1. Educa&on
and
Advocacy
Track:
Overview
of
State
Strategies
to
Stop
the
Epidemic
Presenters:
Sherry
L.
Green
Joanna
Katzman,
MD,
MSPH
Jennifer
Weiss,
MBA,
BSIT
Moderator:
Karen
H.
Perry,
2. Disclosures
• Sherry
L.
Greenhas
disclosed
no
relevant,
real
or
apparent
personal
or
professional
financial
rela&onships.
• Joanna
Katzman
has
disclosed
no
relevant,
real
or
apparent
personal
or
professional
financial
rela&onships.
• Jennifer
Weiss
has
disclosed
no
relevant,
real
or
apparent
personal
or
professional
financial
rela&onships.
3. Learning
Objec&ves
1. Outline
implementa&on
strategies
to
reduce
prescrip&on
drug
abuse
based
on
the
successes
New
Mexico
has
had
specifically
with
prescribers,
medical
facili&es,
legislatures,
educators,
and
other
key
stakeholders.
2. Build
a
statewide
coali&on
comprised
of
an
academic
medical
center,
state
agencies,
community
coali&ons,
legislatures,
and
key
community
stakeholders
in
an
effort
to
reduce
overdose
death
rates.
3. Iden&fy
resources
to
advocate
for
change,
with
specific
focus
on
state
strategies.
4. 2014 NATIONAL PRESCRIPTION DRUG
ABUSE SUMMIT
EDUCATION & ADVOCACY TRACK:
OVERVIEW OF STATE STRATEGIES TO
STOP THE EPIDEMIC
APRIL 22, 2014 3:15 P.M. – 4:30 P.M.
SNAPSHOT OF SELECTED STATE
PRESCRIPTION DRUG LAWS & POLICIES
SHERRY L. GREEN, CEO
NATIONALALLIANCE FOR MODEL
STATE DRUG LAWS (NAMSDL)
5. NAMSDL
● 501(c)(3) non-profit corporation
● Successor to the President’s Commission of
Model State Drug Laws
● 20 years
● Congress funds NAMSDL’s services
● Provides legislative and policy services on
over 40 types of drug and alcohol laws to
stakeholders at the local, state, and federal levels
6. TYPES OF LAWS & POLICIES USED TO
ADDRESS PRESCRIPTION DRUG
PROBLEMS
● State prescription drug monitoring programs
(PMPS)
● Regulation of pain clinics/pain management
● Prescribing & dispensing guidelines/practices
● Proper disposal of unused medications
● Education for the public and health care
providers
7. ● Treatment & prevention
● Good Samaritan & naloxone access
● Identification of person picking up prescription
● Lock-in programs
● Doctor shopping
8. SNAPSHOT OF FOUR TYPES
● State PMPs
● Regulation of pain clinics/pain management
● Prescribing & dispensing guidelines/practices
● Good Samaritan & naloxone access
9. MORE RESEARCH NEEDED
● National Governors Association
Reducing Prescription Drug Abuse: Lessons
Learned from an NGA Policy Academy,
February 2014
● More research needed to determine:
Effective interventions to reduce abuse
Effective approaches to change prescribing
Effective public messaging to change
consumer behavior
10. STATE PRESCRIPTION DRUG MONITORING
PROGRAMS (PMPS)
Law and Policy
● Statewide electronic databases that collect
prescription controlled substance data
● 49 states and D.C. have laws
● 48 PMP programs operational
11. ● Increase usefulness of PMPs as health care tools
Allow delegates/authorized agents for
prescribers and dispensers
Expand healthcare professionals who can use
PMP data
Medical examiners/coroners
Increase frequency of dispenser reporting
Oklahoma – real-time reporting
Most states – 7 days/weekly
12. Provide interstate data sharing
Permit proactive alerts
Mandate registration for prescribers/
dispensers
No clear consensus about usefulness
Mandate use by prescribers/dispensers
No clear consensus about usefulness
13. Research – surveys, studies, assessments
● State practitioners surveys in OH, KY, OK, and
OR suggest that PMPs can enhance patient care
and patient safety by:
Helping practitioners become more
informed prescribers, and
Helping practitioners determine if a patient
may have an abuse or addiction problem
14. Example: Use of OHIO OARRS data by ER
physicians (2009)
41% changed patient prescription plan
61% of patients received fewer or no opioids
39% of patients received more pain
medication than planned
Baehren, DF, Marco CA, Droz DE, Sinha S,
Callan EM, Akpunonu P. A statewide
prescription monitoring program affects
emergency department prescribing behaviors.
Annuals of Emergency Medicine, 2010 Jul; 45
(1):19-23
15. ● 2014 evaluation of impact of state PMPs on opioid
dispensing
Implementation of state PMPs through 2008 had
no measurable overall impact on prescription
opioids dispensed
Result likely related to unexamined factors:
interstate sharing, frequency of reporting,
education about PMP, restrictions on access,
integration into health care systems
J Brady, H Wunsch, C DiMaggio, B Lang, J
Giglio, G Li. Prescription Drug Monitoring and
Dispensing of Prescription Opioids. Public Health
Reports, March-April 2014; vol. 129: 139-147.
16. ● 2012 analysis of Poison Control Center data
In states with PMPs, rate of increase in opioid
misuse/abuse less than in states with no PMP
Independent of # of patients filling
prescriptions
Reifler L., Droz D, Bailey J, Schnoll S, Fant
R, Dart R et al. Do prescription monitoring
programs impact state trends in opioid abuse/
misuse? Pain Medicine 2012; 3(3):434-42.
17. REGULATION OF PAIN CLINICS/PAIN
MANAGEMENT
Law and Policy
● 9 states with pain clinic regulation acts
● Definition of “pain clinic”
publicly or privately owned facility
majority of patients in a specific time frame,
usually a month, are prescribed or dispensed
certain substances, e.g., opioids
18. ● Ownership eligibility
Example: Must be physician with unrestricted
license
● Certification and training requirements for
owners and practitioners at clinic
● Prescribing and dispensing restrictions
● Requirement to access state PMP
● Owners/medical directors have to be on site % of
operating hours
19. ● Indiana
State medical licensing board required to
issue rules for prescribing of controlled
substances
December 2013 – emergency rules for use of
opioids for chronic pain patients receiving
certain dosage amounts
Requirements:
Discuss risks/benefits with patient
Schedule periodic visits
Check PMP at beginning of treatment
and annually
20. ● Alabama
All physicians providing pain management
services must register with the medical board
Registrants must access state PMP
21. Research – surveys, studies, assessments
● Florida – University of Central Florida, Criminal
Justice Assistant Professor Jacinta Gau
“Pill mill” legislation implemented as designed
Impact of legislation
● Kentucky – University of Kentucky, College of
Pharmacy, Institute for Pharmaceutical Outcomes
and Policy
Unintended consequences of pain clinic and
other laws
Recommendations for improvements
22. PRESCRIBING & DISPENSING GUIDELINES/
PRACTICES
Law and Policy
● Seven commonly recommended prescribing
practices for non-cancer or chronic pain
Required or recommended education on selected
topics
Comprehensive patient exam – physical and
substance abuse screening
Treatment plan
23. Informed consent
Periodic review
Use of state PMP
Recommended steps for high risk patients
Referral to addiction or pain management
specialists
Patient agreements – urine drug testing and
lock-in program
24. Limitations on number of days’ supply or
refills of Schedule II or Schedule III
prescriptions
Maintenance of complete and accurate
medical records
25. Research – surveys, studies, assessments
● Washington state evidence-based prescribing
guidelines
23% reduction in drug overdose death rate
since 2008
National Safety Council, Prescription Nation:
Addressing America’s Prescription Drug Abuse
Epidemic, 2013.
● Federation of State Medical Boards (FSMB),
Model Policy on the Use of Opioid Analgesics in the
Treatment of Chronic Pain, July 2013.
26. GOOD SAMARITAN & NALOXONE ACCESS
Law and Policy
● Good Samaritan – 14 states + D.C.
● Naloxone access – 18 states + D.C.
Removes civil and criminal liability for
prescribers and lay administration
Allows third party prescription
● The Network for Public Health Law, Legal
Intervention to Reduce Overdose Mortality:
Naloxone Access and Overdose Good Samaritan
Laws, March 2014.
27. Research - surveys, studies, assessments
● National Association of State Alcohol and Drug
Abuse Directors (NASADAD), Overview of State
Legislation to Increase Access to Treatment for
Opioid Overdose, December 2013.
Trained bystanders can safely and effectively
administer injections like naloxone
Peers able to administer second dose when
needed and prevent victims from additional
opioid use
No evidence that people will increase drug use
by removing threat of overdose
28. SARAH KELSEY
ACTING CEO
NAMSDL
1598 Gray Fox Trail
Charlottesville, VA 22901
Phone: 703-836-6100, ext. 119
Email: skelsey@namsdl.org
WEBSITE: www.namsdl.org
29. Overview
of
State
Strategies:
The
Crisis
of
Unintended
Opiate
Overdose
Deaths
in
New
Mexico
30. Joanna
Katzman,
MD,
MSPH
Associate
Professor,
Neurosurgery,
University
of
New
Mexico
Director,
University
of
New
Mexico
Pain
Center
Project
ECHO®
Pain
Jennifer
Weiss,
MBA,
BSIT
Execu&ve
Director,
Healing
Addic&on
In
Our
Community
31. Known
as
the
Land
of
Enchantment.
Popula&on:
2,085,500.
Biggest
City
is
Albuquerque.
Popula&on:
552,800.
We
are
NEW
Mexico,
not
Mexico.
Yes,
we
have
running
water.
We
are
home
to
the
largest
interna&onal
hot
air
balloon
fiesta.
You
will
be
asked
“red,
green
or
Christmas”
at
every
Mexican
food
restaurant
you
venture
into.
Facts
About
New
Mexico
32. Healing
Addic&on
in
Our
Community
501c3
Non-‐Profit
Dedicated
to
educa&on
and
awareness
regarding
substance
abuse
issues.
40+
volunteer
member
base
comprised
of
parents
and
people
in
recovery.
Speaking
engagements
(over
5,000
people),
advocacy,
grade
school
and
college
educa&on
programs,
legisla&ve
support,
provide
assistance
finding
treatment
resources.
Opening
NM’s
1st
Adolescent
Transi&onal
Living
Center.
33. Rest in Peace!
Grieve not, nor speak of me with tears, but laugh
and talk of me as if I were beside you there.!
34. Drug
Overdose
Death
Rates
Leading
States,
U.S.,
2009
Sources: CDC Vital Signs
Rates are age-adjusted to the 2000 US Standard Population.
35. 0.0
5.0
10.0
15.0
20.0
25.0
30.0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012*
Deaths
per
100,000
persons
Year
Drug
Overdose
Death
Rates
New
Mexico
and
United
States,
1990-‐2012
New
Mexico
United
States
36. 0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Union
Cibola
Curry
United
States
Luna
McKinley
Roosevelt
Lea
Los
Alamos
San
Juan
Dona
Ana
Sandoval
Chaves
Otero
Lincoln
Socorro
Colfax
New
Mexico
Valencia
Guadalupe
Eddy
Santa
Fe
Torrance
Bernalillo
Hidalgo
Grant
Taos
San
Miguel
Quay
Catron
Sierra
Mora
Rio
Arriba
Age-‐adjusted
Rated
per
100,000
persons
Drug
Overdose
Death
Rates
by
County
New
Mexico,
2008-‐2012*
and
U.S.,
2010
37. Senate
Bill
159
Added
new
sec&on
to
the
New
Mexico
Drug,
Devise
and
Cosme&c
Act
in
regard
to
prescrip&on
opioids
which:
Required
a
discussion
with
pa&ent
and
provide
educa&onal
pamphlet
on
opiate
addic&on/risk.
Required
that
prac&&oners
receive
wrilen
consent
from
pa&ents
receiving
opiates
for
the
first
&me
indica&ng
that
they
understand
the
risk.
Limited
those
with
cancer
pain,
chronic
pain,
or
those
in
hospice
care
to
a
30
day
supply
per
Schedule
II
opioid
prescrip&on.
Limited
those
with
acute
pain
or
cough
to
a
7
day
supply
per
Schedule
II
opioid
prescrip&on.
Forbade
refills
for
prescrip&on
opioids.
Mandated
use
of
a
Prescrip&on
Drug
Monitoring
Report.
38.
39. Senate
Bill
215
–
Passed
Senate
and
House
in
2012
Amended
the
pain
Relief
Act
in
the
following
ways:
Provided
specific
defini&ons
of
“chronic”
and
“acute”
pain.
Called
on
licensing
boards
to
adopt
rules,
standards,
and
procedures
for
the
applica&on
of
the
Pain
Relief
Act.
Required
provider
con&nuing
educa&on
(CEUs)
for
the
treatment
of
non-‐cancer
pain
management.
Established
the
Prescrip&on
Drug
Misuse
and
Overdose
Preven&on
and
Pain
Management
Advisory
Council
alached
to
DOH.
Mandatory
use
of
the
Prescrip&on
Drug
Monitoring
Program
(PDMP)
by
all
prescribers.
40.
41. In
2012….
NM
now
requires
all
clinical
licensing
boards
to
mandate
CME
specific
to
pain
and
addic&on.
NM
Medical
Board
and
other
clinical
licensing
boards
require
use
of
Prescrip&on
Monitoring
Program
(PMP)
at
least
on
ini&al
use
of
chronic
opioids
and
every
6
months.
NM
Board
of
Pharmacy
upgrades
PMP
to
share
data
with
other
states
regionally.
NM
Governor
developed
the
Prescrip&on
Drug
Misuse
and
Overdose
Preven&on
and
Pain
Management
Advisory
Council.
42.
43. Rules
and
Values:
A
Coordinated
Regulatory
and
Educational
Approach
to
the
Public
Health
Crises
of
Chronic
Pain
and
Addiction
• UNM
Health
Sciences
Center
• Joanna
G.
Katzman,
MD,
MSPH
• Cynthia
M.
A.
Geppert,
MD,
PhD,
MPH
• George
D.
Comerci,
MD,
FACP
• Sanjeev
Arora,
MD,
FACP
• Summers
Kalishman,
PhD
• Lisa
Marr,
MD
• Chris
Camarata,
MD
• Daniel
Duhigg,
DO,
MBA
• Jennifer
Dillow,
MD
• Eugene
Koshkin,
MD
• Denise
E.
Taylor,
MD
• Healing
Addic[on
In
Our
Community
• Jennifer
Weiss,
MBA,
BSIT
• Project
ECHO®
Ins[tute
• Sanjeev
Arora,
MD,
FACP
• Joanna
G.
Katzman,
MD,
MSPH
• George
D.
Comerci,
MD,
FACP
• Daniel
Duhigg,
DO,
MBA
• NM
Department
of
Health
• Michael
Landen,
MD,
MPH
• NM
Board
of
Pharmacy
• Larry
Loring,
RPH
• NM
Medical
Board
• Steven
M.
Jenkusky,
MD,
MA,
FAPA
• Presbyterian
Health
Care
Services
• Steven
M.
Jenkusky,
MD,
MA,
FAPA
• NM
Veterans’
Affairs
Health
Care
System
• Cynthia
M.
A.
Geppert,
MD,
PhD,
MPH
44. University
of
New
Mexico
Pain
Center
and
Project
ECHO
Pain
Clinical
Centers
of
Excellence
-‐
American
Pain
Society
UNM
Pain
Center-‐
the
only
interdisciplinary
Pain
Center
with
integrated
addic&on
services
in
New
Mexico
Project
ECHO
Pain-‐
began
in
2009,
par&cipants
include
primary
care
clinicians
from
New
Mexico
and
throughout
the
United
States
ECHO
Pain
Program
replicated
by
University
of
Washington
(TelePain),
UC
Davis,
Community
Health
Centers
(CHC),
the
VA
(SCAN-‐ECHO),
the
DoD
(Army
Pain
ECHO),
the
Indian
Health
Service
(ECHO
Pain
and
Addic&on),
and
Canada
(ECHO
Ontario
Pain
and
Addic&on)
University
of
New
Mexico
45. Family
Medicine
Internal
Medicine
Pediatrics
Psychiatry
Emergency/Urgent
Care
Series1
356
150
79
76
72
356
150
79
76
72
0
50
100
150
200
250
300
350
400
Total
=
733
Table
1:
Most
represented
UNM
Pain
Center
Course
par[cipants
by
MD
and
DO
specialty
46. NP
PA
DDS
CNM
Series1
214
113
18
12
214
113
18
12
0
50
100
150
200
250
Total
=
357
Table
1:
Most
represented
UNM
Pain
Center
Course
par[cipants
by
profession
for
non-‐physician
clinicians
47. 0
200,000,000
400,000,000
600,000,000
800,000,000
1,000,000,000
1,200,000,000
2008
Jan-‐
Jun
2008
Jul-‐
Dec
2009
Jan-‐
Jun
2009
Jul-‐
Dec
2010
Jan-‐
Jun
2010
Jul-‐
Dec
2011
Jan-‐
Jun
2011
Jul-‐
Dec
2012
Jan-‐
Jun
2012
Jul-‐
Dec
2013
Jan-‐
Jun
Total
MME
of
Opioids
Dispensed
Total
MME
of
Opioids
Dispensed
48. 0
200
400
600
800
1,000
1,200
1,400
2008
Jan-‐
Jun
2008
Jul-‐
Dec
2009
Jan-‐
Jun
2009
Jul-‐
Dec
2010
Jan-‐
Jun
2010
Jul-‐
Dec
2011
Jan-‐
Jun
2011
Jul-‐
Dec
2012
Jan-‐
Jun
2012
Jul-‐
Dec
2013
Jan-‐
Jun
Opioid
MME
per
prescrip[on
Opioid
MME
per
prescrip&on
49.
50. 0.0
5.0
10.0
15.0
20.0
25.0
30.0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012*
Deaths
per
100,000
persons
Year
Drug
Overdose
Death
Rates
New
Mexico
and
United
States,
1990-‐2012
New
Mexico
United
States
51. Drug
Overdose
Death
Rates
Leading
States,
U.S.,
2010
Sources: CDC Wonder
Rates are age-adjusted to the 2000 US Standard Population.
52. The
NM
Board
of
Pharmacy
has
noted
a
7%
decline
in
the
quan&ty
of
Schedule
II
and
Schedule
III
controlled
substances
dispensed
in
the
first
6
months
of
2013.
Opiate
prescrip&ons
and
benzodiazepines
decreased
more
than
7%
sugges&ng
safer
controlled
substance
prescribing.
New
Mexico
had
35
fewer
overdose
deaths
in
2012
compared
to
2011.
Down
from
521
deaths
to
486.
In
Summary:
53. Mandatory
PDMP
usage
Doctor
Shopping
laws
Support
for
Substance
Abuse
treatment
services
through
Medicaid
expansion
Prescriber
educa&on
required
Good
Samaritan
Laws
Rescue
Drug
Laws
ID
requirement
for
controlled
substances
Lock-‐in
programs
for
Medicaid
pa&ents
New
Mexico
Scored
10
out
of
10
on
New
Policy
Report
Card
of
Promising
Strategies
to
Help
Curb
Prescrip&on
Drug
Abuse
54. Lessons
Learned:
Iden&fy
ALL
of
your
stakeholders
and
bring
them
on
board
early
in
the
process.
Iden&fy
possible
unintended
consequences
and
acknowledge
them
and
alempt
to
address
them.
Don’t
make
assump&ons.
Address
all
issues
associated
with
whatever
change
you
are
proposing
and
work
with
people
to
find
out
pros
and
cons
from
all
perspec&ves.
Funding….
Ensure
you
have
a
plan
to
address
funding
issues
and
incorporate
this
plan
within
your
strategy.
55. Next
Steps
Increase
prescriber
knowledge
for
beler
pain
management
prescribing
prac&ces.
Increase
and
improve
the
use
of
the
PDMP.
Establish
evidence-‐based
drug
preven&on
programs
in
the
middle
and
high
schools.
Expand
and
improve
access
to
evidence-‐based
drug
addic&on
treatment.
Increase
Medically
Assisted
Treatment
and
the
number
of
Bupenorphine
prescribers.
Increased
Naloxone
distribu&on
statewide
in
communi&es,
pharmacies
(April
2014)
and
first
responders.
