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Operator: Welcome, and thank you for standing by. At this time, all participants are in
listen-only mode. After presentations, we will conduct a question-and-answer session.
To ask a question on the phone, you may press *1. This conference is being recorded. If
you have any objections, you may disconnect at this time. I would now like to turn the
conference over to Mr. Mike Koscinski. Sir, you may begin.
Mike Koscinski: And welcome to our webcast on preventing prescription drug abuse. I am
so glad that you could join us this afternoon or this morning, for those of you on the West
Coast. This is a very important webcast on a very significant public health problem that
is daunting our United States, and we have been focusing on this issue for a second time.
The first is a more general overview, but this time on information that could help you,
especially those of you working at the local or state level on specific interventions on
preventing prescription drug abuse. Our speaker today is Dr. Ted Miller. He's an economist
and policy analyst at the Pacific Institute for Research and Evaluation. He has almost
20 years of experience analyzing poisoning prevention and control issues, and you may
know him for his estimates of the cost of underage drinking, by state, or the cost savings
from substance abuse prevention programs. He also directs SAMHSA's Prevention Prescription
Abuse in the Workplace Technical Assistance Center.
Now before we begin, I would hope that you will ask questions. There's a Q&A on the
top there, where you can ask over the Internet, or, if you would like, the operator will be happy
to take your calls, and there will be breaks when Dr. Miller is presenting his material
for you to ask questions either way, through the Internet or through the phone. If you're watching
this live, not on the replay but live, you can download the slides as we speak. If you
see the word "feedback," and to the left, there's a yellow icon, but that's not
the one. To the left of the yellow icon, there's a white icon. If you touch it very gently
with your mouse, you'll see the word "handouts"; just click on that icon "handouts," and
you'll see the ability there to download Dr. Miller's slides. So without further
ado, and I do hope you'll have questions for Dr. Miller today, I'm going to switch
the program to Calverton, Maryland, and to Dr. Miller at the Pacific Institute. Dr. Miller.
Dr. Ted Miller: Thank you, Mike. Mike told me to tell you that this is my picture over
on the right here, so you know who you are talking with, and what I'm going to do today
is talk very briefly about the prescription drug abuse problem and then talk in some depth
about what we are doing, and we could be doing, to respond to it. Prescription drug
abuse is a longstanding problem. I think someone needs to put a mute button on. You can see
that from 1966 Valley of the Dolls, which is all about ***. *** was a very lethal
drug. There were a lot of deaths, and Burt Reynolds asks, "Does anybody have a ***?"
and 40 people offered him their controlled prescription substances. When we replace ***
with less-lethal drugs, deaths from poisoning overdose went down; but with prescription
pain killers, they've come back of late. And what you can see here is the prescription
painkiller deaths now exceed motor vehicle traffic deaths, and the drug poisoning overdoses
went up again in 2011 (we just got the numbers). So this is a continuing problem. No wonder
it's a problem when you look at the chemical composition of oxycodone and ***. Look
at how similar they are; and over on the ends, they are basically the same drug and very
addictive. And we see this huge surge in drug overdose deaths and, particularly, ones
with opioids. And we see a similar surge in emergency department visits both for the prescription
painkillers and for benzodiazepines and generally for illicit drugs going up much faster than
illicits. More teens can get prescription drugs and marijuana in 1 hour, according to
recent study surveys, although that difference does shrink with age. Prescription opioids have now passed
alcohol as the drug of choice in Tennessee. The reason for that is simple: because your
health insurance won't cover your *** bill, but it will help cover your opioid bill.
This was a slide that really struck me because it looked like the slide I used for years
about alcohol. It turns out that two-thirds of the prescription opioids are consumed by
less than 10 percent (or about 10 percent) of the prescription opioid users. Now that is similar to alcohol, where
most of the alcohol is consumed by a small percentage to the drinkers. Many of you have
probably seen this slide, and the way it is usually presented is that most people get
their opioids eventually from one doctor. If we think about 10 percent of the people
as the problem, 4 percent from a drug dealer, 1.9 percent from doctor shopping, a few from
the Internet, some from other (which may be stealing it), and some bought it from a friend
or relative who may have gotten it from a drug dealer, bought on the Internet or bought from
a friend or relative or from more than one doctor. Notice that more than one doctor is
more common than this selling set, more possibly, so there is a different way to look at that
slide that is much more alarming. If we look at where the risk of death is the
greatest, it is among men, among whites, among Native Americans, and among middle-aged people. Fifty-eight percent
of the people who die are over age 40 and low income, and people living in rural areas are
hit hard by this. Fifty-eight percent of those who are dying are taking multiple abuse-able pharmaceuticals,
though it doesn't mean they were taking them in more than the doses prescribed. We
see quite a few people who are on doses of 100 morphine equivalents a day who are dying even when
taking just their prescribed dose. And twenty-one percent of those who died mixed prescription and
illicit drugs. The cost for this problem is more than 56 billion dollars, and the biggest
piece of that is health care costs. The reason for that is not only the cost of the prescription
drugs, but there is the cost of all the doctor visits to go get the prescriptions and all
the tests that those doctors do and the other aspects of lost productivity and criminal
justice costs. So how do we respond? How do we respond to
the man who is managing his pain with his prescribed dosage, but the pain gets so bad
he takes an extra one or just taking what he is supposed to, he gets addicted because it's a very
addictive drug. How do we respond to a "pills party" and kids bring over whatever pills
they can grab out of the medicine cabinet? They mix them all together in a bowl and you
wash them down with *** and when they get you to the ED nobody has any idea what you
just mixed with the alcohol and what they need to treat. The federal response has been to
declare this an epidemic, and the Office of National Drug Control Policy in 2011 put out a federal
plan to respond to the epidemic laying out federal agency roles and responsibilities,
prevention treatment goals, best-practice guidelines, calling for new medications with
lower abuse liability, and calling for more patient and prescriber-patient programs. That
plan expands in the National Drug Control Strategy, and that strategy in general calls
for action in education and monitoring proper medications disposal and enforcement. They
talk a lot about parent, youth, and patient education, engaging in and enlisting antidrug
coalitions and other organizations in public education campaigns, requiring manufacturers
to develop educational materials, developing a mass media campaign.
