Dr. Tom Frieden keynote

Centers for Disease Control and Prevention

From Sounding the Alarm to Turning the Tide:Action to Combat the Opioid Epidemic

Tom Frieden, MD, MPHDirector, Centers for Disease Control and Prevention

National Rx Drug Abuse & Heroin SummitMarch 30, 2016

500,000drug overdose deaths since 1999

4x as many Rx opioid deaths in 2013 as in 1999

1999 DRUG OVERDOSE DEATH RATES

Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System

2002 RAPID INCREASE IN DRUG OVERDOSE DEATH RATES

Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System

2005 RAPID INCREASE IN DRUG OVERDOSE DEATH RATES

Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System

2008 RAPID INCREASE IN DRUG OVERDOSE DEATH RATES

Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System

2011 RAPID INCREASE IN DRUG OVERDOSE DEATH RATES

Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System

2014 RAPID INCREASE IN DRUG OVERDOSE DEATH RATES

Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System

The amount of opioids prescribed has

But the pain that Americans report remains

Any one of these could potentially ruin – or end – a patient’s life

Prescriptions for opioids were written by health care providers in 2013

OPIOID PRESCRIBING RATES ARE 3X HIGHER IN SOME STATES THAN OTHERS

Source: MMWR Vital Signs, July 2014. Source: IMS, National Prescription Audit (NPATM), 2012.

SHARP INCREASES IN HEROIN AND OPIOID DEATH RATES IN RECENT YEARS

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

prescription opioid (natural or semi-synthetic opioid or methadone)

illicit opioid (heroin)

unknown whether pre-scription or illicit opioid (synthetic opioid)

any opioid (prescription or illicit)

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Source: CDC/NCHS, National Vital Statistics System, Mortality.

THE OPIOID EPIDEMIC INVOLVES INTERSECTION AND OVERLAP OF BOTH PRESCRIPTION AND ILLICIT OPIATES

3 out of 4 people reporting Rx opioid and heroin use in past year

took Rx opioids first

7 out of 10 people who used heroin in the past year also misused opioids in the

past year

SCOTT COUNTY, INDIANA: SENTINEL EVENT

Epicenter of 2015 injection drug-associated HIV outbreak (Opana)

80% co-infected with HCV

VULNERABILITY TO HIV/HCV INFECTIONS AMONG PERSONS WHO INJECT DRUGS

26 states with 1 or more vulnerable counties

Ranked indexTop 220 counties

TWO GROUPS, TWO DIFFERENT SETS OF NEEDSAddicted/Dependent

Need accessto services

At risk for addiction/dependence

Protect fromdangerous drugs

POSSIBLE TECHNICAL PACKAGE TO STOP THE OPIOID OVERDOSE EPIDEMIC

Rigorous, real-time monitoring with adaptive response

Improve prescribing for pain Improve management of addiction Prescription drug monitoring programs, science-

based guidelines, pain clinic laws, prescribing defaults in EHRs, prior authorization for risky prescriptions, patient review and restriction programs, naloxone prescriptions, etc.

Involve payors including Medicaid/Medicare, health systems, pharmacy benefit plans; clinicians; patients

Increase access to medication-assisted treatment and improve quality and accountability for treatment outcomes

Link people to treatment and support them through recovery and living with addiction

Increase access to naloxone for emergency reversals

Partner with law enforcement Community awareness and support Enforce laws, policies and regulations to reduce

diversion, abuse & overdose Reduce availability of illicit drugs Criminal justice system as entry point for addiction

treatment

Increase awareness of risks and benefits of opioids Promote economic development to reduce

initiation/continuation of drug use

POSSIBLE TECHNICAL PACKAGE TO STOP THE OPIOID OVERDOSE EPIDEMIC

Rigorous, real-time monitoring with adaptive response

Reduce Supply

Improve management of addiction Increase access to medication-assisted treatment

and improve quality and accountability for treatment outcomes

Link people to treatment and support them through recovery and living with addiction

