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Curbing Prescription Drug Abuse with Patient Review and Restriction Programs

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  1. 1. Curbing Prescription Drug Abuse with Patient Review and Restriction Programs Presenters: • Cecelia M. “CeCe” Spitznas, PhD, Senior Science Policy Advisor, White House Office of National Drug Control Policy • Grant T. Baldwin, PhD, MPH, Director, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC • Jennifer Welch, MPH, Officer, Prescription Drug Abuse Project, The Pew Charitable Trusts Federal Track Moderator: Regina M. LaBelle, JD, Chief of Staff, White House Office of National Drug Control Policy, and Member, Rx and Heroin Summit National Advisory Board
  2. 2. Learning Objectives 1. Explain the value of patient review and restriction programs (PRRs) as tools to help curb Rx drug abuse and coordinate patient care. 2. Describe state Medicaid PRR programs and recent efforts to expand PRR programs to Medicare. 3. Describe the role of PRR programs in the CDC’s Prescription Drug Overdose Prevention for States grant, ONDCP national strategy and federal budget.
  3. 3. The Scope of the National Problem National Rx Drug Abuse Summit March 29, 2016 Cecelia Spitznas, Ph.D. Senior Science Policy Advisor Office of National Drug Control Policy
  4. 4. 0 5,000 10,000 15,000 20,000 25,000 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 opioid analgesic 6,731 7,053 8,132 10,297 11,295 12,243 13,355 16,009 16,624 17,184 17,841 18,690 19,286 18,389 18,483 20,808 cocaine 3,822 3,544 3,833 4,599 5,199 5,443 6,208 7,448 6,512 5,129 4,350 4,183 4,681 4,404 4,944 5,415 heroin* 1,963 1,843 1,784 2,092 2,084 1,879 2,010 2,089 2,402 3,041 3,279 3,038 4,397 5,927 8,260 10,574 NumberofDeaths Drug Poisoning Deaths Involving Opioid Analgesics, Cocaine and Heroin: United States, 1999–2014 % CHANGE 2010 to 2014 +11% +29% + 248% Note: Not all drug poisoning deaths specify the drug(s) involved, and a death may involve more than one specific substance. The rise in 2005-2006 in opioid deaths is related to non-pharmaceutical fentanyl (see http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5729a1.htm). *Heroin includes opium. 12/2015 Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999- 2014 on CDC WONDER Online Database, released 2015. Data were extracted by ONDCP from http://wonder.cdc.gov/mcd-icd10.html on Dec 9, 2015.
  5. 5. 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Synthetic Opioids w/o methadone (T40.4) 730 782 957 1,295 1,400 1,664 1,742 2,707 2,213 2,306 2,946 3,007 2,666 2,628 3,105 5,544 Synthetic Opioids - Methadone (T40.3) 784 986 1,456 2,358 2,972 3,845 4,460 5,406 5,518 4,924 4,696 4,577 4,418 3,932 3,591 3,400 Natural & Semi-Synthetic Opioids (T40.2) 2,749 2,917 3,479 4,416 4,867 5,231 5,774 7,017 8,158 9,119 9,735 10,943 11,693 11,140 11,346 12,159 Other and Unspecified Narcotics (T40.6) 2,888 2,875 2,873 3,140 3,112 2,753 2,864 2,902 2,682 2,918 2,644 2,386 2,810 2,778 2,718 2,552 NumberofDeaths Components of Drug Poisoning Deaths Involving Opioid Analgesics: United States, 1999–2014 % CHANGE 2009 to 2014 +88% -28% + 25% Note: Not all drug poisoning deaths specify the drug(s) involved, and a death may involve more than one specific substance. The rise in 2005-2006 in opioid deaths is related to non-pharmaceutical fentanyl (see http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5729a1.htm). 12/2015 Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015. Data were extracted by ONDCP from http://wonder.cdc.gov/mcd-icd10.html on December 9, 2015. -3%
  6. 6. How the Federal Government is Addressing the Nation’s Opioid & Overdose Epidemic
  7. 7. • Component of the Executive Office of the President • Coordinates drug-control activities and related funding across the Federal Government • Produces the annual National Drug Control Strategy Office of National Drug Control Policy