One thing to realize as you think about this problem is it is a 3-pronged problem, so it
needs a 3-D response. There are people who are just in therapy with these addictive drugs,
and it is not just the opioids, it's also some of the other drugs that are used
for antidepressants that can be hard to shake. That is particularly dangerous for the chronic
user, but even an acute user of the doctor-prescribed 2 weeks of opioids is going to have withdrawal
symptoms. If you stop after a week and then get withdrawal symptoms, you go back to the
bottle because you think you are not ready to go off of them and you are hooked. Then
there are those who are using them recreationally, and they can get addicted, too. And if the
addiction is there, that is a different problem to deal with because now you have an addict,
And what happens if that addict is also in pain and needs a pain relief?
Many of you know the public health approach: we define the problem, we identify the risk
and protective factors, we develop and test our prevention strategies, and we ensure widespread
adoption. And that certainly applies here, and that is the way the SPF-SIGs (Strategic Prevention Framework State Incentive Grants)
do things, for example. I wanted to give you a bit of a different take on it,
so I turned to injury prevention, where they have something called the Haddon Matrix, developed
by the first head of the Highway and Traffic Safety Administration, and he was a public
health guy. He said we should think about responses in terms of: for the event, during
the event, and after the event. I thought about it and said, "What is the event here?"
The event here is people who are abusing or misusing prescription drugs but have not yet
been detected in doing so. Before the event is people who are just in the general public
or people who have been prescribed prescription drugs but aren't yet misusing them. And
after the event is what we do once we detect that somebody is misusing a drug. And Bill
Haddon said, down the other side of the matrix, we should think of the host, that's the
person, the agent--in this case, that's both the drug and the prescription for the
drug, the physical environment, and the social environment. And so that is the conceptual
framework I am going to take you through today. It is important to realize that many of these
cells, nothing is settled, and just take the example of the disposal of prescription drugs,
and should we flush the controlled substance, the opiates, down the toilet, if we're disposing
of them? That is easy, and we can be certain it is not recoverable, but there are cons
to that. One of the major cons is that it can damage the environment. A second major con is that
you don't want to tell them to flush everything down the toilet because we don't want every
prescription drug in the world in our water system. So you get mixed messages between
substances; furthermore, we have some states that went one way. The EPA says flush the
opioids. There are some states who said it was illegal in our state. That is a confusing,
mixed message and leaves people not knowing what to do, so something that seems like it
ought to be simple is not. We are seeing prescription drugs in our tap water right now. So the next
step is we say, "If you are not going to flush it and you don't take it back and
you want to dispose of it yourself, mix it with coffee grounds or kitty litter, or mix
it with sawdust." I went and read a bunch of those fact sheets, and I thought about
it. The first thing I realized is not everyone has coffee grounds, and some people drink
tea and they have a dog, and then I said to myself, "Besides, if I take my oxycodone
and mix it with kitty litter, these things are worth $40 a pill on the street, why doesn't
somebody just fish them out and sell them?" I finally realized that some of the fact sheets,
but not all of them, had this critical additional point: add water, either dissolve the pills
in water and then dump them in, or dump them in and add water.
The Connecticut Disposal Fact Sheet is the one that I think is probably the best done of the group
that are out there right now. So, let's look at the Haddon Matrix now and look at all the
ways we can do things. I am going to start out by going down pre-event and talking about
what we do, and we start with the host, so we want to educate youth, we want to educate elders and put
them through prevention programs just like we would with any other kind of substance abuse. We
want to educate workers because, remember, a lot of these people are middle aged. Educate
patients when they get their prescriptions and before they get their prescriptions because
one of the things to educate them about is that there are alternatives here. Also, educate
pregnant women because we are starting to see a lot of babies show up in birthing rooms
who are addicted to prescription opioids, and we don't want that. What do we do with
the drug? We can reformulate it to stop tampering. OxyContin and some of the others, the addicts
were grinding them up so that they could either shoot them or dissolve them in water, and
they have changed things so if you try to do that, it releases something that causes
the opioids to go away and not work. It's a major change.
There is also something called an ARAP combination, which tends to increase the change of liver
damage, and we get rid of those, and it looks like the FDA is going to ban those we can
move opioids to a higher schedule of danger and put more opioids there so there are more
restrictive prescriptions. Some states have prescriptions that you can easily make yourself
on your computer and look like the prescription pad. There are other states where the prescription
pads have the kind of security that dollar bills now have. There are others where they
are actually moving toward an electronic prescription where there is a secure line between the doctor
and the pharmacy and that is the only way the pharmacy gets prescriptions for controlled
substances. The package warnings need to be rewritten, and package warnings are normally
written when a drug is approved. They need to be changed, and we need the dispenser and
the prescriber when they hand out these drugs to warn people about them and to say, "Hey,
these are addictive and this is what you have to be careful about. And if you have any leftovers,
you've got to dispose of them, and here is a sheet on how to do it."
Physical environment: we need to make sure that our health insurers cover the other things
that are as likely to cure pain as an opioid. Those are things like mindful meditation,
massage, acupuncture, and all of these things are 15 percent effective, and so is non-prescription
pain medication, people should start with those because there is no risk of addiction
with those. We have prescription drug monitoring programs and some of those programs are allowed
to do proactive monitoring for providers to pick up ones who are pill mills because that
is important. We need to regulate our internet and import sales of prescription drugs, and
it is hard to do. There are organizations that have tried drug testing-either random drug testing
or pre-employment testing. That is a questionable issue right now because there are no federal
standards yet on testing. There is a thing called a "medicine cabinet lock box,"
and if you have got a prescription opioid-even if you are the only one in the house, but
people occasionally come over-you ought to keep it locked up. We are getting take-back
programs to take back the leftover drugs. In the social environment, we've got drug-free
policies and programs. We've got to train our providers, put out practice guidelines,
mass media campaigns, and targeted media campaigns, and we need to do surveillance both through
surveys and do some research on what to do. We need to mobilize our communities, and we
need to take our Comprehensive Substance Abuse Prevention programs and make sure that they
have prescription drug abuse covered in them, and we can show that it is effective.
So what do we do during the event? We give people tools to assess whether they have a
problem. We build into our wellness programs self-assessment tools. And it turns out that
if you overdose on opioids and someone quickly sprays Naloxone up your nose, they can save
your life. We need to start to co-prescribe those kits, and there are states that are
trying that now. The prescription monitoring programs, moving to the agent side, serve
to check as they prescribe that people are not getting multiple prescriptions for multiple
places that don't all appear legitimate, and they let the doctor check and they let the dispenser
check. There is also proactive PMP reports allowed in some states, where they send to
a doctor and say, "You have a patient who is getting high doses of opioids from four
sources; make sure that is appropriate." There are states, now, that are starting to
experiment with putting a case manager in the emergency department whose job it is to
check on everybody who is getting opioids and do things like make sure that the number
of pills in the script are small, that there are no refills on that script, that that script
has to be filled in perhaps 5 days or it can't be used, and also checking that the person
is not already in trouble. As we get to the physical environment, there
is screening that can be done out there. There is screening through testing, there are poison
control centers out there who can . . . (and the screening for testing is really for-cause
testing, a little questionable but perhaps a little more common). There are poison control
centers that people can call when they are in trouble, there's law enforcement that
can pick these people up and say, "Ah, there is a problem," and get them some place where
they can get help. Lesson from nonprescription opioids: needle exchanges for those recreational
users who are crushing something-cut the harm.
Social environment: there are assessments by family and friends. There's immunizing
911 callers. Post-event: there is brief interventions, just
like we have with alcohol and drugs, and we are starting to use those and see them be
effective. There is treatment and vocational rehab, and there is Naltrexone, which causes
opioids not to give you joy, and it takes the addiction away. The problem is, if you
are also using it for a painkiller, it no longer works. There are states where they
are starting to say they have caught a person with a problem, and it is very common in Medicaid
in over 30 states that they can limit someone with a problem to either one prescriber or
one dispenser or both. Moving back to the agent, we've got programs
to take it back and get rid of it, and we've got disposal. Those take-back programs can be
police departments, they can be pharmacies, or they can be a funeral director who puts
on to the list of things to do when somebody has died and take their prescription drugs,
which are dangerous, to a place for disposal. There are theft safeguards because it is easy
to have these drugs stolen. There is the restriction of prescribers and dispensers. In terms of
physical environment, once we've caught somebody, we should trace back the sources
of the drugs, perhaps; we need to prosecute the dealers and the pill mills, and that is
how we help find them. There is scheduled testing, and that is a monitoring thing; that
is generally between the patient and the physician who is monitoring the recovery, and that is
essential in monitoring the recovery, perhaps, but it is a medical thing. Social environment:
we need to collect and analyze event data so we know what is happening so we can monitor
it. We need to evaluate the programs that we have, and as people go into recovery, they
need family and peer support. And one thing that is a big issue is Internet and cell phones
as facilitators here. You can buy drugs over the Internet, and you can use your cell phone or the internet
to make appointments with your drug dealer instead of having to go to an old drug market.
It is a very different thing, and I don't know that we have figured out how to intervene
in that new way of dealing drugs. You get to the market and you want to make sure it
is the right pill, and you take out your cell phone and use the pill identifier app in
the cell phone and say, "That is the pill I want to buy."
So, let me pause, and you will see on your screen a poll, "Does Your Coalition or Workplace
Address Prescription Abuse?" If you would either check yes or check no, please, and
we will see what the answers look like. We will come back to the polls. [Skipped over polling]
Let me give you some examples of places that are doing something now that seem to have reasonable programs.
One of those is Madison/Dane County, Wisconsin, where they have a Safe Community for the World
Health Organization and they decided that one of their priority issues would be prescription
drug abuse. They mounted a community-wide, multifaceted effort and started out with a
drug poisoning summit, and they brought in 130 professionals, they brought in data, they
prioritized action steps. They focused on six strategy areas, which were reducing access
to drugs, reducing inappropriate prescription use, primary prevention of substance abuse,
early intervention treatment and recovery, mental health care integration (which wasn't
even one on my list), and overdose intervention and harm reduction.
In Berkeley County, West Virginia, their coalition against substance abuse put out a broad-based
program as well. They started out again with data collection analysis, they put together
a logic model and worked for cross-state access to prescription monitoring programs because
they felt people could be on both sides of the border buying prescription drugs, and
they needed to know it. They did training presentations to parents, youth, and pharmacists
about what are the harmful effects, how can parents monitor, how we can procure and dispose
of prescription drugs. They evaluated pharmacists' experience with prescription monitoring program
and the use of coalition materials. They put together a billboard about prescription abuse
with QUITLINE, and they did something that we thought was great. They went to realtors,
and they said, "Hey, when you have an open house make sure that when you put away the
valuables, put away the prescription drugs." They are trying to revive medicine cabinets
in their community and also put in a feel-good activity of drug-free skate nights. I would
remark that this kind of feel-good activity, they tend to be a little bit expensive, and
we don't have much evidence that they reduce substance abuse, generally. We do have some
evidence that the night ones may reduce violence. The Flight Attendants Drug and Alcohol Program
is another interesting program. It is broad based; these are workers who operate heavy
machinery every day, and if they are taking a prescribed drug that says, "Do not operate
heavy machinery while on this drug," they shouldn't be in service on an airplane.