Increase access to naloxone for emergency reversals

Community awareness and support Increase awareness of risks and benefits of opioids Promote economic development to reduce

initiation/continuation of drug use

POSSIBLE TECHNICAL PACKAGE TO STOP THE OPIOID OVERDOSE EPIDEMIC

Rigorous, real-time monitoring with adaptive response

Improve prescribing for pain

Reduce Demand

Prescription drug monitoring programs, science-based guidelines, pain clinic laws, prescribing defaults in EHRs, prior authorization for risky prescriptions, patient review and restriction programs, naloxone prescriptions, etc.

Involve payors including Medicaid/Medicare, health systems, pharmacy benefit plans; clinicians; patients

Partner with law enforcement Enforce laws, policies and regulations to reduce

diversion, abuse & overdose Reduce availability of illicit drugs Criminal justice system as entry point for addiction

treatment

REDUCE SUPPLY: IMPROVE PRESCRIBING FOR PAIN

1. Non-opioid therapy preferred for chronic pain outside of active cancer, palliative, and end-of-life care

2. When opioids are used, start low and go slow

3. Clinicians should always exercise caution when prescribing opioids and monitor all patients closely

PRESCRIPTION OPIOIDS FOR CHRONIC PAINClear risks and uncertain benefits

Nearly all prescription opiates are no less addictive than heroin

ADDICTION

We know of no other medication routinely used for a nonfatal condition that kills patients so frequently

DEATH

Initiation of treatment with opioids is a momentous decision and should be undertaken only with full understanding by both the physician and the patient of the substantial risks involved

MOMENTOUS DECISION

Frieden TR, Houry D. Reducing the Risks of Relief – The CDC Opioid-Prescribing Guideline. N Engl J Med. 2016 Mar 15. [Epub ahead of print].

REDUCE SUPPLY: LAW ENFORCEMENT, OHIOFentanyl seizures closely mirror fentanyl-related deaths

ADDICTION MANAGEMENT AND TREATMENTMost people with addiction are not receiving medication-assisted treatment

No more than 1 mil-

lion

At Least 1.5 million

Receiving MATNot Receiving MAT

Volkow et al. NEJM 2014;370:2063-2066.

COMMUNITY AWARENESS AND SUPPORT Engaged and empowered

communities support patients and families

We can work together to both prevent addiction and support recovery

The structure of our communities structures our lives in many more ways than we recognize

WE ALL HAVE A ROLE TO PLAYPatientsAsk your doctor if an opioid is needed, and if so for how long and what’s the goal

DoctorsConsider other treatments first; start low & go slow; follow up

Health systemsUse guideline to implement own guidance

InsurersStructure evidence-based programs and evaluate strategies to improve patient safety

State governmentsImprove prescribing; maximize PDMPs

Federal governmentContinue to refine based on data; expand access to care including methadone, buprenorphine, naltrexone, naloxone

Public health, law enforcement, industry & communities working together cut crash deaths in halfWE CAN DO THE SAME FOR OVERDOSES

1980

1981

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1997

1998

1999

2000

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2008

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2011

2012

2013

2014

0

5

10

15

20

25 Motor Vehicle Crash Overdose

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Data: NCHS.

POSSIBLE TECHNICAL PACKAGE TO STOP THE OPIOID OVERDOSE EPIDEMIC

Use data to improve performance

Improve prescribing for pain Improve management of addiction

Partner with law enforcement Community awareness and support

DRUG POISONING DEATH RATES HAVE INCREASED IN ALMOST EVERY STATE

West

Virginia

New Hampshire

OhioUtah

Delaware

Tennessee

Massach

usetts

Missouri

Arizona

Connecticu

t

Louisia

naAlaska

Alabama

United States

Distric

t of C

olumbia

Vermont

Idaho

Florid

a

Oregon

Montana

Kansas

Mississ

ippi

Californ

iaTexa

sIowa

Nebraska05

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20102014

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For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov