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The Problem of Misuse and Abuse of Rx Medications in Arizona and a Multi-Systems Approach to Addressing
the Problem
Phillip Stevenson, Ph.D. Director, Statistical Analysis Center
Arizona Criminal Justice Commission
March 15, 2014
Arizona Opioid Prescribing Summit
What do we know about the Misuse and Abuse of Rx Drugs in Arizona?
585 million Class II-IV pills were prescribed in Arizona in 2012
Pain Relievers had the highest percentage of scripts and pills, accounting for 58.5 percent of all CS II-IV pills prescribed
Hydrocodone and Oxycodone accounted for 82.4 percent of all pain relievers prescribed in Arizona 7.9 percent of youth reported past 30-day Rx drug misuse in 2012
Arizona has the 6th highest rate of Rx drug misuse among individuals 12+ years of age in 2012
0
500
1000
1500
2000
2500
3000
2005 2006 2007 2008 2009 2010 2011 2012
Rate
s per
100,0
00 d
ischa
rges
Emergency Department Discharge Rates† for
Drug Related Conditions, 2005-2012 Amphetamine Barbiturates Cocaine Opium Hallucinogens Alcohol
†Discharge rates are measured as visits with mention of drug-related conditions in any of the nine ICD-9CM codes and are not unique.
0
200
400
600
800
1000
1200
2005
2006
2007
2008
2009
2010
2011
2012
2005
2006
2007
2008
2009
2010
2011
2012
2005
2006
2007
2008
2009
2010
2011
2012
2005
2006
2007
2008
2009
2010
2011
2012
2005
2006
2007
2008
2009
2010
2011
2012
2005
2006
2007
2008
2009
2010
2011
2012
<18 years 18-24 years 25-34 years 35-54 years 55-64 years 65+ years
Rate
per
100,0
00 di
scha
rges
Emergency Department Discharge Rates† by Age-Group for Drug Related Conditions, 2005-2012
Amphetamine Barbiturates Cocaine Opium Hallucinogens
†Discharge rates are measured as visits with mention of drug-related conditions in any of the nine ICD-9CM codes and are not unique.
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
2005 2006 2007 2008 2009 2010 2011 2012
Rate
s per
100,0
00 ad
miss
ions
Inpatient Hospitalization Rates† for Drug
Related Conditions 2005-2012 Amphetamine Barbiturates Cocaine Opium Hallucinogens Alcohol
†Admission rates are measured as visits with mention of drug-related conditions in any of the nine ICD-9CM codes and are not unique.
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
2005
2006
2007
2008
2009
2010
2011
2012
2005
2006
2007
2008
2009
2010
2011
2012
2005
2006
2007
2008
2009
2010
2011
2012
2005
2006
2007
2008
2009
2010
2011
2012
2005
2006
2007
2008
2009
2010
2011
2012
2005
2006
2007
2008
2009
2010
2011
2012
<18 years 18-24 years 25-34 years 35-54 years 55-64 years 65+ years
Rate
per
100,0
00 di
scha
rges
Inpatient Hospitalization Rates† by Age-Group
for Drug Related Conditions, 2005-2012 Amphetamine Barbiturates Cocaine Opium Hallucinogens
†Admission rates are measured as visits with mention of drug-related conditions in any of the nine ICD-9CM codes and are not unique.
152 154
232
296 305
0
50
100
150
200
250
300
350
400
450
500
2008 2009 2010 2011 2012
# of
Cas
es
Neonatal Abstinence Syndrome Cases, 2008-2012
Source: Arizona Department of Health Services
12.2 12.0 13.3 13.8
15.1 15.1 14.9
16.8 17.6
16.8 16.3
9.3 10.1 10.0
11.2 10.3
11.1 11.8 12.0
14.1 14.3 14.2
9.2 8.6 9.5 9.7
10.8 11.6 12.0
13.7 14.0 14.0 12.9
18.5 18.0 18.1 18.9
19.6
16.2
13.6
11.6 11.1
12.1 11.4
0
5
10
15
20
25
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Rate
per
100,0
00
Age-adjusted death rates 2002-2012 Drug-induced deaths Alcohol-induced deaths Accidental poisoning deaths Motor vehicle accidents
Drug-induced deaths include all deaths for which drugs are the underlying cause including deaths attributable to acute poisoning by drugs (drug overdoses) and deaths from medical conditions resulting from chronic drug use. A drug includes illicit or street drugs (e.g., heroin or cocaine), as well as legal prescription drugs and over-the-counter drugs; alcohol is not included. ICD10 codes include D52.1, D59.0, D59.2, D61.1, D64.2, E06.4, E16.0, E23.1, E24.2, E27.3, E66.1, F11-16 (.0-.5, .7-.9), F17 (.0, .3-.5, .7-.9), F18-F19 (.0-.5, .7-.9), G21.1, G24.0, G 25.1, G25.4, G25.6, G44.4, G62.0, G72.0, I95.2, J70.2-J70.4, L10.5, L27.0-L27.1, M10.2, M32.0, M80.4, M81.4, M83.5, M87.1, R78.1-R78.5, X40-X44, X60-X64, X85, Y10-14.Accidental poisoning is a subset (ICD10 X40-X49). ICD10 codes for alcohol-induced deaths F10.3-F10.9 F10.0, F10.1 F10.2 G62.1
0.0%
0.0%
0.1%
12.6%
19.8%
20.8%
27.4%
14.6%
3.1%
1.1%
0.5%
0.0%
0.2%
0.0%
0.0%
5.8%
14.0%
21.3%
31.8%
18.7%
4.9%
2.4%
0.9%
0.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
< 1 yr 1-4 yrs 5-14 yrs 15-24 yrs 25-34 yrs 35-44 yrs 45-54 yrs 55-64 yrs 65-74 yrs 75-84 yrs 85+ yrs MISSINGAGE
Drug-induced deaths by age and gender, 2008-2012 (N = 5,303)
Male Female
5,303 drug-induced deaths 2008-2012 Drug-induced deaths include all deaths for which drugs are the underlying cause including deaths attributable to acute poisoning by drugs (drug overdoses) and deaths from medical conditions resulting from chronic drug use. A drug includes illicit or street drugs (e.g., heroin or cocaine), as well as legal prescription drugs and over-the-counter drugs; alcohol is not included. ICD10 codes include D52.1, D59.0, D59.2, D61.1, D64.2, E06.4, E16.0, E23.1, E24.2, E27.3, E66.1, F11-16 (.0-.5, .7-.9), F17 (.0, .3-.5, .7-.9), F18-F19 (.0-.5, .7-.9), G21.1, G24.0, G 25.1, G25.4, G25.6, G44.4, G62.0, G72.0, I95.2, J70.2-J70.4, L10.5, L27.0-L27.1, M10.2, M32.0, M80.4, M81.4, M83.5, M87.1, R78.1-R78.5, X40-X44, X60-X64, X85, Y10-14.
5,036 poisoning 267 (Mental and behavioral disorders)
(107 or 40% were “mental and behavioral disorders due to use of tobacco”)
29 39 61 46 92
364 417
487 491 514
322 363
309 323 269
130
177 155 138 125 76
87 76 52 51
0
200
400
600
800
1000
1200
2008(n = 950)
2009(n = 1,104)
2010(n = 1,114)
2011(n = (1,064)
2012(n = 1,071)
# of d
eath
s
Number of drugs mentioned in drug-induced deaths† 2008-2012 (N = 5,303)
0 1 2 3 4 5 6 7
692 808 805 783 750
163
182 152 162 124
66
72 94 75 104
0
200
400
600
800
1000
1200
2008(n = 921)
2009(n = 1,064)
2010(n = 1,052)
2011(n = 1,020)
2012(n = 979)
# of d
eath
s
Drug-induced poisoning deaths 2008-2012 (N = 5,036)
Unintentional Suicide Homicide Undetermined
52%
29%
5%
4%
3% 2% 2% 1%
1% 0% 0%
0%
Combination of drugs in drug-induced deaths, 2008-2012 (N=5,303)
More than one combination of drugs (n = 2,763)
Single mention of other drugs that are not opium, heroin,opioids, methadone, cocaine, synthetic drug etc. (n = 1,564)
Mental and Behavior disorders (n = 267)
Other Opioids (i.e. codene, morphine) only (n = 217)
Heroin only (n = 153)
Other unspecified narcotics only (n = 102)
Cocaine only (n = 92)
Methadone only (n = 78)
Other synthetic narcotics (e.g. pethidine ) (n = 45)
Benzodiazepine only (n = 18)
Barbiturates only (n = 4)
Opium only (n = 0)
A Multi-Systemic Approach for Reducing Health and Criminal Justice Consequences
The Arizona Prescription Drug Misuse and Abuse Initiative
Awareness of the Problem
Use of the PDMP
Scripts & Pills Dispensed
The AZ Rx Initiative Conceptual Framework
Attitudes & Beliefs
Antecedent Behavior
Availability Misuse and Abuse Consequences
Social Acceptance Perceived Low Risk Expectations of Health Consumer
Unsafe Storage & Disposal Sharing Scripts Lack of Resistance Strategies Lack of Parent-Child Communication
Health ED visits Deaths NAS Tx Admissions
Crime & Delinquency School Suspensions Drunk/High @ School Youth Arrests Rx Drug Investigations DUI-D
Lack of LE
Training DEMAND
SUPPLY
Strategies STRATEGY MODE
Promote PDMP Sign Up & Use
Education & Training
Report Cards
Email Blasts
Certificate Awards
Letters
Door-to-Door
Promote Proper Storage and Disposal Methods
Education & Training (Rx360 Curriculum)
Permanent Drop Boxes and Take-Back Events
Media
Community Events
Patient Handouts
Promote Responsible Prescribing
Education & Training
*Best Practice Consensus Meetings and Documents
*Board and Professional Organization Endorsement
Email Blasts
Report Cards
Enhance Law Enforcement Practices
Education & Training (Rx Drug Crimes Curriculum)
Efficient Reporting System
Increase Public Awareness and Patient Education
Parent and Youth Education & Training (Rx360 Curriculum) - Risks and resistance strategies
*Patient Education - risks and benefits; adherence to treatment; pain management expectations; available alternatives
Media
Community Events
*Enhance Assessment and Referral to Treatment Education & Training
∗ 34 drop boxes are operational in the pilots and two take-back events were held in each site, collecting 5,783 lbs
∗ 5 of 6 hospitals are implementing ED Guidelines ∗ Over 1,100 prescribers are receiving quarterly report cards ∗ 135 professionals have received comprehensive Best Practice
training or door-to-door ∗ 201 Law Enforcement Officers have received Rx Crimes curriculum ∗ 8,137 youth and 834 adults have received the Rx360 curriculum ∗ 17,834 people have been reached via community events ∗ Over 397,000 people have been reached via public messaging and
media methods
Preliminary Process Evaluation Results
∗ PDMP sign up has increased 115% for law enforcement, 53% for prescribers and 149% for pharmacists in the pilot sites
∗ 40% of prescribers are signed up for the PDMP in the pilots vs. 23% at the state
∗ PDMP use has increased 60% for prescribers in Yavapai County ∗ Number of prescribers making the queries increased 14%
Yavapai County Prescription Drug Monitoring Program Results
∗ PDMP sign up has increased 2500% for law enforcement (from 1
to 26), 89% for prescribers and 189% for pharmacists in Pinal County
∗ 28% of prescribers are signed up for the PDMP in Pinal County vs. 23% at the state
∗ PDMP use has increased 14% for prescribers in Pinal County ∗ Increased 18.4% for ED Prescribers & 13.5% for Non-ED Prescribers
∗ Number of prescribers making the queries increased 43% ∗ Increased 80% for ED Prescribers & 39.6% for Non-ED Prescribers
Pinal County Prescription Drug Monitoring Program Results
-12.68%
-6.96%
-1.42%
-10.47%
-24.28%
-10.10%
-30.0%
-25.0%
-20.0%
-15.0%
-10.0%
-5.0%
0.0%Hydrocodone Oxycodone Other Pain Relievers Benzodiazepine Carisoprodol All Pills
Perc
ent R
educ
tion
in P
resc
ript
ions
Percent Change in Yavapai County Controlled Substance Prescriptions
(May 2012 to June 2013)
Arizona Board of Pharmacy: Prescription Drug Monitoring Program
-3.68% -3.59% -2.41%
-8.06%
-21.36%
-5.44%
-25.0%
-20.0%
-15.0%
-10.0%
-5.0%
0.0%Hydrocodone Oxycodone Other Pain Relievers Benzodiazepine Carisoprodol All Controlled
Perc
ent R
educ
tion
in P
resc
ript
ions
Percent Change in Pinal County Controlled Substance Prescriptions
(September 2012 to September 2013)
Arizona Board of Pharmacy: Prescription Drug Monitoring Program
-13.51%
-8.41%
-1.04%
-10.32%
-23.83%
-10.93%
-30.0%
-25.0%
-20.0%
-15.0%
-10.0%
-5.0%
0.0%Hydrocodone Oxycodone Other Pain Relievers Benzodiazepine Carisoprodol All Pills
Perc
ent R
educ
tion
in P
ills
Percent Change in Yavapai County Controlled Substance Prescriptions Pills (May 2012 to June 2013)
Arizona Board of Pharmacy: Prescription Drug Monitoring Program
-2.65% -3.60%
-8.91% -7.73%
-20.45%
-5.90%
-25.0%
-20.0%
-15.0%
-10.0%
-5.0%
0.0%Hydrocodone Oxycodone Other Pain Relievers Benzodiazepine Carisoprodol All Controlled
Perc
ent R
educ
tion
in P
ills
Percent Change in Pinal County Controlled Substance Prescriptions Pills (September 2012 to September 2013)
Arizona Board of Pharmacy: Prescription Drug Monitoring Program
∗ PDMP needs improvement ∗ Not real-time ∗ Online sign-up an improvement but mandatory tutorial still a roadblock ∗ Physicians asking for ability to have office designee
∗ Reimbursement/Patient Satisfaction issue in ED
∗ Need for Community Prescriber Guidelines
∗ Need for Patient Education
∗ Strengthening Referral to Tx
∗ Report cards ∗ Category groupings have been challenging, especially in small areas ∗ Need more rigorous method of establishing “outliers”
∗ Some difficulty reaching adults with Rx360 curriculum
Lessons Learned