They take sleeping pills to sleep sometimes because of irregular work schedules, they
often have back pain or other pain and may be on prescription painkillers, they sometimes
get depressed, so they may be on antidepressants. All of those are issues, so the flight attendants
have put together a self-assessment tools similar to the CAGE to help flight attendants
recognize that they had a problem and put together the EAP consultation referral, they
put together a brief intervention and treatment, and they put together a surveillance survey
to find out whether their people are out there when they shouldn't be and to make them
aware of what the restrictions were that they needed to pay attention to.
Project Lazarus in Wilkes County in North Carolina that is, again, broad-based and it
is evidence-based, and they have managed to do a fair amount of evaluation of this program.
They started out by monitoring their data, thinking about what to do. They said, "We
are going to put together a toolkit and face-to face meeting to educate primary care providers
about managing pain and about safe opioid prescribing, educate parents and families
on opioid safety, on handling overdose emergencies. We are going to co-prescribe Valtrex and Naloxone."
And they are prescribing it, and they have started that, and it has moved out. They put
together ED case managers and said, "You don't prescribe in the county in ED without
the case manager talking the time to look closely at the patient and whether there is
an issue with that patient." They put together treatment; overdose deaths dropped by 69 percent
in 2 years, 28 straight months of decline. Meanwhile, deaths rose in all other North
Carolina counties, and the deaths that were left in Wilkes County were opioids prescribed
elsewhere. At the same time, there was no change to speak of in how many Wilkes residents
received an opioid painkiller, but they weren't receiving them in overdose quantities, and
they were receiving them with education about how to use them well.
There have been several narrow Naloxone program replications: Massachusetts state wide, Operation
Opioid Safe at Fort Bragg, Eastern Band of Cherokee Indians were ones that struck me
as interesting. Down here at the bottom, you seen somebody administering Naloxone to somebody-I'd
imagine a posed picture, but still, it shows you how easy it is. Some states are immunizing
911 callers, so that if they call in about overdose and they were somehow involved in
that happening, there is no self-incrimination worry. Operation Unite in Kentucky, founded
by a Congressman-broad based, very well-funded-has the goal of combating addiction and corruption
of prescription drug abuse in southern and eastern Kentucky. Activities include undercover
narcotics investigations, coordinating funding treatment for substance abusers, providing
support to family and friends of abusers, education awareness, and a lot of feel-good
activities. Another interesting one is the VetCorps that
CADCA is running. They have added 100 full-time VISTA AmeriCorps staff to CADCA community
coalitions. What those staff are doing is supporting veteran and military family needs,
with emphasis on serving the needs of National Guard and Reserve families. Some of them are
allowed to deliver direct services but many only assist coalitions in developing and carrying
out strategies to address the service gaps for returning veterans and their families,
and that includes prescription drug abuse ,which is a large issue in that group. We
have been with this drug abuse problem for military families for a long time. [Operator working to open polls]
I want you to ask yourself which of these four is not a street name for methadone? Is
it "fizzies," "jungle juice," "Maria," or "512?" And the answer is "512," which
is actually Percocet. But it is interesting to see that these things all have street names,
and it tells you that they are purchased on the street.
Live Right Do Right in Baltimore is a host-focused program and is a youth program, and they took
an evidence-based lifeskills curriculum; they tweaked it to have prescription drug abuse.
They added mentoring, family counseling, mental health evaluations and assessments, and substance
abuse treatment referrals. There are a whole lot of programs out there that are focused
on the host pre, and even some of those that are on NREPP haven't necessarily been evaluated
in terms of the prescription abuse content that was in them, even when they went on NREPP.
Programs like that are Stay on Track, which is school-based, Team Awareness for Youth
in the Workplace. One that has been evaluated in its prescription drugs, and that I will
talk about later, is Healthy Workplace program. The Get Fit Wellness website that SAMSHA developed
has prescription drug content. Pathways *** Overdose Coalition, New Bedford, Massachusetts,
is a youth peer-to-peer and social marketing program that has added this content. San Ramon
Valley, California's, CASA is an adult-guided peer program that has added prescription abuse.
I have listed a few more here, such as We Are Not Buying It in East Brunswick, New Jersey,
fights media misinformation and the media's depiction of what happens with substances
is not accurate. The Partnership for Substance-Free Buncombe County does community risk education
and take-back, and that is a fairly typical program, and these are some examples of the
kinds of community programs we are seeing. There are quite a number of programs that SAMHSA
has funded through its Practice to Science Initiative.
Something else I wanted to talk to you about is the National Council on Patient Information
and Education, and this is their e-mail address up here at the top, their web address, and
one of the reasons I want to talk about them is that with SAMHSA, they are just launching
a national video challenge, and the details of that will be out in mid-March on the website.
It is for youth ages 17-25 who are invited to submit a 2-minute video addressing the
question, "How can technology be used to pass forward information about the availability
of educational resources to promote prevention and recovery; what creative strategies can
help ensure the college- and community-based service organizations across the know about
these resources and encourage them to reach out to other people?" They are focusing
on five resources. Two of those were developed with SAMHSA by NCPIE: one is a resource kit
to inform college peer educators and leaders about the dangers of prescription drug misuse,
prevention, and treatment; the second one is an online educational workshop maximizing
your role as a teen influencer: what can you to do help prevent teen prescription abuse? The
other three are more general but very applicable in the prescription abuse area. There is SAMHSA's
Treatment Locator, recoveryopensdoor.org, and SAMHSA's Recovery Month.
