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WELCOME TO THE 17th SESSION OF THE CDC PUBLIC HEALTH GRAND
I'M TANJA POVERVICH DIRECTOR OF THE GRAND ROUNDS.
I WANT TO WELCOME OUR INTERNAL AND EXTERNAL VIEWERS WHO ARE
FOLLOWING US ALMOST ON TWITTER.
I WOULD LIKE TO POINT OUT THAT THOSE OF YOU WHO ARE INTERESTED
IN GETTING THE CONTINUING EDUCATION CREDIT CAN DO SO GOING
TO THIS WEB PAGE AND TYPING IN THE CODE PHGR.
YOU FIGURE OUT WHAT IT STANDS FOR.
ALLOW ME TO JUST REMIND YOU BECAUSE THIS IS A NICE THING TO
SHOW, WE ARE DRAWING SUBSTANTIAL AMOUNTS OF VIEWERSHIP AND ABOUT
200,000 PEOPLE HAVE WATCHED THE GRAND ROUNDS LAST YEAR ONE WAY
OR ANOTHER.
LIVE VIA YOUTUBE, OR WEBPAGE OR IN ANY OTHER MANNER.
THIS IS THE VALENTINE'S DAY WEEK, AND SINCE THE GRAND ROUNDS
DIDN'T TAKE PLACE ON MONDAY, I WANTED TO WISH EVERYBODY A HAPPY
VALENTINE'S DAY BECAUSE THIS HAS BECOME A DAY NOT JUST FOR
COUPLES BUT FOR PEOPLE WHO ARE FAMILY MEMBERS AND FRIENDS.
I ESPECIALLY WANT TO WISH A BELATED HAPPY VALENTINE'S DAY TO
GRAND BECAUSE HE IS A NEWLYWED.
[ APPLAUSE ] HAVING BEEN MARRIED FOR A WHILE,
I DO HAVE A COUPLE OF WORDS OF WISDOM.
AS HE MOVES ON, THERE WILL BE LESS AND LESS NEED TO TALK, AND
THINGS ARE GOING TO BE UNDERSTOOD WITHOUT EVEN HAVING
TO SAY A WORD.
I ALSO DO WANT TO POINT OUT THAT TODAY WE ACTUALLY HAVE -- WE
HAVE HAD ABSOLUTELY UNBELIEVABLE SPEAKERS FROM ALL PARTS OF OUR
COUNTRY AND THE WORLD, BUT WE DO HAVE A REALLY DISTINGUISHED
SPEAKER WITH US TODAY, MR. GIL KIRLIKOWSKI.
I CONFIRM HE HAS A SENSE OF HUMOR, SO I FEEL BETTER ABOUT
SHOWING THE NEXT FEW THINGS.
WHO IN HIS PREVIOUS LIFE HAD DIFFERENT KINDS OF JOBS, AND ONE
OF THEM IS LOOKING REALLY GOOD IN THE CHIEF OF THE POLICE IN
SEATTLE.
I WAS THINKING SINCE HE'S NOW HAVING THIS JOB, AND YOU KNOW,
SMOOZING WITH THE PRESIDENT, WHAT MIGHT BE HIS NEXT CAREER
AND MAY I SUGGEST THE FOLLOWING.
I THINK THE RESEMBLANCE IS UNKANNE.
SO I REALLY THINK THAT ALL OF US OWE ENORMOUS AMOUNTS OF
GRATITUDE TO HIS OFFICE SXAAND A LOT OF OTHER COLLEAGUES AMONG
THOSE HERE FOR THEIR WORK THEY'RE DOING ON THE ISSUES OF
DRUG ABUSE AND DRUG OVERDOSING.
WE HAVE HAD SEVERAL MONTHS AGO A GROUP OF AN ENTIRE MALE CAST OF
CHARACTERS, AND THIS ONE RESEMBLES THE PREVIOUS ONE.
I THOUGHT THIS IS ANOTHER GROUP OF THE FOUR MUSKETEERS REALLY ON
A MISSION.
THIS TIME, HOWEVER, THERE ARE LADIES, AND THE LADIES ARE FOUR
SPECTACULAR WOMEN FROM GRANDS DIVISION AND INJURY CENTER WHO
HAVE BEEN ABSOLUTELY WONDERFUL TO WORK WITH AND HELP WITH SO
MANY ASPECTS OF PUTTING THIS EVENT TOGETHER.
I REALLY WANT TO RECOGNIZE THEM.
I ALSO WANT TO SAY THAT WORKING WITH MR. CHRISTOPHER JONES HAS
BEEN ABSOLUTELY A PLEASURE AND JOY.
HE'S THE ONE NA SUPPORTS MR.
MR. KIRLIKOWSKI.
THE HIGHER IN THE HIERARCHY PEOPLE ARE, THE EASIER IT IS TO
WORK WITH THEM.
SO I AM PLANNING DR. FREIDEN FOR YOU TO INVITE PRESIDENT OBAMA TO
OUR NEXT GRAND ROUNDS.
WITH THAT I PROVIDE OUR DIRECTOR TO PROVIDE HIS COMMENTS.
>> WELCOME TO PUBLIC HEALTH GRAND ROUNDS AND THANKS TO THE
PRESENTERS AND CONTRIBUTORS FOR THEIR WORK.
YESTERDAY WE RELEASED HEALTH 2010.
THE ONLY MORTALITY STATISTIC GETTING WORSE IS THE INCREASE IN
DEATHS FROM PRESCRIPTION *** ABUSE.
THIS IS A MAJOR PUBLIC HEALTH PROBLEM, AND IT'S GETTING WORSE
AND GETTING WORSE RAPIDLY.
IN JUST THE COURSE OF A FEW DAYS RECENTLY, I WAS REVIEWING
PROGRAMS IN FIVE DIFFERENT AREAS OF CDC.
I HEARD ABOUT AN INCREASED NUMBER OF DEATHS FROM OPIATES,
NOW EXCEEDING WITH PRESCRIPTION OPIATES DEATHS FROM *** AND
*** DEFINED.
MORE BABIES ARE BORN AT RISK FOR CONGENITAL HEART DEFECTS BECAUSE
THEIR MOTHERS HAD BEEN TAKING PRESCRIPTION OPIATES.
I LEARNED ABOUT MORE FALLS AMONG THE ELDERLY WHO ARE TAKING
PRESCRIPTION OPIATES.
ABOUT MORE DRUGGED DRIVING CRASHES.
WITHIN THE INFECTIOUS DISEASE WORLD, A RESURGENCE OF HEPATITIS
C IN AS MANY AS THREE DIFFERENT STATES RELATED TO YOUNG PEOPLE
WHO HAD INITIALLY STARTED ON PRESCRIPTION OPIATES ABUSE AND
THEN GRADUATED, SO TO SPEAK, TO ***, WHICH WAS LOWER COAST
AND HIGH POTENCY.
AN ININCREASECREASE IN INJECTION DRUG
USE RELATED TO A LARGE NUMBER OF PEOPLE ADDICTED TO OPIATES.
OVERALL AN INCREASE FROM 2000 TO 2007 OF PRESCRIPTION OF -- OF
DEATHS FROM POISONING FROM 5 TO 10 AND YOU'LL SEE THE NUMBERS
OVERALL, WHILE EVERYTHING IS GOING DOWN, WE SEE DEATHS FROM
PRESCRIPTION OPIATES GOING UP.
SO YOU'LL NOW HEAR IN THE REST OF THE SESSION MORE DETAILS AND
MORE ACCURATE DETAILS AND MORE SYSTEMIC DETAILS ABOUT THE
BURDEN OF THIS TERRIBLE PROBLEM IN OUR SOCIETY, AND ALSO ABOUT
SOME OF THE WASYS WE MAY BE ABLE TO ADDRESS IT.
ULTIMATELY IN PUBLIC HEALTH WE FOCUS ON POLICY CHANGE, BECAUSE
WE KNOW THAT POLICY CHANGE HAS MADE SUCH AN ENORMOUS DIFFERENCE
IN AREAS SUCH AS MOTOR VEHICLE INJURY.
REDUCING SUPPLY THROUGH POLICY REQUIRES LOTS OF DIFFERENT
PARTNERS AT THE FEDERAL LEVEL, THE STATE LEVEL LOOKING AT
THINGS LIKE OUR PRESCRIPTION DRUG MONITORING PROGRAMS,
GETTING INFORMATION BACK TO DOCTORS TO IMPROVE PERFORMANCE,
USING THE LEVERS THAT THE FEDERAL GOVERNMENT HAS THROUGH
MEDICAID, FOR EXAMPLE, TO LOOK AT WHAT'S BEEN PRESCRIBED AND
WHERE AND IN WHAT QUANTITIES.
LOOKING WHERE LONG-ACTING OPIATES ARE PRESCRIBED AND HOW
TO DRASTICALLY REDUCE THAT TO EFFECTIVELY MANAGE PAIN BUT NOT
HARMFULLY MANAGE PAIN.
LOOKING AT THE ROLE THAT OUR EMERGENCY DEPARTMENTS PLAY IN
THE INAPPROPRIATE PRESCRIPTION OF OPIATES FOR PAIN.
LOOKING AT HOW IN THE NEXT GENERATION OF PHYSICIANS WE CAN
ENSURE THAT ELECTRONIC PRESCRIBING FOR EVERYONE
PRESCRIBING IN THE NEXT FEW YEARS IS SECURE, RESPECTS
PRIVACY, AND CAN DRASTICALLY REDUCE INAPPROPRIATE
PRESCRIPTION OF *** AND OTHER DRUGS.
LOOKING AT ENFORCEMENT ISSUES WITH THE EA AND OTHERS AND HOW
TO ADDRESS PILL MILLS AND UNETHICAL PHYSICIANS WHO ABUSE
THEIR LICENSE TO HARM PATIENTS BY PROVIDING LARGE
KWAUNTSQUANTITIES OF OPIATES.
THE PRESCRIBING OF DRUGS IS LARGELY REGULATED BY STATES, AND
STATE CONTRIBUTION IS CRUCIAL.
ONE OF OUR SPEAKERS TODAY WILL TALK ABOUT STEPS TAKEN IN
WASHINGTON STATE.