  8. 8. National Drug Control Strategy The U.S. President’s science-based plan to reform drug policy: 1) Prevent drug use before it ever begins through education 2) Expand access to treatment for Americans struggling with substance use disorder 3) Reform our criminal justice system 4) Support Americans in recovery Signature initiatives: • Prescription Drug Abuse • Prevention • Drugged Driving 2015
  9. 9. Prescription Drug Abuse Prevention Plan Coordinated effort across the Federal Government Four focus areas: 1) Education 2) Prescription Drug Monitoring Programs 3) Proper Disposal of Medication 4) Enforcement
  10. 10. 2015 National Drug Control Strategy – Opioids Policy Focus: Preventing and Addressing Prescription Drug Misuse and Heroin Use Heroin Call-Out Box Additional Monitoring Activities: Review and Restriction Program Additional Disposal Options: Drug Deactivation Systems Overdose Prevention Progress Pregnancy
  11. 11. Centers for Disease Control (CDC) Prescriber Guideline & Prescriber Education • Changing prescriber behavior involves: – establishing safer ways to prescribe controlled substances and monitor patients – and informing prescribers about them. • On March 15th, CDC published a new guideline on using opioids as part of chronic pain management.1 • Education about the guideline will ensure prescribers understand what they can do to prescribe more safely. • To date at least 15 states and the Federal government require their prescribers to be trained on safer prescribing (sources in notes). 1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain-United States, 2016 MMWR Recomm Rep 2016;65:1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
  12. 12. Monitoring Goals PDMP in every state and interoperability among states. Use of the system by prescribers to identify patients potentially at risk for or engaged in prescription drug misuse or at risk for medication interaction. Main Actions Urged adoption of language for Department of Veterans Affairs to share prescription drug data with state PDMPs. Expansion of state data sharing across state lines. Electronic Health System Integration: Pilot projects with ONC and SAMHSA in Illinois, Indiana, Kansas, Michigan, Nebraska, North Dakota, Ohio, Oklahoma, Tennessee, and Washington State.
  13. 13. ‘High Utilizers’ Decreased When Prescribers Required to Consult PDMPs Tennessee’s PDMP law went into effect at the start of 2013. Prescribers now must access the PDMP before prescribing opioids to a new patient. “High utilizer” defined as a person who used 5 prescribers and 5 pharmacies in a 90-day period. High utilizers decreased 47 percent from the fourth quarter of 2011 to the fourth quarter of 2013. Source: Tennessee Department of Health Controlled Substance Monitoring Database Committee. Controlled Substance Monitoring Database 2014 Report to the 108th Tennessee General Assembly, February 1, 2014. Page 5. Available at Linked to 3-19-2016 https://www.tn.gov/assets/entities/health/attachments/CSMD_AnnualReport_2014.pdf 10/6/2014
  14. 14. Pharmacy Benefits Management Approaches: Patient Review and Restriction • The 2011 Prescription Drug Abuse Prevention Plan contained an action item asking the Department of Health and Human Services, the Department of Justice (DOJ), and ONDCP to evaluate existing Patient review and restriction programs (PRRs). • PRRs can limit patients based on unusual claims data to a single provider, pharmacy, or both. • In Medicaid, lock-in period cannot be indefinite, and patients must: o “Have access to Medicaid programs of adequate quality.” o Be notified in writing. • Only 46 states have these programs, and 16 post their eligibility criteria publicly. • More research is needed on PRR effectiveness for reducing overdose or the prevalence of substance use disorders. Source: Roberts AW, Skinner AC. Assessing the present state and potential of Medicaid controlled substance lock-in programs. J Manag Care Pharm. 2014 May;20(5):439-46c. PMID: 24761815
  15. 15. Other Pharmacy Benefits Management Approaches: • Prior Authorization: Requirements that limit access to medications without permission from the pharmacy benefit management company • Preferred Drug List Review: Either removes or add medications to a formulary to encourage use of one medicine (for example a generic) or discourage use of another riskier or more costly medication • PDMP use by Medicaid directors and pharmacy plans (where authorized) • Step Therapy: For new claims automated prescription approval software denies claims for certain medicines unless another has been tried first and the patient has not benefited Source: Garcia MM, Angelini MC, Thomas T, Lenz K, Jeffrey P. Implementation of an opioid management initiative by a state Medicaid program. J Manag Care Spec Pharm. 2014 May;20(5):447-54. http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=18020
  16. 16. President Barack Obama at the West Virginia Community Forum ”It touches everybody – from celebrities to college students, to soccer moms, to inner city kids. White, black, Hispanic, young, old, rich, poor, urban, suburban, men and women. It can happen to a coal miner; it can happen to a construction worker; a cop who is taking a painkiller for a work-related injury. It could happen to the doctor who writes him the prescription.” Source: Remarks by the President at Community Forum, East End Family Resource Center White House Office of the Press Secretary. October 21, 2015. Available at https://www.whitehouse.gov/the-press-office/2015/10/21/remarks- president-community-forum-east-end-family-resource-center
  17. 17. Presidential Memorandum—Addressing Prescription Drug Abuse and Heroin Use • Purposes • Reduce prescription pain medication and heroin overdose deaths; • Promote the appropriate and effective prescribing of pain medications; and • Improve access to treatment. Source: MEMORANDUM FOR THE HEADS OF EXECUTIVE DEPARTMENTS AND AGENCIES Addressing Prescription Drug Abuse and Heroin Use. The White House Office of the Press Secretary. Available at https://www.whitehouse.gov/the-press-office/2015/10/21/presidential-memorandum-addressing-prescription-drug- abuse-and-heroin Linked to October 29, 2015
  18. 18. Additional 2015 White House Announcements Federal Actions FY2016 Budget State/Local/Private Sector Commitments Source: FACT SHEET. Obama Administration Announces Public and Private Sector Efforts to Address Prescription Drug Abuse and Heroin use. White House Office of the Press Secretary. October 21, 2015. Available at https://www.whitehouse.gov/the- press-office/2015/10/21/fact-sheet-obama-administration-announces-public-and-private-sector Linked to October 29, 2015.
  19. 19. CMS Informational Bulletin • To State Medicaid Directors: inform states they may support: – Prescriber education – Strategies to promote PDMP use by Medicaid providers such as including language in Medicaid managed care contracts – Eliminate prior authorization for Medication Assisted Treatment for opioid use disorder – Strategies to increase naloxone provision • preferred drug list – Strategies states can use to reduce methadone prescribing for pain • Remove from the preferred drug list, step therapy, prior authorization, patient review and restriction programs, Source https://www.medicaid.gov/federal-policy-guidance/downloads/cib-02-02-16.pdf
  20. 20. Budget Proposals for the Opioid & Overdose Epidemic $1 Billion in mandatory funding $920 million for Medication-Assisted Treatment for states $50 million for 700 additional providers for substance abuse disorder treatment services $30 million to evaluate medication-assisted treatment programs and determine how to improve services $500 million (increase of $90 million) for DOJ and HHS to: Expand prescription drug overdose strategies at the state level Increase availability of Medication-Assisted Treatment Programs Improve access to Naloxone Some of this funding is specifically provided for rural areas hit hardest by the epidemic Budget includes a pilot program for PAs and NPs to prescribe buprenorphine for opioid use disorder treatment https://www.whitehouse.gov/the-press-office/2016/02/02/ president-obama-proposes-11-billion-new-funding-address-prescription
  21. 21. On the Web WhiteHouse.gov/ONDCP WhiteHouse.gov/DrugPolicyReform On Twitter @ONDCP On YouTube youtube.com/ONDCPstaff Find Us Online
  22. 22. For More Information WHITEHOUSE.GOV/ONDCP
  23. 23. CDC Approach to Curbing Prescription Drug Abuse with Patient Review and Restriction Programs Grant Baldwin, PhD, MPH March 29, 2016 National Center for Injury Prevention and Control Division of Unintentional Injury Prevention
  24. 24. Three Pillars of CDC’s Prescription Drug Overdose Prevention Work IMPROVE DATA QUALITY AND TRACK TRENDS STRENGTHEN STATE EFFORTS BY SCALING UP EFFECTIVE PUBLIC HEALTH INTERVENTIONS SUPPLY HEALTHCARE PROVIDERS WITH RESOURCES TO IMPROVE PATIENT SAFETY
  25. 25. Health System Strategies to Prevent Prescription Drug Overdose • Aligning with recommendations contained within CDC Guidelines • Maximizing use of Prescription Drug Monitoring Programs (PDMPs) • Coordinated Care Plans (CCPs) • Implementing Insurance/payer strategies – Drug Utilization Review – Drug Utilization Management (e.g. prior authorization) – Patient Review and Restriction (PRR) programs
  26. 26. Prescribing Guidelines • Intended for primary care providers • Will apply to patients >18 years old in chronic pain • Not intended for patients undergoing active cancer treatment, palliative care, or end-of-life care • Determining when to initiate or continue opioids for chronic pain • Opioid selection, dosage, duration, follow-up, and discontinuation • Assessing risk and addressing harms of opioid use CLINICAL PRACTICES ADDRESSEDTARGET AUDIENCE
  27. 27. PDMPs • Databases of controlled prescription drugs dispensed by pharmacies • Effective tool for public health surveillance and to inform clinical decision making
  28. 28. Coordinated Care Plans (CCPs) for Patients on Chronic Opioid Therapy • CCPs address the entire system to coordinate patient’s care and promote the best, most effective, and safest treatment • CDC developing, implementing, and evaluating a CCP • Informed by Group Health and the VA to protect patients at the highest risk of opioid addiction and abuse • Intended to assist clinicians and health systems in safely managing patients already on chronic opioid therapy • Includes: • Practice-level elements (i.e., use of MAT) • Clinical elements (i.e., operationalizing CDC guideline recommendations)
  29. 29. Patient Review and Restriction Programs (PRRs) • Require patients to use one prescriber and/or pharmacy for all controlled substance prescriptions
  30. 30. Why Focus on PRRs? • Compared to those with other forms of insurance and/or those who are uninsured, Medicaid patients have higher rates of: – hospitalizations for poisoning by opioids and related narcotics – emergency department visits for drug poisoning • Medicaid patients are prescribed opioid prescriptions at more than twice the rate as people with private insurance • PRRs have the potential to reduce opioid usage for these patients to lower, safer levels and therefore, save lives 1) Agency for Healthcare Research and Quality. Nationwide Emergency Department Sample. 2012 [cited 2012 July 2012]; available from http://hcupnet.ahrq.gov. 2) Raofi S, Schappert SM. Medication therapy in ambulatory medical care; United States, 2003–2004. Vital Health Stat 2006;13(163):1–40.
  31. 31. CDC Convening Among Individual Experts on PRRs: Background • In 2012, CDC convened a meeting among experts to discuss Medicaid Patient Review and Restriction strategies • Individual experts: – Examined current practices of PRR programs – Identified barriers to implementation and suggested strategies and solutions – Found that most challenging barriers were related to funding and staffing shortages Full Report: http://www.cdc.gov/drugoverdose/pdf/pdo_patient_review_meeting-a.pdf
  32. 32. CDC Convening Among Individual Experts on PRRs: Findings • Use objective and subjective criteria that is designed to reflect the needs of each state • Use criteria that are associated with opioid use disorder/overdose (e.g., high daily dosage, number of providers, number of pharmacies) • Facilitate data sharing (e.g., between Medicaid and PDMPs, sharing across states) • Identify problematic providers or pharmacies and prohibit patients from selecting them
  33. 33. CDC Convening Among Individual Experts on PRRs: Findings • Build multi-sector partnerships, leverage resources across departments, and engage with stakeholders • Seek a balanced investment in staffing and automation systems • Evaluate impacts on utilization, patient health, and costs for intended and unintended outcomes • Communicate program successes
  34. 34. Prescription Drug Overdose Prevention for States (PDO PfS) • Provides states guidance and resources to prevent prescription drug overdoses by addressing problematic opioid prescribing • 29 states funded with average award ranging from $750K to $1M • Funding to states with high burden and readiness to act • Focus on high impact, data driven activities and give states flexibility to tailor their work
  35. 35. Enhance and Maximize PDMPs Community or Health System Interventions State Policy Evaluation Rapid Response Projects  Move toward universal PDMP registration and use  Make PDMPs easier to use and access  Move toward a real-time PDMP  Expand and improve proactive reporting  Conduct public health surveillance with PDMP  Implement or improve opioid prescribing interventions for insurers, health systems, or pharmacy benefit managers. This includes:  Prior authorization, prescribing rules, academic detailing, CCPs, PRRs  Enhance adoption of opioid prescribing guidelines  Allow states to move on quick, flexible projects to respond to changing circumstances on the ground and move fast to capitalize on new prevention opportunities.  Build evidence base for policy prevention strategies that work like pain clinic laws and regulations, or naloxone access laws Prevention for States Program 1 2 34
  36. 36. Prevention for States and PRRs • Funded states are advancing innovative work to tie PDMP data into PRR programs – Illinois is leveraging PDMP data to identify recipients who are accessing multiple prescriptions from multiple prescribers or paying cash for prescriptions outside of what they are getting from Medicaid – Tennessee’s PDMP will send automatic alerts regarding a patient’s status to prescribers and providers logged into this patient’s record
  37. 37. PRR Promising Practices: Lessons from Washington State • From 2005-2012, Washington’s PRR program caseload increased from 200 enrollees to more than 3,800 enrollees • Total savings of the PRR through 2012 are estimated at $120 million • Since implementation, the program has seen: – 37% decrease in physician visits – 33% decrease in ED visits – 24% decrease in the number of prescriptions 1. Centers for Disease Control and Prevention. Patient Review and Restriction Programs: Lessons Learned From State Medicaid Programs. CDC, Atlanta, GA (2013) 2. G. Franklin, J. Sabel, C.Jones, J. Mai, C. Baumgartner, C.Banta-Green, D. Neven, & D. Tauben. A Comprehensive Approach to Address the Prescription Opioid Epidemic in Washington State: Milestones and Lessons Learned. American Journal of Public Health: March 2015, Vol. 105, No. 3, pp. 463-469.
  38. 38. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
  39. 39. Patient Review and Restriction Programs: Learning from Medicaid Agencies Jennifer Welch, MPH The Pew Charitable Trusts
  40. 40. What is a Patient Review and Restriction Program (PRR)? • Programs that Medicaid and private insurance plans use to identify and manage patients at-risk for prescription drug abuse • Plan identifies a patient receiving large quantities or duplicative opioids from multiple prescribers or pharmacies • Patient is required to use a designated pharmacy and/or prescriber to obtain controlled substance prescriptions • PRR programs can improve continuity of care • Patient protections ensure access to pain medicine while lowering the risk of overdose
  41. 41. How do PRRs currently operate? www.pewtrusts.org/PRRfactsheet