In Utah, they have got a Use Only as Directed Campaign and Take-Back Initiatives, and these
are host and social-environment focused pre, plus the take-back post; mass media campaigns;
individual education, information and strategies focusing on safe use, storage, and disposal;
and then prescription take-back events. This shows you the kind of a deposits thing that
they use, and this is as lock box which you can lock up meds if you have taken them back.
But the thing about the locked box is that it is more portable, but you have to worry 342 00:38:01,809 --> 00:38:08,809,700 about the box getting stolen if it is unattended. There are ways to do that. The National Coalition Against Prescription
Abuse is pre-event host and social environment. It is a major education website, and I put
the web address here as well, and the reason because is that I like their screening and
self-assessment tools and I like the stories they had up from people. They also have parent
and student education in there and initiate and support legislative action and they're
building wide-ranging coalition partnerships to push legislation and push enforcement where
political action is needed. Another project that is out there that is a broad-reaching
one is the Medicine Abuse Project (youth) and to prevent host and social environment
again. It has resources for educators, a curriculum called Prescription for Understanding developed
by the National Education Association and Health Information Network. I have not been
able to find any information on the evaluation of that curriculum as yet, though. They also
work also on education awareness and prescription drug abuse awareness for parents and grandparents; they provide
steps family members can take for prescription abuse by their children.
So, think about which of these is not a street name of OxyContin: so, is it "blue crack,"
"Cotton," "hillbilly horse," "killer," "Roxi," or "40-bar?" It turns out
that "Roxi" is Percocet again. But think about the ability of kids to be having a nice talk about "killer"
OxyContin, "Man, did you see that 'hillbilly horse' in that movie?" and nobody knows
what they are talking about. Or they're talking about, "Gee, I'd like to get five
'hillbilly horses' myself. I wonder how expensive they'd be?"
This is that program for the workplace that's an extension of Healthy Work Life, and it's
been evaluated with an NIH grant. It's called SmartRX, Your Prescription for Good Health.
It is a 1- to 2-hour, self-directed, online tool designed to prevent misuse of prescription
drugs among adult women. It covers use of analgesics and anxiety drugs, sedatives, and
stimulants, and it is part of a wellness website, and that makes it less threatening, which
the research shows. It increases knowledge of proper prescription medication administration
and increases the ability to manage their own medications or concerns about medication
administration. Users describe the program as comprehensive, clear, informative, and useful.
They are currently extending this program to add content more tailored to men and male
workers. Another program that is out there that is on NRAPP that is a prescription drug
abuse program that has been evaluated is Enhance Wellness, and it is for older adults, and
it is participant-centered motivational intervention that complements formal health care. It addresses
wellness including managing prescription drug use and reducing use of psychoactive drugs.
It has been evaluated and reduced length of hospital stays and lowered the use of psychoactive
drugs, it alleviated symptoms of mood disorders among participants. I thought it was useful
to put a reminder up here of what a pill manager looks like, which could be one way to reduce your chance
of taking too many drugs at one time or forgetting you took them and taking them again.
Another one that has been evaluated with NIDA funding is called Mobilizing the Community
to Reduce Teen Prescription Drug Abuse Use operated in Rural Tennessee. It is a pre-event
physical and social environment modeled on an Alaska inhalant prevention program. They
did a lot of community mobilization, home and environmental strategies, parent education,
and safer disposal and storage. This over here is a medicine cabinet locked shelf, and
they are about $20 and not expensive. Then the medical environment they promoted using
the Prescription Monitoring Program and have educated physicians about the problems and
contribution of prescribing practices. They are improving pharmacy practices and looking
at where over-the-counter medications can interact with the opioids are kept and the
ones that can be abused are kept and they are saying, "Get those off shelves where
kids can just grab a bunch or steal them." In Oregon, they have put together a whole
action plan and is medically oriented. They are working on communication with media packet
templates, so they actually give the doctors something they can use to write, say, an op-ed
to their local community paper about the issue. They are assessing needs for opioid prescriber
education, they are enhancing the detox model throughout the state-funded treatment system
to align with the medically monitored model, including medication-assisted treatment. They
are looking at clinical system coordination there, so it is a very different thing. They
are now approaching that environment and the medical environment.
In Aroostook, Maine, there is a Diversion Alert Program from their ASAP Coalition that
is focusing, very heavily, based on having gone and collected and having analyzed local
data and said, "What is our problem, and what do we do?" They have modeled themselves
on a responsible beverage service training; they've got providers out educating other
health care providers about the problem, and then they are providing those providers with
monthly lists of names of residents who have newly been charged by the police with pharmaceutical
crimes, either buyers or sellers. With ongoing access to the names of those that are being
convicted so it is a complement to the prescription abuse, and they are saying, "Hey, this is
law enforcement data, but let's try to use it for a public health use."
The last quiz that I get to do (or don't get to do) is, "Which of these is not a
street name for Adderall?" Is it "beans," "black beauties," "Christmas trees,"
"double trouble," or "pineapple?" It turns out "pineapple" is Ritalin.
Another program that is out there in Ohio is Recovery to Work Vocational Rehab Initiative, and it
is post-event and host and physical environment. It is blending addiction, mental health, and
vocational rehabilitation services to address needs of eligible clients. They have considered
social and mental benefits that employment contributes to recovery, and they are trying
to build that in and giving priority to individuals addicted to opioids, including prescription
opioids. The one problem is that the job market is not very good now in Ohio right now, so
they have got a whole lot of people in this program but haven't, as yet, found them
any jobs. Hopefully the economy will be improving there, and they will see a lot more success.
In Bucky County, Pennsylvania, they have focused on take-back, and they did that after looking
at their data and looking at what was needed in their community. They built their program
around the SAMHSA Strategic Prevention Framework, and they built it as a take-back program within
that framework. They launched a wide range of actors, and they are using take-back messaging
as a way to educate people about the risks so that the education is what is threatening
and is embedded that way. It will be very interesting to see what happens as that gets
evaluated, and I hope it will be. The C.A.R.E.S. Alliance, funded by the industry, has picked
up on that. They actually have things like a pain management toolbox, pharmacist toolkit,
and prescriber education on the website. The reason I put their web address up here is
because they have a toolkit that basically builds on that Bucks County experience. It
is 15 pages of details on how do you set up and run a take-back program in your community.
CADCA likes that toolkit; they're actually testing it out in seven other communities
now. One thing that worried me a little about that program and perhaps many of these take-back
programs is when you have a Take-Back Day, you are going to get lots of people together
in one place bringing back their medications. You run the risk of developing a marketplace
right in the place, of John saying to Mary, "What are you taking back?" and Mary saying,
"Oh, my dentist gave me 30 days of painkillers when he pulled my tooth, and I have 28 days
of them left, so I was bringing it back." [John says]"You know, I have been having back pain, so maybe
you can give me that bottle, and I'd even give you $10 for it." You have added to
the problem instead of reducing it. So it's an issue. I was just noticing in Q&A there's 4 questions"
Let me talk now some about Prescription Monitoring Programs and I could give you a whole lecutre on it, but I'll be very brief about it
and we may do a webinar one of these days just about Prescription Monitoring Programs. We're planning to do a series
of webinars where we will bring in some of these best programs and let you hear directly
from those folks in detail about their programs. Prescription Monitoring Programs are set up
by government; they collect, monitor, and analyze electronically transmitted prescribing
and dispensing data from pharmacies and practitioners. Some of them are law enforcement-oriented,
and some public health oriented, and some both. Forty-eight states have authorized these;
almost 40 have them up and operating now. The theory here is the prescribers and dispensers
can check patient prescription history and make sure that somebody doesn't have six
prescriptions for high-dose opioids. Some states are allowed to send proactive reports
about patients that a provider might need to check on. Some states can scan and say,
"Here are people who are issuing sixty 100 mg opioid/oxycodone/OxyContin prescriptions
an hour-that might be a pill mill, somebody needs to check on it." And, depending on
the state, they may be able to say to law enforcement, "You can check on it," and
they may be able to say to the medical association, more in a public health mode, "Maybe you
need to check on this prescriber." Something that's ironic is that, in some
states, Medicaid may have access so that Medicaid can check a Medicaid recipient and see all
the prescriptions they are getting, but there are no states where private health plan case
managers, pharmacy managers, or fraud control people can have access or where medical review
officers at companies have access to prescription monitoring programs. That means that we are
saying, "OK, doctor who is a pill mill, your job is to detect that this person is
abusing drugs;" dispensers that is being used by all the pill mills, "Your job is
to check;" but payer, whose pharmacy manager has financial incentives to catch up with
this person who has gotten hooked, "You are not allowed to have access to the data."
There is a lot of policy discussion going around right now that takes the position I
just took, and we think we may see changes in legislation in some states; there are model
laws are being written right now. There are also a series of federal prescription drug
monitoring program priorities, and one of these is to integrate the electronic health
record right in with the Prescription Monitoring Program so that when the doctor goes to prescribe,
the Prescription Monitoring Program kicks up without taking extra time and says, "This
person has three other prescriptions for this same drug."
Increasing interstate compatibility and communication: currently, these systems are home-grown state
things. There is not a standard set of data collected in a standard way. There are some
of them where it comes in the same day; there are some of them where, once a month, they
upload the data. Evaluating the effectiveness of these programs: and we started to show
that they have some effect, but they vary so much from state to state that we need to
evaluate more about what works best. Exploring the feasibility of reimbursing prescribers
who check the monitoring programs before writing a substance controlled through prescription.
Evaluating those Medicaid programs that limit doctor shoppers and that limit people abusing
prescription drugs to one doctor and one pharmacy; those are all the things that the feds are
working towards. There is technical assistance about prescription drug monitoring programs
from Brandeis, they've got their Monitoring Program Training Technical Assistance Center
and their Center of Excellence working in this area. Chris Jones and Len Paulozzi at
CDC have also done a lot of work in this area, as has Jinhee Lee at CSAT, so there is a lot
of available support in that area. The National Governor's Association and AASTHO are both
out there; they are identifying best practices in the states, and with funding that they
got from pharmaceutical industry, they have been funding planning efforts in several states.
Finally, the National Safety Council has launched their Preventing Deaths from Prescription
Drug Overdose Initiatives-this is a big deal. The National Safety Council had two
initiatives, workplace/ occupational injury and illness, and motor vehicle crash; and
for many, many years, those have been their two big priorities. They were so alarmed by
the number of deaths from prescription death overdoses, and a number of them were people
whose prescriptions in part came from worker's compensation and, in many cases, were only
what came from worker's compensation. They said this is a third area we have to be in
and have a major presence in for a while. They have launched a series of large expert
meetings to plan strategies and get commitments, and the next one will be in Atlanta in late March.
It is open to the public, and they are trying to change employer, purchaser,
and payer practices around prescription opioids and their impact on the workplace. They are
trying to educate the public about safe use and storage, changing opioid prescriber behavior,
supporting efforts to reduce misuse, looking at regulatory and legislative policy changes.
They have got some interesting fact sheets that we have given them some advice on, around things
like how do you modify your health plan to incorporate prescription drug abuse, considerations
Considerations for what an EAP needs to know about prescription drug abuse and how to integrate that in there.
What to do in terms of how to modify your drug-free workplace policy to incorporate
workplace drug abuse, and what to do with respect to return to work, and I believe those
fact sheets will be out shortly. Let me turn now to telling you a little bit
about our resource center. Our resource center is called Preventing Prescription Drug Abuse
in the Workplace (PAW) Technical Assistance, but the people who wrote that said community
coalitions include-or, if they don't, should include-workplaces because workplaces
are important partners. So one of your jobs is to support preventing prescription drug
abuse by community coalitions and help them with that, too. So we assist workplaces and
their community partners, particularly SAMHSA grantees, with resources, networking, strategies,
and evaluation efforts. The reason for workplaces is that is where we reach adult abusers and
the parents of young abusers. And the most deaths here are in adult abusers, so we took
the main focus in part to where they are at. We developed resources; our website is pawta@pire.org,
and if you e-mail pawta@pire.org, that is one way to request technical Assistance or
the resources. If you are a SAMHSA grantee, you can go to your project officer and request
our services that way (and that is probably the most appropriate). Our project officer
is Deborah Galvin, and her phone number is here; and her e mail address I will give you
later. My staff is Rekaya Gibson, and this is her phone number, and she is easier to
get on than I am, and my e-mail address is here, and I will give you Rekaya's later.
One of the things that we have done is that we have put out a weekly summary now of new
reports and resources that have come out on prescription drug abuse, so everything that
comes out in journals or important in the newspaper, reports that come out, we are putting
it out as a weekly e-mail. If you want to subscribe to that, it is paw@dsgonline.com.
It is free, and if you don't like it, it's really easy to get off, you just click on
something at the bottom. Past issues of it are now archived by our partners at West Virginia
University Injury Control Research Center, and we use CDC funds to put up that archive
because they thought these were important for people. The archive link is on their home
page on the left-hand side. We have a lot of fact sheets that we are starting
to be able to release, "Prescription Drug Abuse Awareness: Information for Employers"
and "Monitoring Prescription Drug Use in the Workplace: What Can Employers Ask?"
These are legal drugs, so what can you legally ask your employee (who has the right to privacy
about their health with respect to their use of these drugs)? "Opioid and Narcotic Painkillers:
Know the Benefits, Understand the Dangers" is designed for people to hand out to large
numbers of people who may be using these and give them some specific education about them.
"Five Reasons Not to Share Prescription Drugs at Work," this is one I am really
particularly proud of because it is so important when you look at most of these fact sheets,
they never really explain clearly to people, well, why it is that if your wife has pain
because she hurt her back, give her one of your pain pills. That means you are playing
doctor, and you may not know about something else in her medical history that means that
the painkiller can be dangerous for her even though it is not dangerous for you. We have
a whole series of fact sheets that we have put together on theft, "Realtors, Warn Your
Clients;" "Pharmacists, Warn Your Customers," particularly in grocery stores; "Attention
Shoppers, Don't Let Your Prescription Drugs Get Stolen Out of Your Shopping Cart." If
your drugs come by mail, watch out that they don't get stolen, and we are probably about
to do one of those for people in hotels saying, "Hey, when you are in the hotel, don't leave your prescription
opioids sitting out in the room unless you would leave your money sitting out in the
room;" those things are worth $40 a pill on the street. "How to handle left over medication,
why throw it away, and how do you dispose of it" is another one. There are how to dispose
of it and take-back programs all on one sheet. We put together for community groups and technical
assistance providers a fact sheet and resource guide. It says, here are all the fact sheets,
and we can find out they are on the Web and from people's materials, and we have reviewed
them all. We have looked at the reading level, we looked at the content, and if you want one
to distribute to your coalition or workplace on this topic, here is what looks like probably
the ones you should choose from. We can narrow it down to one, or two, or three-and, in some
cases, there are half a dozen good ones-but it tells you that they are for preventing
unintentional prescription abuse, for abuse risk due to drug interaction, for proper disposal
of prescription and over the counter drugs, for recognizing that you have a problem, and
there are some of those that are generic and some of those for specific drugs. Different
fact sheets of recognizing you have a problem and getting help; recognizing someone else
has a problem and getting help. There is some stuff for workplaces that we found that were
generic supervisor guidance or employer education about the issue that we felt worked for prescription
drug abuse. There are some other resources that we have
listed, and the fact sheets we put together were based on gaps that we saw when we finished
that review. We have other fact sheets nearing completion, and there is one that should be
released any time now that's for employers that explains to them what they need to know
about prescription drug monitoring programs, that those can be a cost-saving tool for them,
and they should be telling their health plans if they are basically a large provider, a
large company. They should be telling their health plans that they want their physicians
using the programs and that that will save them money because they won't have any of
their patients who are doctor shopping and they are paying for them to get their medication
of abuse, who they are paying not only for the meds but paying for all those doctor visits
and all those tests to get the prescriptions for those meds.
I already mentioned the National Safety Council fact sheets that we have been working with
them on, and we are working on a series of fact sheets that are alternatives to prescription
drugs for pain management explaining to people that alternatives are out there: one that
is sort of an overview, and specific ones so that they can get more details if they
are considering a specific intervention. We have one coming out on prescription abuse
statistics and trends; what is hard about that one is every time you think you have
it in clearance, the trends come out again, and new studies come out because this is a
very rapidly evolving target. We have been working on one on Native Americans and prescription
abuse as well. And, as I said, TA from your SAMHSA project officer or Deborah Galvin's
e-mail address is here, Rekaya Gibson's address from my staff is here, and mine is
here. [Mike: Is it time for questions?] Dr. Miller: We are up to the summary first.[Mike: okay]
In summary, the evidence-base is weak but is starting to improve. We are addressing prescription
abuse for therapeutic effect is hardest, and our ability to prevent and treat other abuses
is growing, though. The reason the therapeutic effect is hardest is if the person is still
in pain, they may need painkillers, and yet we know they got addicted to them, so we have
to have a very tight control schedule so that they get enough to control their pain but
we keep them from tipping back over into addiction. We know that, as in other areas of substance
abuse, environmental strategies can be potent here. The existing coalition models appear
to be applicable that assess your problems; make your plan around the SPF-SIG framework; think
about the Haddon Matrix and what it tells you about the things you could do and the
different areas you want to cover; decide which parts of the event you want to target,
whether you are targeting just the host and the social environment, which is a comfort
zone in many cases, for SAMHSA programs, or whether you are also going to try to affect
the medical providers, the physical environment, or even the agents. We know that work cases
are key here because there's an adult problem that's major, unlike with some substance
abuse, where our work has been largely with youths. And we know that the Internet and
apps for the cell phones can be major facilitators, and we don't quite know how to intervene
on those. Let me turn back to Mike now for questions. I'll leave on the screen contact information for our Technical Assistance centers. Thank you.
[Operator provides instructions for participant's who want to ask questions.] Our first question comes from Nan Miller: "How do we watch a repeat of this webinar,
where, and how, and when?" Mike: We will actually have recorded this and send
out a link, and you can just send me an e-mail to me, and I will send the link out, or I
can send a link over to Ted at PIRE, and he will send the link to you. I will show a slide
with my e-mail address for reference. Dr. Miller: One easy way is to email Rekaya Gibson.
Operator: Our next question comes from Donna Patterson: "Can I get the presentation?" Mike: For those of you who do not have the presentation,
you can get it while this meeting is still live. Do you see the word "feedback" there,
on the top, on the gray bar, the gray-bluish bar? There's a little yellow icon-that's
not the one-but the white icon next to the very left of the yellow icon, that is the
icon for the slides. Dr. Miller: Your mouse will say it's "handouts."
Operator: Our next question comes from Lisa Coleman: "I had a question-When you were talking about Naloxone and how it works
with opiates, does that include *** addiction as well?" Dr. Miller: Yes it does, I believe.
Lisa Coleman: "You also said the data showed a decreasein drug overdoses, but, then, did it also show a decrease in actual *** use in that community?"
Dr. Miller: No--the number of people who have *** prescriptions in that community did not drop.
I think probably the total quantity of opiates prescribed dropped substantially, and it's
mining country, there is lots of back pain out there, and there's lots of legitimate,
mostly work related, *** prescription in that part of Kentucky, in that part of the
country. (I just confused myself-it's not mining country.) There's a lot of legitimate
prescription use because of work and pain. What they have done is they have gotten it
so that people are using their painkillers more responsibly and are being prescribed more responsibly.
They have educated them that this kills people, and a lot of people have died in our community before we learned how to handle it.
Operator: At this time, there are no other phone questions. Mike: Ted, there's a few on the internet.
[Internet question: What is immunizing 911 callers?]
Dr. Miller: Immunizing 911 callers is when you call 911 and you say, "I am calling because John
just passed out, and he was taking oxycodone at the time." If you were his oxycodone
dealer, you could be prosecuted. What some states decided was that they thought that
it was a lot better to have John live than to prosecute you. So they said, "Okay-we'll say that there is no prosecutability."
If you call 911 and tell them that, "Somebody has overdosed on something," that does not expose you
to our saying, "That the cell phone belonged to Mary." And going after Mary as to why are you involved in this overdose.
Dr. Miller: Next [internet] question "Is there an appropriate pill-identifying app
that we can share with local police and rural communities to use when they come across pills?"
The answer to that is that there's probably a dozen of them, and they
are very helpful to the police when they come across pills. Unfortunately, at the same time,
they are very helpful in the bigger market to people who are buying pills on the street
or stealing pills out of somebody else's medicine cabinet.
[Internet Question] "Where do we stand with health insurance covering alternative pain control such as acupuncture?"
It is a great question; the answer is, there are some places that do, there are some places
that don't, and we need to increase how many do, in my opinion.
Someone says she tries to open and print slides after downloading them, she can not because they are corrupt.
If you will e-mail Rekaya, we will send you a set of the slides that has not been through
the system, and hopefully your system will like that better.
[Internet Question] "How long does the Naloxone last? Does it work to bring the person back, and then they need
to get to the hospital?" Dr. Miller: I actually don't know the answer to that-I
am not a doctor-and I'm going to say that the safest thing for me to say is that we
could probably find that out on the internet.
[Internet Question] "Where can we access the Fact Sheets?"
If you e-mail Rekaya, she can e-mail them to you, as yet, we don't have them
available on the Web yet because of the way processes work of approval and clearance,
but we are allowed to e-mail you the Fact Sheets that we showed you in the seminar/webinar.
Mike: Last call for questions-any others? [Operator provides instructions for participant's who want to ask questions.]
Operator: There are no questions on the phone. Mike: Well, if there are no questions, I want to thank Ted Miller at PIRE for his great content. We do hope that it's been helpful to you.
If you would like the slides, we're going to leave the meeting open to you for a few more minutes so that you can download those.
Dr. Miller: Hold on, Mike. Somebody just gave me an answer- Naloxone lasts 30 minutes, so you need to get the person to the hospital.
Mike: There you go. There's the answer. I'm going to show Rekaya's email for those who want to see the link of the replay.
or get the slides if they have not had the opportunity to download them during the meeting.
That's about it. We hope you'll join us again. Keep an eye out for the listserv Ted had mentioned.
Ted, you want to go back to the slide with the address of the listserv you created.
If people want to sign up for that, I think it's a great resource for folks to be subscribed to.
Dr. Miller: We've had over 800 people sign up and we've only had about 20 people drop back off.
Some of those 800 sign-ups were ones that we started initially as complimentary-to see if you like it.
So almost nobody has dropped thet subscription. If you're working on this issue, it keeps you up-to-date.
Mike: paw@dsgonline.com So thank you. We hoped you enjoyed it.
We'd like to hear feedback from you, so if you'd drop us an email, me or Ted,
we'd love to get your comments, etc., etc. on what you thought of today's webcast.
So, best wishes in your work and we will see you next time. Take care.
Operator: This concludes today's conference call. You may disconnect your phones at this time.