THESE ARE VERY ENCOURAGING AND REPRESENT AN EXAMPLE OF THE KIND
OF THING THAT WE HOPE TO SEE MORE OF IN THE MONTHS AND YEARS
TO COME.
THE OFFICE OF NATIONAL DRUG CONTROL POLICY IS A KEY PARTNER
AND LEADER FOR ALL FEDERAL AGENCIES INVOLVED IN TRYING TO
ADDRESS PRESCRIPTION DRUG ABUSE.
THEY HAVE MADE IT ONE OF ITS SIGNATURE ISSUES AND HAS TAKEN
AN INTEREST IN ISSUES RANGING FROM SURVEILLANCE, WHICH CDC IS
VERY PLEASED TO BE A CORE PART OF, TO PREVENTION.
WE LOOK FORWARD TO NOURISHING THIS PARTNERSHIP.
THIS IS A BIG PROBLEM.
IT WILL NOT BE SOLVED BY ANY ONE ENTITY OR AGENCY.
IT WILL BE QUITE IMPORTANT THAT WE HAVE GOOD COLLABORATION AND
COORDINATION AMONG MANY DIFFERENT PARTNERS WORKING ON
IT.
IN THAT REGARD I'M DELIGHTED THAT WE HAVE WITH US PAM HYDE,
ADMINISTRATOR OF SAMSA HERE WITH US TODAY AND WILL JOIN THE PANEL
FOR A QUESTION AND ANSWER AT THE END OF THE PRESENTATION.
THANK YOU ALL VECHL.
>> GOOD AFTERNOON.
I AM GRANT BALDWIN.
I'LL SHOW DATA ON PRESCRIPTION DRUG OVERDOSES THAT SDMON
STRAIGHTS IT'S A PROBLEM.
NEXT WE WILL HIGHLIGHT KEY RISK FACTORS AND OUTLINE PROMISING
INTERVENTIONS.
DR. GARY FRANKLIN WILL DISCUSS SUCCESSES AND CHALLENGES
IMPLEMENTING INNOVATIVE POLICY SOLUTION AT THE STATE LEVEL.
MR. KIRLIKOWSKI WILL PROVIDE INSIGHT.
LET'S BEGIN BY DEFINING THE EPIDEMIC.
A PRESCRIPTION DRUG OVERDOSE IS A TYPE OF POISONING, ONE THAT
RESULTS FROM THE USE OF PRESCRIPTION DRUGS IN AMOUNTS OR
IN WAYS THAT ARE NOT RECOMMENDED.
MOST FATAL OVERDOSES IN THE U.S.
ARE UNINTENTIONAL.
IN OTHER WORDS, THE PERSON INTENDED TO TAKE THE DRUG OR
DRUGS BUT DID NOT INTEND TO HARM THEMSELVES.
ONLY A SMALL FRACTION ARE INGESTIONINGEST
INGESTIONS BY YOUNG CHILDREN OR INNOCENT MISTAKES BY PATIENTS.
OVERALL, THERE ARE TWO TYPES OF DRUGS MOST FREQUENTLY INVOLVED
IN AN OVERDOSE, LARGELY BECAUSE THEY DEPRESS BREATHING.
THEY ARE *** ANALGESICS SUCH AS OXYCONTIN AND HYPNOTICS.
INDIVIDUALS USUALLY TAKE MULTIPLE PRESCRIPTION DRUGS AT
THE TIME OF DEATH FREQUENTLY COMBINED WITH ALCOHOL OR ELICIT
DRUGS.
ORIGINALLY THEY MAY HAVE STARTED TAKING THE DRUG FOR ITS INTENDED
PURPOSE.
HOWEVER, THEY DEVELOP A TOLERANCE TO THE DRUG OVER TIME
AND MAY ESCALATE ITS USE BECAUSE OF HIGH IT PROVIDES.
IF WE LOOK FIRST AT THE BROAD CATEGORY OF DRUG-INDUCED DEATHS,
WE CAN SEE THAT THE OVERDOSE PROBLEM HAS GROWN TO RIVAL OR
EXCEED OTHER TYPES OF INJURY DEATHS.
DRUG INDUCED DEATHS INCLUDE UNINTENTIONAL OVERDOSES.
DRUG SUICIDES, OVERDOSE DEATHS OF UNDETERMINED INTENT, AND
MEDICAL CONDITIONS DUE TO DRUGS.
THIS IS SHOWN BY THE RED LINE ON THE GRAPH.
IN THIS NINE-YEAR PERIOD FROM 1999 TO 2007, THE NUMBER OF
DRUG-INDUCED DEATHS BASICALLY DOUBLED TO ROUGHLY 38,000.
THIS APPROACHES THE NUMBER OF DEATHS DUE TO MOTOR VEHICLE CAR
CRASHES AND HAS PASSED THE NUMBERS DO YOU TO SUICIDE,
HOMICIDE AND FIREARM INJURIES.
FOCUSING IN ON JUST THE UNINTENTIONAL OVERDOSES AND
LOOKING AT LONG-TERM TRENDS REVEALS THAT THE RECENT NUMBERS
ARE UNPRECEDENTED.
THEY ARE PART OF THE WORST OVERDOSE EPIDEMIC IN THE UNITED
STATES IN OVER FOUR DECADES.
THE EPIDEMICS OF BLACK TAR *** BARELY REGISTER WHEN
COMPARED TO THE MAGNITUDE OF THIS EPIDEMIC.
OVER 27,000 UNINTENTIONAL DRUG OVERDOSE DEATHS OCCURRED IN 2007
IN THE U.S.
ONE EVERY 19 MINUTES.
IN 17 STATES IT'S NOW THE LEADING CAUSE OF INJURY DEATHS.
THIS MAP SHOWS AGE-ADJUSTED DRUG OVERDOSE DEATH RATES BY STATE.
THERE ARE CLUSTERS OF HIGH RATES IN APPALACHIA AND IN THE
SOUTHWEST.
WASHINGTON STATE, THE FOCUS OF DR. FRANKLIN'S PRESENTATION, IS
ALSO IN THE TOP TERTILE.
THE CDC INJURY CENTER HELPED TO DETERMINE THE TYPES OF DRUGS
CAUSING THE INCREASE.
THE PRIMARY CAUSE IS A CLASS OF PRESCRIPTION PAINKILLERS CALLED
*** ANALGESICS.
FOR SEVERAL YEARS THERE HAVE BEEN MORE DEATHS THAN FROM
*** AND *** COMBINED.
LET'S TAKE A CLOSER LOOM AT OPEN YOIDS.
TO BETTER MANAGE PAIN THEY INCREASED THEIR OPEN YOID
PRESCRIBING FOR PAIN RELATED VISITS.
TLE ADMINISTERED 700 MILLIGRAMS PER PERSON BY TWEVEN, AN
INCREASE OF OVER 600%.
700 MILLIGRAMS PER PERSON IS ENOUGH FOR EVERY AMERICAN TO
TAKE A TYPICAL DOSE OF 5 MILLIGRAMS OF VICODIN EVERY FOUR
HOURS FOR THREE WEEKS.
IN 1999 THEY WERE RECORDED AS A CAUSE OF DEATH IN APPROXIMATELY
2900 UNINTENTIONAL OVERDOSE FATALITIES.
BY 2007 THAT NUMBER HAD INCREASED TO ALMOST 11,500.
AN INCREASE OF ALMOST 300%.
AS IS OFTEN THE CASE WITH INJURY ISSUES, DEATHS RELATED TO
OPENIOD ANALGESICS ARE THE TIP OF
ICEBERG.
FOR EVERY UNINTENTIONAL DEATH, THERE ARE NINE ABUSE TREATMENT
ADMISSIONS, 35 ED VISITED, 161 PEOPLE WITH ABUSE OR DEPENDENCE
AND 461 PEOPLE REPORTING NON-MEDICAL USE IN THE PAST
MONTH.
WHILE *** ANALGESICS HAVE USES THEY HAVE A TYPICAL ABUSE,
AND THEY HAVE HEALTH EFFECTS.
PEOPLE USING THESE DRUGS ARE EXPERIENCE MENTAL IMPAIRMENT
LEADING TO OTHER TYPES OF INJURIES SUCH AS FALLS AND MOTOR
VEHICLE CRASHES.
PEOPLE ABUSING THESE DRUGS ARE AT A GREATER RISK OF SUICIDE AND
CRIME-RELATED VIOLENCE.
AT THIS POINT LET ME TURN IT OVER TO DR. LEN PELASI.
LEN.
>> GOOD AFTERNOON.
I'M GOING TO DISCUSS RISK FACTORS FOR OVERDOSE DEATHS AND
SHOW YOU SOME PREVENTION STRATEGIES THAT DERIVE FROM
THEM.
FIRST, SOME BACKGROUND ON THE HIGHEST RISK DEMOGRAPHIC GROUPS.
RATES OF *** USE AND OVERDOSE DEATH ARE HIGHEST AMONG PEOPLE
IN THE WORKING YEARS OF LIFE AND NON-HISPANIC WHITES.
POOR AND RURAL POPULATIONS ARE IN GENERAL MORE LIKELY TO
EXPERIENCE PRESCRIPTION OVERDOSES.
PEOPLE WHO HAVE MENTAL ILLNESS HAVE OVERREPRESENTED IN THOSE
USING THEM AND OVERDOSING ON THAT.
WE ALSO KNOW SOMETHING ABOUT THE CIRCUMSTANCES OF USE OF THESE
TYPES OF DRUGS.
THERE ARE TWO AT-RISK POPULATIONS IN THE UNITED
STATES.
IN RECENT SURVEYS APPROXIMATELY 9 MILLION AMERICANS REPORTED
USING OPIODS IN THE LAST MONTH.
A LITTLE OVER 5 MILLION REPORT USING ONE NONMEDICALLY WITHOUT A
PRESCRIPTION OR USE FOR THE FEELING IT CAUSES.
SOME PEOPLE, OF COURSE, MIGHT BELONG TO BOTH GROUPS.
WE KNOW A LITTLE BIT HOW THE NONMEDICAL USERS ARE GETTING THE
DRUGS.
76% OF THEM IN A RECENT SURVEY REPORT GETTING THE DRUGS THAT
THEY HAD BEEN PRESCRIBED TO SOMEONE ELSE.
ONLY 20% REPORT USING DRUGS THAT HAD BEEN -- THAT THEY HAD GOT
FRN THEIR OWN DOCTOR.
THEREFORE, SOME OF THE PEOPLE WHO ARE GOING TO DOCTORS MUST BE
GIVING OR SELLING OUR OTHERWISE PASSING ALONG THEIR DRUGS TO
NONMEDICAL USERS.
IN STATES WHERE THIS HAS BEEN STUDIED, NONMEDICAL USERS
CONSTITUTE A LARGE FRACTION OF PEOPLE WITH FATAL PO IOD
OVERDOSES.
THE PEOPLE THAT DIED, A SIGNIFICANT FRACTION DID NOT
HAVE A PRESCRIPTION IN THEIR RECORDS FOR THE OPEN YOID THAT
KILLED THEM, ONE MARKER FOR NONMEDICAL USE.OPIOD.
MANY HAD GOT A DRUG THAT WAS ORIGINALLY PRESCRIBED TO SOMEONE
ELSE.
IN THE WEST VIRGINIA STUDY ONE IN FIVE PEOPLE DIED IN OVERDOSES
SAW FIVE OR MORE PHYSICIANS IN THE PAST YEAR.
IN THE OHIO STUDY, ONE OUT OF SIX PEOPLE WHO DIED HAD SEEN AN
AVERAGE OF FIVE PRESCRIBERS PER YEAR.
NOW, SOME OF THE PEOPLE THAT USE THE DRUGS MEDICALLY ARE ALSO AT
HIGH RISK.
THOSE ARE THE PEOPLE GETTING A LARGE DOSE OF OPIODS THROUGH
LEGITIMATE CHANNELS.
THIS STUDY FOCUSED ON THE DISTRIBUTION OF OPIOD IN A POP
PLAGS INITIATING USE FOR CHRONIC PAIN CONDITIONS.
COMPARED WITH PEOPLE WITH DOSAGE DOSAGES OF LESS THAN 20
MILLIGRAMS PER DAY HERE, PEOPLE AT 20 TO 49 MILLIGRAMS HAVE AN
ODDS RATIO OF 1.4 AND RISKS INCREASED TO 8.9 AT 100 OR MORE
MILLIGRAMS OF OPIOD PER DAY.
IN THIS SAME STUDY PEOPLE WITH DOSAGES OF LESS THAN 20
MILLIGRAMS PER DAY REPRESENTED THE VAST MAJORITY OR 78.3% OF
YEARS OF USE.
BECAUSE OF THEIR RELATIVELY LOW RISK THEY ACCOUNTED FOR ONLY
48.9% OF THE OVERDOSES.
BY COMPARISON PEOPLE GETTING 50 TO 99 MILLIGRAMS ACCOUNTED FOR
5% OF USAGE AND 13% OF OVERDOSES AND PEOPLE AT 100 MILLIGRAMS
WERE 3% OF USAGE AND 24% OF OVERDOSES.
NOW, THIS FIGURE SUMMARIZES ALL OF THESE FINDINGS IN ONE MODEL.
AMONG PATIENTS THE MAJORITY IN GREEN ARE LOSS DOSE SEEING ONE
DOCTOR DOCTOR.
THEY ARE LOW RISK AND RESPONSIBLE FOR A SMALL FRACTION
OF THE OVERDOSES.
A SECOND SUBSET ARE IN BLUE BECAUSE THEY ARE HIGH RISK.
A THIRD FRACTION IN PURPLE ARE SEEING PEOPLE SEEING MULTIPLE
DOCTORS.
THEY ARE HIGH RISK THEMSELVES AND THEY'RE PROVIDING OR
DIVERTING DRUGS TO OTHER USING THEM NONMEDICALLY.
IN AGGREGATE THIS MODEL SUGGESTS WE SHOULD CONCENTRATE STRATEGIES
ON THE HIGH DOSE AND THE PEOPLE INVOLVED IN THE DIVERSION OF
DRUGS.
THESE ARE WHAT WE CONSIDER THE THREE MOST PROMISING OVERALL
GENERAL STRAJS.
FIRST, IMPROVING THE EFFECTIVENESS OF PRESCRIPTION
DRUG MONITORING PROGRAMS.
THESE ARE STATE PROGRAMS THAT TRACK ALL PRESCRIPTIONS AND
OTHER DRUGS PRONE TO ABUSE.
SECOND, USE OF INSURANCE MECHANISMS TO PREVENT DOCTOR
SHOPPING AND TO REDUCE INAPPROPRIATE USE OF OPIODS,
FINALLY IMPROVING STATE LEGISLATION.
I WILL ELABORATE ON THESE AND OTHER STRATEGIES AND SHOW HOW
THEY APPLY TO HIGH RISK GROUPS.
FIRST IMPROVING MONITORING AND INSURANCE.
USERS OF MULTIPLE PROVIDERS AND PEOPLE WITH HIGH DOSAGE CAN BE
TRACKED WITH STATE PRESCRIPTION MONITORING PROGRAMS BECAUSE THEY
LINK PRESCRIPTIONS TO INDIVIDUAL PATIENTS NO MATTER WHAT DOCTOR
PRESCRIBES THEM ACROSS THE STATE.
MEDICAID AND OTHER INSURERS SHOULD LIMIT THE REIMBURSEMENT
OF CLAIMS FOR OPIOD PRESCRIPTIONS TO A SINGLE DOCTOR
AND PHARMACY FOR PATIENTS SEEING MULTIPLE PROVIDERS.
THIS IS IMPORTANT BECAUSE MEDICAID AND OTHER LOW-INCOME
POPULATIONS ARE AT HIGH RISK.
FINALLY, BECAUSE LONG-ACTING OPIODS LIKE OXYCONTIN AND
METHADONE ARE FREQUENTLY USED NONMEDICALLY, INSURERS CAN STOP
PAYING FOR ANY INAPPROPRIATE USE OF THESE DRUGS SUCH AS A USE FOR
SHORT-TERM PAIN.
IMPROVING LEGISLATION AND ENFORCE IS ANOTHER KEY STRATEGY.
EXISTING LAWS AGAINST DOCTOR SHOPPING NEED BETTER
ENFORCEMENT.
IN MANY PARTS OF THE COUNTRY TO-PROFIT CLINICS THAT
DISTRIBUTE DRUGS ARE MAJOR SUPPLIERS TO NONMEDICAL USERS.
LAWS AGAINST THESE PILL MILLS AND LAWS THAT REQUIRE PHYSICAL
EXAMS BEFORE PRESCRIBING MIGHT HELP ADDRESS THE SOURCE AS WOULD
STOPPING DRUG DISTRIBUTIONS TO SUCH CLINICS BY WHOLESALERS.
IN ADDITION, A VARIETY OF OTHER CONTROLS AND PRESCRIPTION FRAUD
ARE EMPLOYED IN SOME STATES.
FOR EXAMPLE, 11 STATES NOW REQUIRE THAT A PERSON PICKING UP
ABUSABLE DRUGS SHOW PHOTO IDENTIFICATION.
IT'S ALSO IMPORTANT TO IMPROVE PHYSICIAN PRACTICE.
GUIDELINES CAN EDUCATE PRESCRIBERS ABOUT THE
UNDERAPPRECIATED RISK AND FREQUENTLY EXAGGERATED BENEFITS
OF HIGH-DOSE OPIOD THERAPY.
GUIDELINES ARE ESPECIALLY NEEDED FOR EMERGENCY DEPARTMENTS.
SINCE HIGH-RISK PEOPLE FREQUENTLY VISIT E.D.s SEEKING
DRUGS.
GUIDELINES ARE MORE EFFECTIVE IF THERE'S BUILT IN ACCOUNTABILITY
VIA HEALTH SYSTEM OR PAYOR REVIEWS.
EXPERTS AT A RECENT METHADONE MORTALITY CONFERENCE RECOMMENDED
PHYSICIANS DEMONSTRATE COMPETENCY IN PRESCRIBING
METHADONE, WHICH IS RESPONSIBLE FOR OVERDOSES.
FINALLY, USE OF SINGLE COPY, SERIALIZED TAMPER RESISTANT
PAPER FORMS HAS BEEN SHOWN EFFECTIVE IN REDUCING
PRESCRIPTION FRAUD IN THE PAST.
THE SAME EFFECT MIGHT COME FROM USE OF ELECTRONIC OR
E-PRESCRIBING.
THE LAST CATEGORY OF STRATEGIES INCLUDE SECONDARY AND TERTIARY
PREVENTION MEASURES TO IMPROVE LONG-TERM TREATMENT.
OVERDOSE HARM REDUCTION PROGRAMS EMPHASIZE BROADER DISTRIBUTION
IN THE LOCK ZONE TO PEOPLE USING DRUGS NONMEDICALLY.
THEY CAN BE USED IN AN EMERGENCY BY ANYONE WITNESSING AN
OVERDOSE.
SUBSTANCE ABUSE TREATMENT PROGRAMS REDUCE THE RISK OF
OVERDOSE DEATH.
CONTINUED EFFORTS ARE NEEDED TO REMOVE BARRIERS TO SHIFTING
PROGRAMS FROM METHADONE CLINICS TO OFFICE-BASED CARE.
SUCH CARE IS LESS STIGMATIZING AND MORE ACCESSKCCESSIBLE TO THE
RURAL POPULATIONS.
LET ME NOW TURN IT OVER TO GARY FRANKLIN.
>> I'M GARY FRANKLIN REPRESENTING ALL THE PUBLIC
PAYORS IN WASHINGTON STATE.
IT IS OFTEN A CHALLENGE TO CARE FOR PATIENTS WITH COMPLEX,
CHRONIC PAIN PROBLEMS.
OUR GOAL IN WASHINGTON IS TO PROVIDE BEST PRACTICE TOOLS AND
INCENTIVES, NOT JUST RULES, SO YOU CAN SAFELY AND EFFECTIVELY
CARE FOR YOUR PATIENTS.
BY THE LATE 1990s, AS THE DOCTOR MENTIONED EARLIER, SEVERAL
FACTORS CONVERGED AT THAT LET MANY STATES TO LIBERALIZE
INCLUDING WEAK SCIENCE SUGGESTING ADDICTION WAS NOT
COMMON, LOBBYING BY PAIN ADVOCACY GROUPS AND USE OF
OPIODS TO MANAGE MALIGNANT PAIN.
WITHIN A COUPLE OF YEARS, HOWEVER, UNINTENTIONAL DEATHS
FROM OPIODS BEGAN TO CROSS MY DESK IN THE WASHINGTON WORKERS'
COMPENSATION SYSTEM.
WE THEN MORE SYSTEMICALLY REVIEWED ALL DEATHS IN OUR
SYSTEM AND PUBLISHED THE FIRST PEER REVIEWED PAPER DESCRIBING
THESE DEATHS RELATED TO PRESCRIBED OPIODS.
THESE NUMBERS ARE SMALL BECAUSE THEY OCCURRED IN THE WORKERS'
COMPENSATION POPULATION AT THE SAME TIME, HOWEVER, A SIMILAR
TREND INVOLVING 50 TIMES MORE PATIENTS WAS EVOLVING IN
WASHINGTON STATE.
CON CONTAMINANT WITH THE DEATHS, WE HAD A DRAMATIC RISE IN THE
AVERAGE DAILY MORPHINE EQUIVALENT DOSES OF THE MOST
POWERFUL OPIODS SUCH AS OXYCONTIN AMONG INJURED WORKERS.
THESE DOSES INCREASED 50% WITHIN THE FEW YEARS AFTER THE LAWS
WERE MORE PERMISSIVE AND STABILIZED THROUGH THE MID
1990s.
BY THAT TIME SOME PAIN EXPERTS NOTED THAT THE STRENGTH OF THE
EVIDENCE WAS WEAK REGARDING LONGER TERM USE.
WHILE PAIN MAY IMPROVE MODESTLY IN THE SHORT TERM, FUNCTION
MANTS IMPROVE SUBSTANTIALLY AT ALL.
SOME PATIENTS DEVELOP WORSE PAIN OR HYPERALGESIA.
DR. JANE VALENTINE FIRST SUGGESTED THAT PATIENTS MAY BE
DEVELOPING SEVERE TOLERANCE, AND TREATS TOLERANCE BY CONTINUING
TO INCREASE THE OPIOD DOSE SHOULD BE QUESTIONED.
MORE RECENTLY SHE STATED PUBLICLY THAT SHE BELIEVES THAT
100% OF PATIENTS ON CHRONIC OPIOD THERAPY ARE DEPENDENT.
IN A PROSPECTIVE POPULATION BASED STUDY OF INJURED WORKERS
WE PUBLISH WITH COMPENSABLE LOW BACK PAIN, MORE THAN ONE THIRD
RECEIVED AN OPIOD EARLY ON, MOST AT THE FIRST VISIT.
THIS IS CONTRARY TO MOST PUBLISHED GUIDELINES.
AMONG THE 6% WHO WENT ON TO RECEIVE OPIODS FOR CHRONIC PAIN
FOR ONE YEAR, THE VAST MAJORITY DID NOT REPORT CLINICALLY
MEANINGFUL IMPROVEMENT IN PAIN AND FUNCTION, BUT THEIR OPIOD
DOSES ROSE SIGNIFICANTLY.
WASHINGTON STATE HAS AGGRESSIVELY MOVED FORWARD TO
ADDRESS THIS ISSUE WITH THE FOUR STRATEGIES LISTED HERE.
I'LL TALK ABOUT EACH OF THESE INDIVIDUALLY.
THE FIRST STRATEGY IS OPIOD DOSING GUIDELINES.
THE AGENCY MEDICAL DIRECTOR'S GROUP CALLED TOGETHER A PANEL OF
15 HIGH-LEVEL CLINICAL AND ACADEMIC PAIN SPESHTS TO ADVISE
US ON POTENTIAL PREVENTION EFFORTS.
AT THE BEGINNING OF THE VERY FIRST MEETING, ONE PAIN EXPERT
SUGGESTED THAT THE VAST MAJORITY OF HIS PATIENTS WITH CHRONIC
NONMALIGNANT PAIN DID NOT REQUIRE MORE THAN THE EQUIVALENT
OF 90 MILLIGRAMS PER DAY OF MORPHINE
MORPHINE.
PRIOR TO THIS TIME, THERE WAS NO DOSING GUIDANCE WHATSOEVER IN
NATIONAL GUIDELINES.
AND PEER REVIEWED PUP INDICATIONS MENTIONED PREVIOUSLY
HAD NOT YET BEEN PUBLISHED.
THE ADVISORY PANEL AGREED ON A YELLOW FLAG WARNING DOSE OF 1250
MILL GLAMS PER DAY OF MORPHINE AND SUGGESTED AN EDUCATIONAL
GUIDELINE SHOULD BE DISSEMINATED AS A PILOT, NOT AS POLICY.
THERE'S 120 MILLIGRAMS PER DAY MORPHINE EQUIVALENT FOR INCIDENT
OR NEW PATIENTS WITH CHRONIC PAIN.
IF SUCH A PATIENT'S DOSE ESCALATED TO 120 MILLIGRAMS AND
PAIN AND FUNCTION HAD NOT SUBSTANTIALLY IMPROVED, THEN
TAKE A DEEP BREATH AND EITHER ASK FOR HELP, SAY, FROM A PAIN
CONSULTATION, OR HOLD THE LINE OR TAPER THE DOSE.
WE RECALLED THAT, AND WE DID NOT FOCUS ON THE PATIENTS ALREADY ON
HIGH DOSES OF OPIODS AT THAT TIME, BUT RATHER ON PREVENTS
MORBIDITY AND MORTALITY.
THE GUIDELINES WAS INTRODUCED IN APRIL OF 2007 AS A WEB-BASED
TOOL INCLUDING TWO HOURS OF FREE CME AND SPECIFIC BEST PRACTICE
GUIDANCE, USE OF AGREEMENT AND JUDICIOUS USE OF RANDOM URINE
DRUG SCREENING.
TRACKING PAIN AND FUNCTION IS CRUCIAL TO RECOGNIZING IMPORTANT
DEGREES OF TOLERANCE DURING DOSE ESCALATION.
WE CONDUCTED A SURVEY OF PRIMARY CARE DOCTORS ABOUT ONE AND A
HALF YEARS AFTER THE GUIDELINE WAS INTRODUCED TO ASSESS OVERALL
CONCERNS, ACCEPTANCE OF DOSING GUIDANCE, AND TO IDENTIFY GAPS
IN KNOWLEDGE FOR WHICH TOOLS COULD BE ADDED TO AN UPDATED
GUIDELINE.
86% OF RESPONDING PRIMARY CARE DOCTORS THOUGHT THE 120
MILLIGRAM YELLOW FLAG WARNING DOSE WAS PERFECT.
EVEN AFTER TEN YEARS OR MONTH OF PERMISSIVE PRESCRIBING, WE WERE
SURPRISED TO SEE THAT A MAJORITY OF PRESCRIBERS SURVEYED WERE
VERY CONCERNED STILL.
THIS BOLSTERED THE NEED TO OFFER MORE PRACTICAL TOOLS.
WE ALSO DISCOVERED THAT THE MAJORITY OF DOCTORS ARE NOT
USING ALL BEST PRACTICES LIKELY DUE TO NOT HAVING BRIEF USEABLE
TOOLS OR EVEN ADEQUATE INCENTIVES.
FOR EXAMPLE, ONLY 38% WERE USING RANDOM URINE DRUG SCREENS OFTEN
OR ALWAYS AND 69% NEVER OR ALMOST NEVER TRACKED PHYSICAL
FUNCTION.
THESE BRIEF, OPEN-SOURCE TOOLS WERE ADDED TO THE JUNE 2010
UPDATE TO THE GUIDELINE FOR EASE OF INCORPORATION INTO ROUTINE
PRACTICE.
ONE GOOD EXAMPLE IS THE TWO QUESTION GRADED CHRONIC PAIN
SCALE FOR TRACKING PAIN AND FUNCTION.
WITH THIS TYPE OF TOOL, ALONG WITH THE WES-BASED OPIOD DOSING
CALCULATOR SHOWN HER, YOU CAN MORE EASILY IDENTIFY IF
SIGNIFICANT OR POTENTIALLY DANGEROUS TOLERANCE IS
DEVELOPING IN YOUR PATIENTS.
VERTICAL LINE IN THIS FIGURE INDICATES THAT THE APRIL 2007
START DATE OF THE GUIDELINE, WE BELIEVE THE GUIDELINES HAVE
ALREADY HAD AN IMPACT ON SUBSTANTIALLY REDUCING THE
HIGHER DOSES OF THE MOST POTENT, LONG-ACTING OPIODS IN OUR
WORKERS' COMPENSATION SYSTEM.
AND ALTHOUGH VERY PRELIMINARY, IT DOES APPEAR THAT BOTH
MORTALITY AND MORBIDITY STATEWIDE MAY HAVE MODERATED IN
2009 TWO YEARS AFTER GUIDELINE IMPLEMENTATION.
OUR SECOND STRATEGY IS LEGISLATION.
THE WASHINGTON LEGISLATURE PASSED LEGISLATION IN MARCH 2010
THAT WILL REPEAL THE CURRENTLY PERMISSIVE RULES BY JUNE 2011
AND WILL IMPLEMENT NEW RULES LARGELY REFLECTIVE OF THE DOSING
GUIDANCE AND OTHER BEST PRACTICES EMPHASIZED IN THE
GUIDELINES.
THE LED SPONSOR IS AN ADDICTION COUNSELOR WHO INHERITED MANY
PATIENTS ON VERY HIGH DOSES OF OPIODS WHEN A PILL MILL IN
VANCOUVER, WASHINGTON WAS SHUT DOWN BY THE DEA.
HE HAD NEVER SEEN THESE TYPES OF DOSES IN HIS HMO PRACTICE AND
BECAME CONVINCED THAT A NEW STANDARD EMBODYING BEST
PRACTICES WAS NEEDED.
BESIDES THE SPECIFIC GUIDANCE, ALL OF THE BEST PRACTICES IN THE
NEW RULES ARE IN COMMON ACROSS ALL RECENTLY PUBLISHED OPIOD
GUIDELINES?
THERE ARE EVIDENCE OF TREATMENT AGREEMENTS COMBINED WITH URINE
DRUG SCREENS.
THE THIRD STRATEGY AND I KNOW THIS IS IMPORTANT TO YOU IS
IMPROVING PHYSICIAN ACCESS TO PAIN SPECIALISTS.
ALTHOUGH MOST PATIENTS WITH CHRONIC PAIN ARE SEEN BY PRIMARY
CARE PROVIDERS, WE RECOMMEND THAT THOSE DOCTORS SEEK
SPECIALIST HELP WHEN THEY REACH DOSAGE LEVELS AND THERE ARE
SUBSTANTIAL ISSUES REGARDING LOW AVAILABLE OF SUCH PAIN
SPECIALISTS OFTEN NOT AVAILABLE TO CONSULT ON COMPLEX OPIOD
ISSUES.
WE ADDRESS THIS BY DEVELOPING SPECIFIC METHODS FOR OFFERING
PAIN HE PROFICIENCY TRAINING FOR PRIMARY CARE PRESCRIBERS WHO MAY
THEN BECOME MENTORS OR CONSULTANTS TO THEIR COLLEAGUES,
PARTICULARLY IN RURAL AREAS.
IN ADDITION, WE ARE DEVELOPING PAYMENT INCENTIVES TO MAKE PAIN
CONSULTATIONS WITH SPECIAL HEISTS
MORE INFORMATIVE WITH TELEPHONE AND VIDEO CONSULTATION.
OUR FINAL STRATEGY IS COMMUNITY-BASED TREATMENT OF
CHRONIC PAIN.
AS OPIOD DOSING MODERATES, PRIMARY CARE DOCTORS TELL US
THEY NEED ALTERNATIVES FOR THE EFFECTIVE TREATMENT OF CHRONIC
PAIN.
WE'RE IN THE EARLY DEVELOPMENT PHASE OF DETERMINING WHICH BEST
PRACTICES AND QUALITY INDICATORS OF BEST PRACTICE COULD BE
EFFECTIVELY IMPLEMENTED IN COMMUNITY-BASED PRIMARY CARE
SETTINGS.
THESE ELEMENTS COULD BE DEVELOPED IN CONCERT WITH
EVOLVING CONCEPTS SUCH AS ORGANIZATIONS AND MEDICAL HOMES
SUCH AUZ FOR CHRONIC PAIN AS FOR OTHER CHRONIC DISEASES.
THESE ARE THE GUIDELINES RELEASED WITH THE OTHER EFFORTS.
MY FINAL SLIDE SUMMARIZES KEY LESSONS LEARNED SO FAR.
THE OVERALL PROBLEM IS RELATED TO HIGH DOSES AND RAMPANT
TOLERANCE.
DOSING GUIDANCE CAN ADDRESS THIS PROBLEM.
A MORE COMPREHENSIVE APPROACH TO EFFECTIVELY TREATING CHRONIC
PAIN MUST BE DEVELOPED THROUGH MORE INTEGRATED COMMUNITY BASED
PAIN SERVICES.
FINALLY, PRESCRIBER EDUCATION ALONE IS NOT ADEQUATE TO ADDRESS
EXTREME PRESCRIBING OUTLIERS OR SOCIETYAL ISSUES NOT UNDER
PROVIDER INFLUENCE.
>> I WANT THE TO THANK THE CDC AND DR. FRIEDEN FOR THIS
INVITATION.
IT'S A GREAT PLEASURE TO BE HERE WITH US, AND I APPRECIATED THE
SENSE OF HUMOR.
I WAS CONCERNED COMING FROM SEATTLE THAT GROUND ROUNDS WOULD
BE LIKE GRAY'S ANATOMY, BUT I CAN SEE IT'S NOT.
LET ME TELL YOU ABOUT WHAT WE'RE DOING IN THE OFFICE OF NATIONAL
DRUG CONTROL POLICY WHEN IT COMES TO PRESCRIPTION DRUG ABUSE
AND THE OVERDOSES.
IT REALLY IS A WHOLE OF GOVERNMENT APPROACH.
I'LL GIVE YOU OUR OFFICES AUTHORITY, OUR FEDERAL
PERSPECTIVE.
WE WERE ESTABLISHED AS A CREATURE OF CONGRESS IN 1988.
IT WAS BECAUSE THE MEMBERS OF CONGRESS WERE VERY FRUSTRATED
THEY COULDN'T POINT THEIR FINGER AT ONE VISIT AND SEE WHAT'S
GOING ON IN THIS COUNTRY.
ITS PRINCIPAL PURPOSE IS TO DO THE POLICIES, PRIORITIES AND
OBJECTIVES OF THE NATION'S DRUG CONTROL PROGRAM.
WE ALL HAVE, I THINK, IN THIS ROOM, WE CERTAINLY ALL HAVE MANY
OF THE SAME GOALS.
WE'RE RESPONSIBLE AND THE MOST IMPORTANT THING I'M CHARGED WITH
IS BEING RESPONSIBLE FOR THE NATIONAL DRUG CONTROL STRATEGY
THAT COMES OUT EVERY YEAR.
IT COMES OUT BY LAW IN FEBRUARY, AND WE ARE UPDATING THE
PRESIDENT'S STRATEGY NOW.
HIS WAS RELEASED, PRESIDENT OBAMA'S WAS RELEASED IN MAY OF
LAST YEAR IN THE OVAL OFFICE, AND PRESCRIPTION DRUG MONITORING
PROGRAMS THAT WERE MENTIONED AND A NUMBER OF OTHER THINGS
SURROUNDING THE PRESCRIPTION DRUG PROBLEM WAS PROMINENTLY
MENTIONED.
FRANKLY, IN SEVERAL OTHER ITERATIONS THE PRESCRIPTION DRUG
ISSUE WAS NOT REALLY VERY HIGH ON THE RADAR SCREEN.
WE COORDINATE THE FEDERAL DRUG CONTROL ALLERGY'S ACTIVITIES AND
WE HAVE INTERNATIONAL RESPONSIBILITIES.
WE ESTABLISH FOR ALL OF THOSE FEDERAL DEPONENTS AND ILTS
SOMEWHERE IN THE NEIGHBORHOOD OF ABOUT 259$25 BILLION AND ALMOST
50 DIFFERENT FEDERAL COMPONENTS ALL
HAVE A STAKE IN THE DRUG PROBLEMS NATIONALLY AND
INTERNATIONALLY WITHIN THE FEDERAL GOVERNMENT.
THE PRESIDENT'S POLICY IS ONE THAT IS ZION-BASED AND FROM HIS
EXECUTIVE ORDER THE IMPORTANCE HE PLACES ON EVIDENCE IN
SCIENCE.
IT IS A PUBLIC HEALTH APPROACH TO THIS PARTICULAR DRUG PROBLEM.
TWO YEARS AGO -- ALMOST TWO YEARS AGO WHEN I GOT THE JOB, I
DID AN INTERVIEW AND PRETTY MUCH ENDED THE WAR ON DRUGS, OR AT
LEAST I TRIED TO END THE WAR ON DRUGS.
THAT'S BEEN TALKED ABOUT A LOT FOR ALMOST 40 YEARS SINCE
PRESIDENT NIXON DECLARED DRUGS PUBLIC ENEMY NUMBER ONE.
I FELT IT WAS TOTALLY INAPPROPRIATE TO TALK ABOUT WHAT
CLEARLY IS A PUBLIC HEALTH AND A PUBLIC EDUCATION AND A PUBLIC
SAFETY PROBLEM WITH THREE WORDS THAT FIT ONE ON A BUMPER STICKER
BUT REALLY DON'T GIVE THE LEVEL OF COMPLEXITY AND DISCUSSION
THAT'S NEEDED AROUNDED THE DRUG ISSUE.
WE ALSO HAVE WITHIN OUR OFFICE THREE SIGNATURE ISSUES, AND AS
DR. FRIEDEN MENTIONED, PRESCRIPTION DRUG ABUSE.
I WAS GETTING READY FOR CONFIRMATION AND BEING BRIEFED.
AS A POLICE CHIEF I KEPT UP WITH DATA AND READ A LOT OF RESEARCH
AND PREPPED WELL.
YOU KNOW THAT MORE PEOPLE DIE FROM DRUG OVERDOSES, OF COURSE,
LED BY PRESCRIPTION DRUGS THAN DIE FROM GUNSHOT WOUNDS.
I SAID, ACTUALLY, NO, I DIDN'T KNOW THAT.
I WENT OUT AND TESTED ALL MY COLLEAGUES, POLICE CHIEFS,
SHERIFFS, PROSECUTORS, JUDGES, ET CETERA.
SO YOU KNOW IT WELL HERE IN THIS ROOM.
THE EXPERTISE THAT EXISTS HERE IS PHENOMENAL, BUT TO THE REST
OF THE PUBLIC, THE PRESCRIPTION DRUG PROBLEM JUST REALLY WASN'T
THERE.
WE ALSO, BY THE WAY, SELECTED PREVENTION BECAUSE WE KNOW
PREVENTION WORKS AND WE'VE LEARNED A LOT MORE ABOUT
PREVENTION, PARTICULARLY IN THE LAST DECADE.
AND OF COURSE, DRUGGED DRIVING, WHICH HASN'T BEEN AS WIDELY
ATTENDED TO IN THIS COUNTRY AS PERHAPS IN SOME OTHER COUNTRIES
BULLET ALSO HADN'T BEEN TESTED AS WELL.
THE FEDERAL POLICY PERSPECTIVE ON THIS IS THAT WE WANT TO
MINIMIZE THE ABUSE, BUT WE CERTAINLY DON'T WANT TO AND HAVE
NO INTENTION OF WORKING FOR DIRECTING AND COLLABORATING ON
EFFORTS THAT WILL REDUCE THESE VERY VITAL -- THESE VERY
IMPORTANT MEDICATIONS TO PEOPLE THAT NEED THEM.
THAT IS NOT THE WANT ANSWER.
IT HAS TO BE ALSO A WHOLE OF GOVERNMENT OR THIS MULTI-FACETED
APPROACH AND THE COLLABORATION AMONG THE FEDERAL AND STATE AND
LOCAL PARTNERS.
AS GARY TALKED ABOUT FROM THE STATE OF WASHINGTON, EVERYONE
DOES HAVE A HUGE STAKE IN THIS.
NEXT WEEK WE'LL BE IN APPALACHIA FOR FOUR DAYS IN SOME OF THE
POOREST AREAS OF THE COUNTRY WHERE THE PRESCRIPTION DRUG
ABUSE HAS HAD HORRENDOUS EFFECTS.
LET NELL YOUME TELL YOU THE FOUR FOCUS
AREAS.
THE EDUCATION MONITOR PROGRAMS AND DISPOSING OF DRUGS AND
LASTLY ENFORCEMENT.
WE WANT TO MAKE SURE AND I THINK WE'VE DONE A GOOD JOB WITH OUR
PARTNERS AT SAMSA, OUR PARTNERS AT CDC AND OTHERS OF BRINGING TO
THE ATTENTION OF THE PUBLIC THE PROBLEM OF PRESCRIPTION DRUGS.
SUNDAY'S "NEW YORK TIMES" FRONT PAGE PIECE, A NUMBER OF OTHER
PIECES THAT HAVE BEEN DONE INCLUDING THE "USA TODAY" ABOUT
OUR ACTIVE DUTY MILITARY AND OUR RETURNING -- AND OUR VETERANS
ALSO.
BRINGING THIS INFORMATION ABOUT THE MEDICAL USE OF THESE OPIOD
PAINKILLERS, HOW THEY'RE STORED BUT PARTICULARLY HOW THEY CAN BE
DISPOSED OF IN AN APPROPRIATE MANNER.
AND THEN THE IMPORTANCE OF EDUCATION FOR HEALTH CARE
PROVIDERS, AND I THINK GARY DISCUSSED A GREAT DEAL OF THAT
THAT'S GOING ON.
IT'S GOING ON IN THE MEDICAL SCHOOLS, BUT IT GOES ON THROUGH
CEUs AND VOLUNTARY WORK AND OTHERS BECAUSE IT HAS BECOME
SUCH A SIGNIFICANT ISSUE IN THE COUNTRY.
YOU CAN CLEARLY SEE IN THE PIE CHART WHERE THE MAJORITY OF THE
PRESCRIPTIONS FOR THESE ANALGESICS COME FROM, EITHER
EMERGENCY DEPARTMENTS OR CERTAINLY THE PRIMARY CARE
OFFICES.
AND WE KNOW HOW BUSY THE PHYSICIANS ARE.
WE KNOW HOW LITTLE TIME THEY GET WITH THE THE PATIENTPATIENTS AND
PARTICULARLY ON A FRIDAY OR SATURDAY EVENING.
I SPENT A LOT OF TIME IN THE EMERGENCY DEPARTMENTS BECAUSE OF
PARTICULAR INCIDENTS OR OFFICERS BEING HURT.
I KNOW HOW HARRIED AND BUSY EVERYONE IS, BUT THE MORE
EDUCATION AND INFORMATION THAT THEY CAN HAVE ABOUT PAIN
MEDICATION WITHIN THOSE FACILITIES, THE BETTER.
PDMP AS IT'S BEEN DISCUSSED AND WE THINK THEY'RE A GOOD FIRST
START.
THEY'RE A GREAT TOOL TO IDENTIFY.
WE KNOW THAT IN LOOKING AT ALL OF THE DIFFERENT STATUTES THAT
HAVE BEEN WRITTEN AND ADDRESSED AROUND THIS, THERE ARE HUGE
NUMBERS OF PATIENT PRIVACY AND CONFIDENTIALITY PIECES THAT HAVE
BEEN WRITTEN IN.
THEY'RE NOT MADE FOR THE PUBLIC TO BE AWARE OF.
THEY'RE IN MANY STATES, LAW ENFORCEMENT HAS NO ACCESS TO
THAT DATABASE AND PERHAPS THAT'S EXACTLY AS IT SHOULD BE.
IT NEEDS TO BE A TOOL THAT IS USED, AND IT HAS TO BE ROBUST.
WE WANT STATES TO HAVE THESE OPERATIONAL PDMPs, AND THAT'S
WHY THE FEDERAL GOVERNMENT THROUGH SEVERAL DIFFERENT GRANT
PROGRAMS PROVIDED THE INITIAL FUNDING.
THEY ALSO NEED EVENTUALLY TO COMMUNICATE ACROSS STATES.
YOU KNOW, AS YOUR NEIGHBOR IN FLORIDA HAS BECOME ESSENTIALLY
THE EPICENTER OF PILL DISPENSING NOT JUST FOR THE STATE OF
FLORIDA AND THE TRAGEDIES THAT OCCUR THERE TO THE PEOPLE LIVE
INNING THAT STATE, BUT TO PEOPLE HERE IN GEORGIA, TENNESSEE, WEST
VIRGINIA, KENTUCKY.
WE ALSO HAVE INITIAL INFORMATION IN LOOKING AT THE PDMPs THAT
THEY CAN BE VERY POSITIVE AND THEY CAN BE VERY HELP.
.
WE ALSO KNOW THAT WITH E-PRESCRIBING AND ELECTRONIC
HEALTH RECORDS THAT MORE CAN BE DONE PARTICULARLY IN THIS AREA.
WE ALSO KNOW THAT BRINGING THIS TO THE ATTENTION OF PUBLIC HAS
BEEN REALLY VERY HELPFUL.
I THINK WE WERE SURPRISED, AS WAS THE DRUG -- THE MEMBERS OF
THE DRUG ENFORCEMENT ADMINISTRATION AND ALL OF THE
STATE AND LOCAL LAW ENFORCEMENT AGENCIES THAT PARTICIPATED IN
THE TAKE-BACK DAY IN SEPTEMBER.
IT'S ONE FOUR-HOUR PERIOD, 4,000 SITES, POLICE DEPARTMENTS,
SHERIFF'S DEPARTMENTS AND OTHERS ALL AROUND THE COUNTRY, 121 TONS
OF DRUGS TAKEN BACK.
CLEARLY, WE RECOGNIZE THAT THOSE AREN'T ALL THE MOST -- THE DRUGS
MOST SUBJECT TO ABUSE, BUT IT DID BRING TO THE ATTENTION OF A
LOT OF PEOPLE EXACTLY WHAT'S IN THEIR MEDICINE CABINETS.
A LOT OF LEGISLATION HAS STALLED IN THE LAST YEAR, AND THERE'S
BEEN A LOT OF CONTROVERSY ON CAPITOL HILL ABOUT CERTAIN
PIECES OF LEGISLATION.
THE SECURE AND RESPONSIBLE DRUK DISPOSAL ACT WAS PASSED BY BOTH
HOUSES.
IT WAS PASSED WITH BY PARTISAN SUPPORT, AND THE PREDZ SIGNED IT
INTO LAW AND THE DRUG ENFORCEMENT ADMINISTRATION IS
NOW IN THE RULE-MAKING PROCESS HAVING TAKEN INFORMATION FROM A
LOT OF PEOPLE THAT ARE TRUE STAKEHOLDERS IN THIS AREA, HOW
LAWS CAN YOU WRITTEN SO THE DRUG TAKE BACK CAN BE MADE EASIER AND
DOESN'T TIE UP LAW ENFORCEMENT AND ALSO IT CAN BE DONE IN A
VERY SAFE AND ENVIRONMENTALLY CONSCIOUS WAY.
PROPER MEDICATION DISPOSAL, TO BE ABLE TO EASILY ACCESS AND TO
DESTROY THESE OUTDATED PRODUCTS, ARE THE ONES THAT ARE IN
MEDICINE CABINETS OFTEN -- OR CAN BE SUBJECT TO ABUSE AND
MISUSE.
IT HAS TO BE COST-EFFECTIVE.
THE LAST THING WE NEED TO DO IS ADD ANY ADDED EXPENSE IN THIS
AREA IN HELPING TO DISPOSE OF THESE AND TO REDUCE THE AMOUNT
OF DRUGS OVERALL THAT HAVE BEEN AVAILABLE.
YOU KNOW FROM THE EARLIER DISCUSSION OF THE EARLIER CHART,
THE MAJORITY OF PEOPLE THAT MISUSE AND ABUSE OFTEN GET THEM
THROUGH SOMEONE ELSE OR FROM SOMEONE ELSE.
THIS WAS THE SLIDE THAT WAS ADDED FOR ME.
THIS IS WHERE WE CAN HAVE A LITTLE BRIEF DISCUSSION.
I DON'T THINK THE MUSIC WILL START PLAYING, BUT I THINK IT'S
IMPORTANT TO RECOGNIZE THAT THESE PILL MILLS TRULY FALL
OUTSIDE THE LEGAL LIMITS OF WHAT'S GOING ON.
I'VE SEEN A NUMBER OF INDICTMENTS, A NUMBER OF CASES
THAT HAVE OCCURRED IN THE PAST BUT ALSO AS A FORMER POLICE
XHEEF AND HAVING CHIEF AND HAVING WORKED WITH
PROSECUTORS AND OTHERS, THESE ARE OFTENTIMESES THE MOST
DIFFICULT CASES.
WHEN THESE INDICTMENTS OCCUR AND THESE ARRESTS ARE MADE FOR
PEOPLE OVERPRESCRIBING, THAT ARE CLEARLY ACTING OUTSIDE THE LAW,
I HAVE ASKED THE LAW ENFORCEMENT AGENCIES TO GO OUT OF THEIR WAY
TO EXPLAIN TO PHYSICIANS EXACTLY WHAT THE STANDARDS WERE FOR THAT
ARREST.
WE DON'T WANT PHYSICIANS TO THINK THAT THIS IS A PARTICULAR
CASE WHERE A PHYSICIAN WAS MERELY TRYING TO HELP, MERELY
TRYING TO TREAT WITHIN ALL OF THEIR GUIDELINES SOMEONE WHO
NEEDED PAIN MEDICATION.
THESE ARE SO FAR OUTSIDE AND IT'S CLEARLY GONE OVER THE
TIPPING FACTOR OF WHAT WOULD BE CONSIDERED PROBABLE CAUSE.
THAT IT SHOULD NOT BE A WORRY AND IT SHOULD NOT BE A CONCERN
FOR ANY PATIENT THAT'S OPERATING WITHIN THOSE GUIDELINES.
WE'RE NOT IN -- LAW ENFORCEMENT IS NOT IN THE BUSINESS OF
PRESCRIBING OR PRACTICING MEDICINE NOR DO THEY WANT TO BE.
OUR HIGH INTENSITY DRUG TRAFFICKING AREAS, WE FUND 28
AROUND THE COUNTRY.
WE CHARGE THEM WITH A RESPONSIBILITY TO MEPHELP
PROVIDE TO LAW ENFORCEMENT AND
PROSECUTORS, THE KIND OF TRAINING AND INFORMATION THEY
NEED SO THAT THEY CAN RECOGNIZE THESE CRIMINAL CASES AND MAKE
THAT DECISION.
THE SUPPORT FOR THE PRESCRIPTION DRUG ABUSE RELATED TRAINING
PROGRAMS THAT WE CAN ACTUALLY HELP LAW ENFORCEMENT ATTEND
GIVEN ALL OF THE DIFFICULT BUDGET PROBLEMS AT NO COST AND
AT VERY LITTLE TIME AND TRAVEL SO THAT MORE INFORMATION CAN BE
MADE AVAILABLE TO THEM.
WE DO A LOT OF COORDINATION.
THAT'S REALLY OUR JOB.
WE'RE A SMALL OFFICE, AND THE EXECUTIVE OFFICE THE PRESIDENT,
BUT WE ACTUALLY HAVE INCREDIBLEABILITYINCREDIBLE
AMOUNTS OF LEGISLATIVE AUTHORITY WHEN IT IT COMES TO THE FEDERAL
GOVERNMENT.
WE THINK THE ANSWER ISN'T IN THE STICK APPROACH.
THE ANSWER IS IN BRINGING PEOPLE TOGETHER, WORKING TOGETHER.
THAT'S WHY WE HAVE RECEIVED SUCH UNPREPS
UNPRECEDENTED COOPERATION AND COLLABORATION NOT ONLY IN THE
PRESCRIPTION DRUG AREA AND OTHER AREAS.
WE DON'T DO THE WORK.
WE'RE A POLICY SHOP.
SAMSA AND CDC DOES THE WORK.
WE WANT TO MAKE SURE IT'S DONE IN ACCORDANCE WITH THE
PRESIDENT'S STRATEGY, DONE IN A WAY THAT BRINGING EVERYBODY TO
THE TABLE.
WHETHER IT'S THE DEPARTMENT OF EDUCATION, THE DEPARTMENT OF
JUSTICE, OR ALL OF THOSE OTHER FEDERAL COMPONENTS THAT I
MENTIONED, IT'S BEEN ABSOLUTELY PHENOMENAL TO WORK WITH THESE
ORGANIZATIONS.
SAMSA ADD MISTHE DRUG-FREE COMMUNITIES.
OVER 700 DRUG-FREE COMMUNITIES AROUND THE COUNTRY.
IT'S JUST A VERY SMALL GRANT, ABOUT $125,000, TO THE REALLY
GRASS ROOTED PEOPLE THAT CAN PUT TOGETHER COALITIONS THAT INVOLVE
EDUCATION, FAITH-BASED GROUPS, LOCAL LAW ENFORCEMENT AND
OTHERS.
THEY CAN PUT TOGETHER THESE COALITIONS THAT ACTUALLY CAN
PROVIDE SOUND INFORMATION ABOUT POOEVENTING DRUG ABUSE.
YOU CAN SEE THEY'RE ALL OVER THE COUNTRY FROM OUR URBAN AREAS TO
OUR RURAL AREAS.
LET ME MENTION THE NATIONAL YOUTH ANTI-DRUG MEDIA CAMPAIGN.
A COUPLE OF YOU IN THE ROOM ARE OLD ENOUGH TO REMEMBER THIS IS
YOUR BRAIN ON DRUGS WITH THE TWO FRIED EGGS.
I CAN SEE SOME SMILES.
SOME OF YOU WERE TOO YOUNG TO REMEMBER THAT.
ACTUALLY, THE EVALUATIONS OF THAT PROGRAM WERE NOT ALL THAT
GLOWING.
SO WE COMPLETELY REVISED AND RE-DID THIS PROGRAM TO GIVE
YOUNG PEOPLE AN ANTI-DRUG MESSAGE THAT IS ONE THAT IS MORE
HOLISTIC AND IT'S AGE CONSISTENT.
IT COMES FROM TRUSTED CARE-GIVERS, AND IT'S NOT JUST
THE NATIONAL MEDIA CAMPAIGN BUT IT HAS BEEN CLEARLY PICKED UP AT
THE LOCAL LEVEL.
IT IS A COMBINED NATIONAL AND LOCAL APPROACH, AND IT SEEMS TO
WORK VERY, VERY WELL.
IN FACT, ABOVE THE INFLUENCE AROUND THE SAME BRAND
RECOGNITION RIGHT NOW THAT COCA-COLA HAS SOMETHING TO DO
WITH ATLANTA AND BURGER KING HAVE.
THESE ARE YOUNG PEOPLE WORKING WITH, FOR EXAMPLE, THE DRUG-FREE
COMMUNITIES AND MANY OTHERS THAT HAVE PICKED THIS UP TO GIVE
YOUNG PEOPLE THE KIND OF ARMOR THAT THEY NEED TO MAKE GOOD
DECISIONS.
NOT JUST GOOD DECISIONS ABOUT PREVENTING DRUG ABUSE, BUT ALSO
GOOD DECISIONS ABOUT DIET AND EXERCISE, TOBACCO, AND ALCOHOL.
ALSO, OF COURSE, WORKING WITH OUR NATIONAL GUARD PARTNERS WHO
ARE SO WELL REGARDED IN THIS COUNTRY.
WHEN THEY GO INTO THE SCHOOLS IN THE UNIFORMS -- IN THEIR
UNIFORMS, THEY CAN ALSO PROVIDE THIS KIND OF INFORMATION.
IT'S BEEN TERRIFIC TO HAVE THIS JOB FOR THESE LAST TWO YEARS, TO
PARTNER WITH CDC, TO PARTNER WITH SAMSA AND TO PARTNER WITH
MANY OTHERS.
I'M VET OPTIMISTIC.
I KNOW SOME OF YOU AFTER LISTENING TO THE DATA WON'T BE
AS OPTIMISTIC AS I AM.
I BELIEVE THAT ALL OF THESE THINGS WORKING TOGETHER, THE
FOUR PILLARS, ARE VERY APPROPRIATE TO HELPING ALL OF US
PULL TOGETHER TO REDUCE THIS PROBLEM.
I THINK OUR CONCLUSIONS VERY MUCH SPEAK FOR THEMSELVES, BUT
I'M DELIGHT TO HAVE BEEN HERE AND TO HAVE HAD THIS
OPPORTUNITY.
THANK YOU SO MUCH.
>>> THANK YOU VERY MUCH.
AT IN THE POINT I'LL START THE Q AND A PORTION OF THE GRAND
ROUNDS AND WOULD LIKE TO INVITE THE ADMINISTRATOR TO PARTICIPATE
WITH THAT.
THERE ARE MICROPHONES AT THE LEFT AND RIGHT OF THE ROOM.
PLEASE GIVE YOUR NAME AND AFFILIATION AND ASK YOUR
QUESTION.
>> I'LL GET THE BALL ROLLING.
BOB BREWER WITH THE CHRONIC DISEASE CENTER.
EXCELLENT AND VERY THOUGHTFUL PRESENTATIONS.
AS I LOOK AT THE INFORMATION YOU PRESENTED AND BASED ON MY OWN
SOMEWHAT LIMITED KNOWLEDGE OF THIS ISSUE, IT STRIKES ME THAT
TO A CERTAIN DEGREE WE'RE A VICTIM OF OUR OWN SUCCESS IN
TRYING TO SENSITIZE CLINIC SHUNS AND OTHER HEALTH PROFESSIONALS
TO BE MORE ATTENTIVE TO PAIN MGTS IN MORE PATIENTS.
IT RESULTED IN A MASSIVE INCREASE IN ACCESS TO DRUGS.
SOME OF WHICH IS INDICATED AND A LOT OF WHICH YOU SUGGESTED IS
NOT.
I'M WONDERING IF YOU THINK THERE NIB LESSONS LEARNED FROM OUR
EXPERIENCE IN TRYING TO PROMOTE MORE APPROPRIATE USE OF
ANTIBIOTICS THAT MIGHT RELATE TO THIS SITUATION?
PART OF IT, I THINK, PERHAPS RELATING TO ALTERNATIVE PAIN
MANAGEMENT APPROACHES BESIDES OPIOD PAIN MEDICATIONS, BUT I
ALSO WONDER ABOUT PATIENT EXPECTATIONS AND MANAGING
PATIENT EXAMINATIONPECTATIONS AND WHAT
ROLE THAT MIGHT PLAY.
HAVE WE GOTTEN TO A PATIENT WHERE PATIENTS EXPECT OPIOD
PRESCRIPTIONS, AND HOW MIGHT WE DEAL WITH THAT?
>> GREAT.
THANK YOU.
>> WELL, THANK YOU FOR THE QUESTION, BOB.
THOSE ARE GOOD SUGGESTIONS.
I THINK THIS PROBLEM IS DAIR REFLECTS A GENERAL INCREASE IN A
WIDE VARIETY OF CATEGORIES OF DRUGS IN THE UNITED STATES,
INCLUDING ANTIBIOTICS, AND THERE ARE LESSONS TO BE LEARNED IN THE
AREAS OTHER THAN SCHEDULED OR ABUSABLE DRUGS.
I THINK THAT THE GUIDELINES THAT ARE COMING OUT IN MORE RECENT
YEARS, WHICH ARE EVIDENCE-BASED, EMPHASIZE MORE WHAT YOU TALK
ABOUT.
MODERATING EXPECTATIONS THAT YOU WILL BE STARTED ON AN OPIOD
IMMEDIATELY AS THE BACK PAIN PATIENTS WERE STARTED ON THE
FIRST VISIT AND MODERATING EXPECTATIONS YOU WILL GET MUCH
BENEFIT IN THE LONG RUN.
WE NEED TO RAMP IT DOWN IN TERMS OF THE HYPE, I GUESS, ABOUT THE
ADVANTAGES OF LONG-TERM OPIOD USE.
THERE ARE OTHER MODALITIES THAT WILL WORK, AND THEY SHOULD BE
TRIED FIRST.
BUT THIS IS PART OF A GENERAL EDUCATION OF THE PUBLIC,
EDUCATION OF THE PROVIDER APPROACH, WHICH MANY PEOPLE ARE
WORKING ON.
>> GO AHEAD.
>> THIS IS A MAN-MADE PROBLEM, AND WITH NEED TO FIND MAN-MADE
SOLUTIONS.
TO MY VIEW THE MAIN PROBLEM AT THE VERY BEGINNING IN THE LATE
'90s WAS THE GATE SWUNG 180 DEGREES, BUT THERE WAS NO
GOVERNOR ON DOSING.
JUST THE LANGUAGE IN THE OWN REGULATION, NO DISCIPLINARY
ACTION IS TAKEN AGAINST THE PRACTITIONER BASED SOLELY ON THE
QUANTITY OR FREQUENCY OF OPIODS PRESCRIBED, NOTHING.
YELLOW SCHOOL BUSES HAVE GOVERNORS, BUT OPIOD DOSING DID
NOT.
I THINK THAT WAS THE MAIN PROBLEM.
>> JUST JUMP IN.
I THINK YOUR POINT IS WELL-TAKEN, AND WE HAVE A
BEHAVIORAL HEALTH COORDINATING COUNCIL WITHIN.
WE'VE IDENTIFIED PRESCRIBERS, BECAUSE WE THINK THERE LITERALLY
IS PRESCRIBER EDUCATION AND OVERSIGHT.
WE IDENTIFIED THE PUBLIC AS ONE OF THE TARGETS FOR NEEDING TO
INCREASE INFORMATION.
A LOT OF PEOPLE FROM WHAT WE UNDERSTAND THINK BECAUSE A
DOCTOR DID IT, IT MUST BE OKAY.
SO WE HAVE A LOT OF EDUCATION, I THINK, TO DO ON THE PRESCRIBER
LEVEL AND THE EXPECTATIONS.
>> YES, SIR.
>> I'M AN E.R. DOC AT GRADY AND DOWN THE STREET.
I FACE A BIG PROBLEM WITH PATIENTS THAT HAVE CHRONIC PAIN
CONDITIONS.
THERE ARE SEVERAL NEW DIAGNOSES FLOATING AROUND LIKE CHRONIC
ABDOMINAL PAIN, AND PEOPLE DO REQUEST SPECIFIC DRUGS THAT HAS
MORPHINE.
I STRUGGLE WITH THE LACK OF COMMUNICATION BETWEEN THE
EMERGENCY DEPARTMENTS ABOUT THE DRUGS THEY'RE PRESCRIBED.
I THINK THE STATE OF GEORGIA NEED PAY PMP PROGRAM.
THE OTHER ISSUE THAT WE FACE IS THAT WE ARE JUDGED AS A CLINICAL
CARE PARTLY BY PATIENTS' SANCTION THAT USES SURVEYS THAT
LOOK AT PAIN CONTROL.
PATIENTS COME IN AND BRING THEIR PATIENTS WITH THEM TO ADVOCATE
FOR THEM TO RECEIVE THESE PRESCRIPTION DRUGS.
WE HAVE TO ACTUALLY ARGUE WITH THE PATIENTS.
WHAT I USUALLY DO IS I DO ANY BLOOD WORK AND DIAGNOSE A
PATIENT ACCORDINGLY THAT THERE ARE NO INFECTIONS OR EMERGENCY
AND REFUSE TO GIVE THEM THE DRUG.
USUALLY THEY'RE ANGRY WITH ME, AND THEY LEAVE UPSET.
WE NEED HELP FROM LEGISLATION AND POLICY TO PROTECT EMERGENCY
PHYSICIANS TO DO THE RIGHT THING.
WE KNOW WHAT IS RIGHT AND WHAT IS WRONG.
YOU'RE RIGHT.
WE'RE SOMETIMES BUSY AND DON'T HAVE A LOT OF TIME TO DEAL WITH
IT OR SIT DOWN FOR AN HOUR TO FIGURE THIS OUT.
A PRESCRIPTION MONITORING PLAN IS IMPORTANT AND POLICY CHANGES
TO PROTECT US AND ENCOURAGE US TO DO THE RIGHT THING ARE
ENCOURAGED.
>> THANK YOU FOR THOSE COMMENTS.
WE HAVE STARTED SO DISCUSSIONS NOW AT THE CDC AND FDA AND OTHER
PARTNERS ABOUT DEVELOPING EMERGENCY DEPARTMENT GUIDELINES.
THERE ARE A LOT OF CHRONIC OPIOD USE GUIDELINES OUT THERE, BUT
NOTHING HAVING TO DO WITH EMERGENCY DEPARTMENTS, WHICH
INCLUDE THE ACUTE PAIN TREATMENT.
WE HOPE TO DEVELOP GUIDELINES, AND THOSE GET TRANSLATED INTO
STANDARDS, JOINT COMMISSION STANDARDS, WHICH WILL COUNT
BALANCE THE EVIDENCE YOU FEEL IN THE EMERGENCY DEPARTMENT THAT
YOU MUST DIAGNOSE AND MANAGE PAIN AS THE STANDARD FOR CARE
NOW.
THE OTHER PART OF THAT IS THAT THERE ARE SOME PARTS OF THE
COUNTRY.
THERE'S A CONSISTENT CARE PROGRAM IN EASTERN WASHINGTON,
WHICH IS A CONSORTIUM OF HOSPITALS, WHICH HAVE THEIR OWN
GUIDELINES.
THEY KEEP RECORDS OF INDIVIDUAL PATIENTS.
THEY ARE MANAGING TO SUPPORT THEIR PROVIDERS IN THE EMERGENCY
DEPARTMENT WITH A SPECIFIED STANDARD OF CARE, WHICH HAS
ENABLED THEM TO REDUCE THE FREQUENCY OF VISITS TO THE
EMERGENCY DEPARTMENTS.
>> JUST WANTED TO LET YOU KNOW WE'RE ALSO WORKING WITH SOME
PHYSICIAN ASSOCIATIONS AND PRACTITIONER GUILDS TO HELP THEM
DO SOME MENTORING PROGRAMS AND DEVELOP EXPECTATION AND SUPPORT
BASICALLY AMONG THE GUILDS AND ASSOCIATIONS FOR.
I APPLAUD YOU FOR BEING WILLING TO TAKE THE TOUGH STANDS.
WE'RE TRYING TO FIGURE OUT HOW THE PHYSICIAN GUILDS CAN HELP
EACH OTHER AS WELL.
>> I THINK WE MAY HAVE TIME FOR JUST ONE MORE QUESTION.
ALL OF US WILL BE AROUND AFTER THE SESSION TO TAKE ADDITIONAL
QUESTIONS, BUT ONE MORE.
>> THANK YOU.
MY NAME IS VICTOR CORONADO.
I'M A PHYSICIAN FOR THE NATIONAL CENTER ON INJURY AND CONTROL.
A COMMENT.
WHEN I CAME TO THIS COUNTRY TO BE AT CDC, I WAS ALREADY 20
YEARS AFTER THE MEDICAL SCHOOL.
I WORK IN THE EMERGENCY DEPARTMENT.
I USED TO DO A LOT OF DIALYSIS AND KIDNEY TRANSPLANTATION.
I USED IN ONE SINGLE NIGHT HERE MORE OPIODS NAN IN MY 12 YEARS
IN PERU.
IT'S DIFFERENT HOW WE TREAT PAIN HERE AND BROAD.
WHAT ARE WE DOING IN TERMS OF DEVELOPING NON-*** DRUGS TO
CONTROL CHRONIC PAIN AND ACUTE PANG
PAIN.
WHAT ARE WE DOING WITH THE DEPARTMENT OF THE DEFENSE TO
REDUCE THE USE OF DRUGS IN THE MILITARY, WHICH IS VERY HIGH?
THANK YOU.
>> I WANT TO EMPHASIZE SOMETHING I SAID IN MY PRESENTATION.
WE'VE HEARD TIME AND AGAIN FROM PRIMARY CARE DOCS WHAT THEY NEED
IS ALTERNATIVES TO OPIOD THERAPIES.
IF THERE'S A TIPPING POINT IN THE DOSING, THERE NEEDS TO BE
ALTERNATIVES.
A LOT OF INSURANCE COMPANIES DON'T PAY FOR THE ALTERNATIVES
THAT THE PATIENTS IN CHRONIC PAIN NEED.
COGNITIVE BEHAVIORAL THERAPY, GRADED EXERCISE, ET CETERA.
THAT'S WHAT WE'RE WORKING ON IN WASHINGTON STATE RIGHT NOW.
>> THERE CERTAINLY IS WORK BEING DONE ON ALTERNATIVES OF A OPIOD
ANALGESICS BECAUSE THERE'S A HUGE MARKET FOR IT.
WE WOULD THINK UNTIL BETTER DRUGS ARE AVAILABLE, WE WOULD
TRY TO MAKE -- HOPE THERE IS BERLT REIMBURSEMENT FOR
NONPHARMACOLOGICAL MODALITIES FOR TREATING PAIN.
AS FAR AS THE DEPARTMENT OF DEFENSE IS GOING, THEY HAVE A
MAJOR PROBLEM THERE.
WE HAVE HAD SOME COMMUNICATIONS WITH THEM.
I THINK WORK NEEDS TO CONTINUE TO BE DONE WITH VETERANS
ADMINISTRATION AND THE ONGOING COLLABORATIONS.
>> THANK YOU VERY MUCH FOR YOUR TIME AND ATTENTION AND FOR