The Prescription Drug Abuse Epidemic & Health Policy

University of VirginiaGNUR 6056

Carrielyn Rhea

An ObituaryPALMYRA, Va. - Christopher J. White of Palmyra, died Dec. 31, 2011, in Dover. He was 32. Chris was born on Oct. 13, 1979, in Greensboro, N.C., to Clifford J. and Linda Brown White. He had lived in Wyoming, Del., for 21 years and worked for Lightning Fence Company in Dover for seven years until his move to Virginia about a year ago. He enjoyed playing video games. Chris is survived by his parents, Cliff and Linda White of Palmyra, Va.; a sister, Carrielyn Rhea and her husband John of Palmyra; two nephews, Zachery and Gabriel; and paternal grandmother, Alice White. A

memorial service will be 2 p.m.,

Monday, Jan. 2, 2012, at the Torbert Funeral Chapel, 1145 E. Lebanon Rd. (Rt. 10), Dover, where friends may call from 1 p.m. until service time.

Christopher J. WhiteWhat his obituary does not say is that Chris was hit by a truck when he was 13 years old and put on high doses of pain medication to keep him comfortable until he passed. But he lived and was discharged 5 months later. The obituary doesn’t say that he expected to go back to life like it was before his accident. It doesn’t say that he realized he could not function without the high doses of pain meds he had in the hospital. It doesn’t say that he used illegal drugs first, then alcohol, and then when arthritis set in at the age of 30 and a bad case of osteomyelitis in his foot, OxyCodone became his drug of choice. It doesn’t say that he got this medication from multiple doctors, his PCP, his pain management doctor, his podiatrist, and sometimes from people selling it on the street. It doesn’t say that his family tried desperately to get him help, but could not afford the costly pain management drug rehabilitation centers. It doesn’t say that after he moved away from his sources, he was able to get clean and stay clean for one year. It doesn’t say that on a hometown visit to celebrate a friend’s birthday, he got some drugs from an old street supplier. He tried to take the amount of OxyCodone he used to take, but his heart couldn’t take it. The obituary doesn’t say that he went to sleep in a chair and never woke up. And it doesn’t say that he died just 9 days before his third nephew was born.How can we prevent such senseless loss?

Objectives• Define the problem• Describe the scope of the problem• Discuss how policy influences prescription drug

abuse• Explain who can impact policies aimed at

curbing prescription drug abuse• Describe past and current legislation on

preventing prescription drug abuse• Discuss nursing implications and the role of

health care providers in decreasing prescription drug abuse

Definition of the Problem• Prescription drug abuse: “the intentional use of a

medication without a prescription; in a way other than as prescribed; or for the experience or feeling it causes” (Prescription Drug, 2011)

• Prescription drug abuse has become a national crisis reaching epidemic proportions in the United States (Fact Sheet, 2011)

• Prescription drugs are the second most abused drug in the United States. Opioid analgesics are the most commonly abused prescription drug (Fact Sheet, 2011).

• More than 12 million Americans over the age of 12 reported using prescription drugs for non-medical purposes in 2010, a number that continues to rise (Fact Sheet, 2011).

• People from every race, age, and socioeconomic status misuse and abuse prescription drugs (Prescription Drug, 2011).

Where are the Drugs Coming From?

(Balwin et al., 2011)

Where are the Drugs Coming From?

• 70% of people report taking opioids for the first time when given to them by a family member or friend.

• The majority of the remaining 25% of people report taking opioids for the first time when prescribed for them after an injury or surgical procedure.

• 5% of people report taking opioids for the first time when purchased from a drug dealer on the street

(Prescription Drug, 2011)

What is the Issue?• Enough pain medicine was prescribed in 2010 to supply

every adult American for one month. Many of these drugs ended up in the hands of people who misused or abused them (Vital Statistics, 2011).

• Overdoses of prescription drugs killed over 15,000 people in the US in 2008, more than 3 times the number of 1999 fatalities (Vital Statistics, 2011).

• Prescription drug abuse costs taxpayers in the United States $534 billion each year in preventable health care and law enforcement services (Drug Abuse, 2007).

• Abusers of opioids often develop tolerance which leads them to graduate to using illicit drugs such as heroin (Drug Abuse, 2007).

• Access to drug rehabilitation is limited, so drug abuse consumes years of ones life with costly health effects (Epidemic, 2011).

More Drugs Means More Deaths

Unintentional Overdose Deaths Involving Opioid Analgesics Parallel Opioid Sales in the United States, 1997–2007

(Balwin et al., 2011)

Overdose Deaths are Increasing

(Balwin et al., 2011)

Public Health Impact• Mental impairment causes

unintentional injuries– Falls and fractures in the

elderly– Motor vehicle accidents in

drivers

• Drug abuse causes intentional injuries

– Self harm related to drugs– Violence to obtain drugs

• IV drugs cause infections– Injections of dissolved tablets

increases HIV and Hepatitis C transmissions

• Drug abuse effects reproductive health

– Congenital defects– Newborn withdrawal

syndrome– Heavy use causes infertility

• Increased drug abuse has increased

– Number of ED visits– Number of people admitted to

substance abuse treatment centers

– Crime and needed law enforcement

• Long-term effects– Enlargement of heart– Liver damage

(Balwin et al., 2011)

How did the issue emerge?• New laws passed “moving from near

prohibition of opioids to use without dosing guidance” in the late 1990s

• Laws were passed as a result of studies done on the pain of cancer patients

• Cure all attitude of Americans• Lack of patient education about effects,

use, addiction, and tolerance of opioids

(Balwin et al., 2011)

The Central QuestionHow can we prevent prescription drug

abuse?• Ensuring that the people who need

prescription pain medication can get it• Preventing them from becoming

dependent and/or addicted to the medication

• Preventing them from giving medication to friends and family members

Who can Solve the Crisis?• Individuals and Families• Communities• Healthcare Providers• Health Insurance Companies• Law enforcement officers• State and Federal Governments

Role of Individuals & Families• Use prescription medication as prescribed by a

healthcare provider only• Ensure that the person the medication is prescribed

for is the only one taking it and that it is never given to someone else

• Keep medication in a secure location and properly dispose of any leftover medication

• Seek help if you or someone you love may be dependent on prescription pain medication

• Talk to your children about prescription drug use and abuse

• Support individuals in recovery• Advocate for legislation on the issue

(Prescription Painkiller, 2011)

Role of Communities• Drug-Free Communities Support Program (DFC)

– Funds communities around the country that are dedicated to identifying and responding to substance abuse issues in their community

• National Youth Anti-Drug Media Campaign– National campaign to prevent and reduce youth drug

use by increasing exposure to anti-drug messages through a highly visible media and activities in the community

• Take-back and disposal locations– Designates locations for people to drop off unused

medications

(Prescription Painkiller, 2011)

Role of Nurses & Healthcare Professionals

• Screen and monitor for substance abuse • Prescribe opioids only when all other treatments for pain have not

been effective• Prescribe only the quantity of opioids needed for the expected

duration of the pain • Prescribe opioids only if you have seen and assessed the patient• Use patient-provider agreements and urine drug tests for people

using prescription opioids chronically• Educate patients about properly using, storing and disposing of

prescription drugs• Educate patients about the risk of addiction and tolerance to

opioids and possible adverse effects• Stay up-to-date on current drug research• Use single-copy, serialized, tamper-resistant paper prescription

forms or E-prescribing

(Prescription Painkiller, 2011)

Role of Health Insurance Companies

• Establish a prescription claims review process to recognize and handle improper prescribing and use of opioids

• Increase coverage for alternative treatments to reduce pain and for treatment of substance abuse

(Prescription Painkiller, 2011)

Role of States• Start or improve prescription drug monitoring

programs (PDMPs), which are electronic databases that track prescriptions for controlled substances in the state

• Identify inappropriate prescribing of opioids by using Medicaid, PDMP, and workers’ compensation data

• Pass, enforce, and evaluate laws to stop “pill mills” (the use of multiple doctors by a patient) and other laws to reduce opioid abuse

• Urge professional licensing boards to revoke licenses for inappropriate prescribing

• Improve access to substance abuse treatment(Prescription Painkiller, 2011)

Current State LegislationTypes of Laws Enacted:• “Doctor Shopping” laws (Arizona)• Immunity (New Mexico)• Interstate Sharing of Information (Virginia)• Pain Management Clinic Oversight (Florida)• Physical Examination before Prescribing (Rhode Island)• Prescription Drug Monitoring Programs

– 43 states have enacted PDMP laws• Required Identification before Dispensing (Idaho)• Tamper-Resistant Forms (Tennessee)There are currently about one hundred more pending

prescription drug abuse laws in various state legislatures For a complete list:

http://www.ncsl.org/issues-research/health/prevention-of-prescription-drug-overdose-and-abuse.aspx

(Prevention of, 2012)

Role of the Government• Should there be legislation to prevent prescription drug abuse?• The federal government is:

– Tracking drug overdose trends to better understand the problem– Providing education for health care providers and the American

people about prescription drug abuse – “Developing, evaluating and promoting programs and policies shown

to prevent and treat prescription drug abuse and overdose, while making sure patients have access to safe, effective pain treatment” (Prescription Painkiller, 2011)

– The Obama Administration has adopted the “Prescription Drug Abuse Prevention Plan” which expands on the Administration’s National Drug Control Strategy. It focuses on:

• Education• Monitoring• Proper disposal• Enforcement(Epidemic, 2011)

Government Involvement: The DebateStakeholders For

• Families of those who have died from drug overdoses or who have loved ones addicted to opioids

• Health insurance companies• Law enforcement officers• American College of

Occupational and Environmental Medicine (ACOEM)

• American Nurses Association• National Association of

School Nurses (NASN)

Stakeholders Against

• Pharmaceutical companies

• Americans who make a living by selling prescription pain meds

• Americans living with chronic pain

Physicians are divided on the issue. Some think government legislation will interfere with their prescribing abilities and clinical judgment, while others think it will establish better guidelines for them to follow to enhance their practice

National Legislation• S. 507 and H.R. 1925: Prescription Drug Abuse Prevention and

Treatment Act of 2011– Introduced on March 8, 2011, referred to committees in both the House

and Senate, never enacted– This bill intends to prevent opioid abuse, misuse, and death, establish

guidelines for treating those with opioid dependence, and develop an appropriate reporting system for opioid related deaths

• Provides grants to states and nonprofit organizations for education on opioid abuse

• Provides training requirements for practitioners who prescribe or dispense opioids and requires registered opioid treatment clinics to make arrangements for patients who are not allowed to take controlled substances at home to be able to take the medication under supervision when the clinic is closed

• Prohibits the prescribing or dispensing of a 40 milligram diskette of methadone unless the prescription abides by the Drug Enforcement Administration’s methadone policy

• Requires states who receive controlled substance monitoring grants to provide information about individuals under investigation for drug related offenses to drug enforcement officials, and it requires opioid related deaths to be reported

• Directs the development of a Model Opioid Treatment Program Mortality Report by the administrator of the Substance Abuse and Mental Health Services Administration

• Requires the establishment and implementation of a National Opioid Death Registry by the National Center for Health Statistics to track deaths related to opioids

(Bill Summary, 2011)

National Legislation, cont.• S. Res. 261 designated October 2011 as

“National Medicine Abuse Awareness Month”– Passed and was enacted

• S. 2254 and H.R. 4292: Interstate Drug Monitoring Efficiency and Data Sharing Act of 2012– Introduced March 29, 2012 referred to committees

in both the House and Senate, never enacted– Would direct the establishment of uniform

standards for exchanging information on prescriptions of controlled substances in order to prevent fraud and abuse of controlled substances

(Bill Summary, 2011)

Timeline• 1909-1956

– Shanghai Opium Commission Act of 1909– Smoking Opium Exclusion Act of 1909– Webb-Kenyon Act of 1913– Harrison Narcotics Act of 1914– Volstead Act of 1920– Narcotics Drugs Import and Export Act of 1922– Federal Narcotics Control Board of Prohibition Unit established 1922– Porter Narcotic Farm Act of 1929– Federal Bureau of Narcotics (FBN) established in 1930– Uniform State Narcotics Act of 1932– Marijuana Tax Act of 1937– FDA gets control of drug safety in 1938– Opium Poppy Control Act of 1942– Boggs Act of 1951– Interdepartmental Committee on Narcotics created in 1951– Durham-Humphrey Amendment of 1951– Narcotic Control Act of 1956

Timeline cont.• 1957-1989

– President’s Advisory Commission on Narcotics and Drug Abuse replaces FBN in 1962

– Community Mental Health Centers Act of 1963• Established addiction as a mental illness

– Drug Abuse Control Amendments of 1965– Narcotic Addict Rehabilitation Act of 1966

• Allowed treatment instead of prison time for drug convictions– Comprehensive Substance Abuse Act of 1970

• Replaced all previous federal drug laws• Created the Drug Enforcement Administration (DEA)• Created the National Institute on Drug Abuse (NIDA)

– Drug Abuse Office and Treatment Act of 1972• Set up federal funds for program for prevention and treatment

– Methadone Control Act of 1973– Heroin Trafficking Act of 1973– Drug Abuse Treatment and Control Amendments of 1974 and 1978– Alcohol and Drug Abuse Education Amendments of 1978– Drug Offenders Act of 1984– Analogue (Designer Drug) Act of 1984– Crime Control Act of 1984– Anti-Drug Abuse Act of 1986