  42. 42. The Current PRR Landscape • PRRs are widely used in both the public and private sector, including in: – Medicaid fee-for-service programs – Medicaid managed care plans – Private insurance plans • There is also a need for PRRs in Medicare; however, current law does not permit their use in Medicare – Legislation passed in both the House and Senate – Included in the President’s FY 2016 and 2017 Budget requests for HHS1 – Listed as one of 25 quality improvements that should be implemented in OIG’s 2015 Compendium of Unimplemented Recommendations2 – CMS Acting Administrator, Andy Slavitt, expressed his support for PRRs at a Senate Finance Committee hearing in January 20163 1 Department of Health and Human Services (DHHS), “HHS FY2016 Budget in Brief” (2015), http://www.hhs.gov/about/budget/budget-in-brief ; DHHS, “HHS FY2017 Budget in Brief” (2016), http://www.hhs.gov/sites/default/files/fy2017-budget-in-brief.pdf 2 Office of the Inspector General, “Compendium of Unimplemented Recommendations” (2015), http://oig.hhs.gov/reports-and- publications/compendium/files/compendium2015.pdf 3 Healthcare Co-ops: A Review of the Financial and Oversight Controls. Senate Finance Committee Hearing, (2016) (statement of Andy Slavitt, acting administrator of the Centers for Medicare and Medicaid Services), http://www.finance.senate.gov/hearings/healthcare-co-ops-a-review-of-the- financial-and-oversight-controls
  43. 43. Optimizing PRRs in Medicaid • Pew conducted a nationwide survey and literature review of Medicaid PRR programs to provide an overview of program characteristics, structures and trends – 41 states, DC and Puerto Rico completed the survey – Of these, 37 states and DC operate a PRR in Medicaid fee-for-service (FFS) • Published a report that presents the findings from the survey and literature review • States can use the report as a resource to guide program improvements – It can serve as a starting point for encouraging state-to-state dialogue between Medicaid agencies and among other stakeholders
  44. 44. Medicaid PRR Program Outcomes The survey also collected outcomes data: – TN: decreases in controlled substance use when comparing prior to and at least six months after PRR enrollment (n=96) • 51 percent decrease in pharmacies visited • 33 percent decrease in prescribers visited, and • 46 percent decrease in number of paid prescriptions – MN: estimated cost savings of $1.2 million in the first year of patient enrollment (based on projected enrollment of 245) • Reductions in prescriptions, emergency room utilization, and clinic visits • Average savings of $4,800 per patient
  45. 45. Medicaid PRR Program Outcomes (cont’d) – OK: decreases in pre- and post- enrollment (n=52) in the mean monthly average for: • Narcotic claims (from 2.16 to 1.32), • Emergency department visits (from 1.26 to 0.81), • Number of pharmacies visited (from 2.05 to 0.89), and • Number of prescribers seen (from 2.48 to 1.63)
  46. 46. States Structure their Medicaid PRRs in One of Three Ways www.pewtrusts.org/PRRreport
  47. 47. Medicaid PRRs Apply a Variety of Different Criteria to Identify Enrollees www.pewtrusts.org/PRRreport
  48. 48. Pharmacists or Registered Nurses Most Commonly Perform the Clinical Review www.pewtrusts.org/PRRreport
  49. 49. Most Medicaid PRRs Provide Beneficiaries with at Least Thirty Days to Appeal Enrollment www.pewtrusts.org/PRRreport
  50. 50. Most Medicaid PRRs Include All Controlled Substance Prescriptions www.pewtrusts.org/PRRreport
  51. 51. More than Half of Medicaid PRRs Do Not Offer Beneficiaries Additional Services www.pewtrusts.org/PRRreport
  52. 52. Most Medicaid PRRs Do Not Have Access to the State Prescription Drug Monitoring Programs Those that Do Most Frequently Use PDMPs to Monitor Cash Transactions www.pewtrusts.org/PRRreport
  53. 53. Conclusion & Next Steps • Our results show variation among several characteristics, including: – Type of PRR offered – Criteria used to identify patients for enrollment – Additional services offered to beneficiaries • There is an opportunity for program enhancement through further discussions with Medicaid directors and staff • We will begin to work towards the development of recommendations to strengthen PRRs
  54. 54. Thank You Cynthia Reilly, B.S., Pharm. Director, Prescription Drug Abuse Project The Pew Charitable Trusts creilly@pewtrusts.org 202-540-6916
  55. 55. Curbing Prescription Drug Abuse with Patient Review and Restriction Programs Presenters: • Cecelia M. “CeCe” Spitznas, PhD, Senior Science Policy Advisor, White House Office of National Drug Control Policy • Grant T. Baldwin, PhD, MPH, Director, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC • Jennifer Welch, MPH, Officer, Prescription Drug Abuse Project, The Pew Charitable Trusts Federal Track Moderator: Regina M. LaBelle, JD, Chief of Staff, White House Office of National Drug Control Policy, and Member, Rx and Heroin Summit National Advisory Board

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