users to misuse other drugs; 45% THC + used other non-prescribed drugs vs. 36% non-users • Those using prescription cannabinoids: not more likely to misuse other drugs than non-marijuana users • Dr. Harvey Kaufman, Quest – “decline in misuse. . . not the case” QuestDiagnostics.com/dms/Documents/healthtrends/2013_health_trends_prescription_drug_misuse. ExamOne Confidential – Do not copy or distribute | 39 Other misused drugs In Quest Diagnostics study, marijuana was the most frequently detected nonprescribed drug. Non-prescribed marijuana was detected in more than one in four patients (26%) with inconsistent test results. ExamOne Confidential – Do not copy or distribute | 40 Recreational marijuana users – 1.3x more likely to use more Among recreational marijuana users, the most frequently detected additional nonprescribed drugs were sedative medications, such as alprazolam and oxazepam, and narcotic pain killers, such as hydromorphone; ExamOne Confidential – Do not copy or distribute | 41 Costs associated with prescription drug misuse • Fighting wrong war? $15 billion on illicit drugs • Coalition Against Insurance Fraud 2007 study: the annual cost to health insurers due to the nonmedical use of prescription painkillers - $72.5 billion • Doctor shoppers cost insurers $10,000 to $15,000 apiece • 2011 Study: Loss in total productivity - $42 billion Criminal justice costs - $8.2 billion • Department of Justice - estimated annual costs related to health, crime and productivity associated with illicit drug use, including prescription drug misuse, total more than $193 billion Centers for Disease Control and Prevention 2012 James O'Toole @CNNMoney February 24, 2012 ExamOne Confidential – Do not copy or distribute | 42 How do we reduce the abuse? • Prescription Drug Monitoring Programs (PDMPs) - databases used to track the prescribing and dispensing of controlled prescription drugs to patients • Patient review and restriction programs • Health care provider accountability • State laws to prevent Rx drug misuse and diversion-doc shopping & pill mills • Better access to substance misuse treatment • Synthetic Drug Abuse Prevention Act of 2012 – outlaw 2C-E • FDA – tighter regulations for Hydrocodone; restrict to 90 day supply; Schedule II • ER docs – “ask the right questions; save more lives, they don’t want to die” ExamOne Confidential – Do not copy or distribute | 43 Insurance drug screens Drug 5 Drug 8 • Amphetamine/Methamphetamine • Amphetamine/Methamphetamine • Cocaine • Cocaine • Opiates (codeine, morphine) • Opiates (codeine, morphine) • Phencyclidine (PCP) • Phencyclidine (PCP) • Marijuana (THC) • Marijuana (THC) • Methadone • Benzodiazepine • Barbiturates ExamOne Confidential – Do not copy or distribute | 44 Detection • Screening by Immunoassay • Confirmation by Gas Chromatography/Mass Spectrometry (GC/MS) ExamOne Confidential – Do not copy or distribute | 45 Protective solutions • Expanded opiate panel • Prescription drug history ExamOne Confidential – Do not copy or distribute | 46 Expanded opiate panel • Current opiate panel – codeine, morphine, heroin • Not sensitive enough! • Opiate screen; 300 ng/mL cutoff; good cross-reactivity with hydrocodone Will report - morphine/codeine/hydrocodone/hydromorphone/oxycodone, if confirmed • Oxycodone screen; 100 ng/mL; will report - oxycodone/oxymorphone, if confirmed. • More poppy seed positives ExamOne Confidential – Do not copy or distribute | 47 Prescription drug history • Broad access to prescription drug records Results of five-year history Detailed drug and insurance eligibility information Treating physicians Drug indications Pharmacy information • Critical real-time insight in assessing an applicant’s risk • Data underwriters can utilize ExamOne Confidential – Do not copy or distribute | 48 Possible? ExamOne Confidential – Do not copy or distribute | 49 Raise awareness ExamOne Confidential – Do not copy or distribute | 50 References • LA Times Legal drugs, deadly outcomes By Scott Glover, Lisa Girion. Video and photos by Liz O. Baylen November 11, 2012 • Valarie Honeycutt Spears. Ky. sees rise in overdose deaths from pills obtained in Fla. Lexington Herald-Leader 2009 Apr 12. Available from URL: http://www.kentucky.com/2009/04/12/758845/ky-sees-rise-in-overdose-deaths.html. • Cathy McKitrick. Youth’s overdose sends strong message. Salt Lake City Tribune 2011 May 17. Available from URL: http://www.sltrib.com/sltrib/news/51689248-78/prescription-drugs-drug-watson.html.csp. • CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008. MMWR 2011; 60: 1-6 • Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network: selected tables of national estimates of drug-related emergency department visits. Rockville, MD: Center for Behavioral Health Statistics and Quality, SAMHSA; 2010. • Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: volume 1: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2011. Available from URL: http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.htm#2.16. • CDC. Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, 19992006. NCHS Data Brief;22 Sept 2009. Available from URL: http://www.cdc.gov/nchs/data/databriefs/db22.pdf . • Substance Abuse and Mental Health Services Administration. Substance abuse treatment admissions by primary substance of abuse, according to sex, age group, race, and ethnicity 2009 (Treatment Episode Data Set). Available from URL: http://wwwdasis.samhsa.gov/webt/quicklink/US09.htm. • Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SRB. Characteristics of opioid prescriptions in 2009. JAMA 2011;305(13):1299–1301. • Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, Bixler D, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA 2008;300(22):2613-20. ExamOne Confidential – Do not copy or distribute | 51 Thanks for your time Betsy Sears [email protected] 913.577.1306 ExamOne Confidential – Do not copy or distribute | 52