A new CDC document examines the extent of the prescription drug "epidemic" and outlines ongoing and potential solutions. It says the problem requires specific actions by payers, medical providers, and legislative/regulatory authorities.
The CDC cites the following as examples of the extent of the problem:
- Approximately one death every 19 minutes due to unintentional drug overdose occurred in the U.S. in 2007.
- For every death related to an opioid analgesic, nine persons are admitted for substance abuse treatment, 35 visit emergency departments, 161 report drug abuse or dependence, and 461 report nonmedical use of opioid analgesics.
- Rates of misuse and overdose death are highest among men, persons aged 20-64 years, non-Hispanic whites, and poor and rural populations.
- The two main populations at risk for prescription drug overdose are the approximately 9 million persons who report long-term medical use of opioids and the roughly 5 million persons who report nonmedical use -- use without a prescription or medical need.
- Drug distribution of opioid prescribing through the pharmaceutical supply chain was the equivalent of 96 mg of morphine per person in 1997 and approximately 700 mg per person in 2007, an increase of more than 600 percent. "That 700 mg of morphine per person is enough for everyone in the United States to take a typical 5 mg dose of Vicodin every 4 hours for 3 weeks."
Armed with the data, the CDC says prevention should focus on high dosage medical users and persons who seek care from multiple doctors, receive high doses, and likely are involved in drug diversion.
Combining insurance restrictions with prescription data to prevent doctor shopping is cited as a promising way to reduce inappropriate use of opioids. The CDC says state prescription drug monitoring programs or insurance claim information can target users of multiple providers for the same drug.
Insurers can also address the situation by limiting "the reimbursement of claims for opioid prescriptions to a designated doctor and a designated pharmacy," the report says. "Insurers also can identify inappropriate use of certain opioids for certain diagnoses -- e.g., the use of extended-release or long-acting opioids like transdermal fentanyl or methadone for short-term pain."
Medical providers generally receive inadequate training on treating complex chronic pain problems. "As a result, prescribers too often start patients on opioids and expect unreasonable benefits from the treatment," the CDC says.
The report calls for evidence-based guidelines to educate prescribers, especially those in emergency departments. The CDC says the guidelines will be more effective if payer reviews hold prescribers accountable for their behaviors.
Improving legislation and enforcing existing laws is another strategy touted in the report. "Most states now have laws against doctor shopping but they are not enforced uniformly. In contrast, only a few states have laws regulating for-profit clinics that distribute controlled prescription drugs with minimal medical evaluation."
The CDC says laws against pill mills and legislation to require physical exams before prescribing opioids "might help reduce the diversion of these drugs for nonmedical use." Finally, the report lauds the 15 states that require or permit pharmacists to request identification from persons obtaining controlled substances, as of March 2009.
Washington state's efforts to curb opioid misuse is held up as an example of a state that has moved aggressively to address the problem. The report notes Washington's dosing guidelines and its focus on improving practitioner access to pain specialists.
On a national level, the CDC says any policy must "balance the desire to minimize abuse with the need to ensure legitimate access to these medications." It cites the administration plan for addressing prescription drug abuse and the fact that the first component calls for mandatory prescriber education.
In its strategy, Epidemic: Responding to America's Prescription Drug Abuse Crisis, the administration seeks a requirement that prescribers be trained on appropriate prescribing of opioids before obtaining their controlled substance registration from the Drug Enforcement Administration.
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February 9, 2012
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