Timeline cont.• 1987-2004

– Minimum Drinking Age of 21 established in 1987– Omnibus Drug Abuse Act of 1988

• Created drug-free America as a policy goal• Established the Office of National Drug Control Policy (ONDCP)

– Warning labels placed on all alcoholic beverages by 1989– NIDA, NIMH, & NIAAA became part of NIH– Violent Crime Control and Law Enforcement Act of 1994– Comprehensive Methamphetamine Control Act of 1996– Drug-Free Communities Act of 1997– Media Campaign Act of 1998– Office of National Drug Control Policy Reauthorization Act of 1998– Personal Responsibility and Word Reauthorization Act of 1996

• Eliminated disability benefits for addiction• Denied welfare for drug offenders

– Ecstacy Anti-Proliferation Act of 2000– Vulnerability to Ecstacy Act of 2002– Illicit Drug Anti-Proliferation act of 2003(Presidential Timeline, 2008)

Longest’s Model• Longest’s model of public policy-making

process describes policy formation by three cyclical phases– Policy formulation

• Problem identification• Problem assessment• Policy agenda• Solutions to political circumstances

– Implementation• Enactment of legislation

– Modification• Feedback and evaluation of legislation• Modify as needed

(Cox, 2012)

Longest’s Model

(Cox, 2012)

Longest’s Model for Prescription Drug Abuse

• Legislation on drug abuse in the US has been extensive with a cycle of policy formulation, implementation and modification

• A new problem of prescription drug abuse is not covered under current federal legislation

• Research has already been done and some proposals for policies have been laid out in both the House and the Senate, none have been implemented yet

Predictions for the Future• Prescription drug abuse will not go away on its own, and

more people will die if something is not done soon.• Awareness is being raised through the deaths of many

celebrities to overdoses of prescription drugs and many Drug-free campaigns.

• The CDC has done extensive research on the topic and presented it to the president. The president has approved the “Prescription Drug Abuse Prevention Plan” which emphasizes:

• Education• Monitoring• Proper disposal• Enforcement

• Many states have enacted and/or have pending legislation.• Federal legislation is coming!!!

Policy Alternatives & Recommendations

• The president’s Prescription Drug Abuse Prevention Plan needs to solidify into legislation in order to get the necessary funds

• The implementation, monitoring, and evaluation of prescription drug abuse prevention tools, such as PDMPs, is overseen by individual states

• The CDC has and continues to evaluate the outcomes of prescription drug abuse laws enacted by states

• Since no real federal legislation has passed, states, healthcare workers, families of those who have died from overdoses and health insurance companies need to advocate for better legislation to prevent prescription drug abuse

Nursing & Healthcare Professionals Can Make a Difference

• All healthcare providers, including nurse practitioners are key in the fight against prescription drug abuse

• Join local and national nursing organizations• Write to your local and federal government

representatives• Report co-workers who you have witnessed

stealing narcotics• Use your brain and be responsible with

access to opioids and/or with prescribing power

Less opioids = Less deaths = Less pain for families like mine

ReferencesBill summary & status. (2011). Library of Congress Website. Retrieved from:

http://thomas.loc.gov/Cox, K. Summer 2012. Lecture materials for GNUR 6056.Drug Abuse Prevention. (2007). National Institute on Drug Abuse Website. Retrieved

from: http://drugabuse.gov/Epidemic: Responding to America’s prescription drug abuse crisis. (2011). Executive

office of the President of the United States. Retrieved from: www.whitehouse.gov/sites/default/files/ondcp/.../rx_abuse_plan.pdf

Fact sheet: A response to the epidemic of prescription drug abuse. (2011). Office of National Drug Control Policy. Retrieved from: www.WhiteHouseDrugPolicy.gov

Prescription drug abuse. (2011). National Institute on Drug Abuse website. Retrieved from: http://drugabuse.gov/

Prescription painkiller overdoses in the US. (November 2011). In CDC Vital Signs. Retrieved from: http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html.

Presidential timeline of federal drug legislation in the United States. (2008). Retrieved from: www.udel.edu/soc/tammya/pdf/crju369_presidentTimeline.pdf.

Prevention of prescription drug overdose and abuse. (2012). National Conference of State Legislatures. Retrieved from: http://www.ncsl.org/issue-research/health/prevention-of-prescription-drug-overdose-and-abuse.aspx.

Baldwin, G., Franklin, G., Paulozzi, L., & Kerlikowske, R.G. (2011). Prescription drug overdoses: an American epidemic. Retrieved from: http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf.