The Arizona Rx Drug Misuse and Abuse Initiative

The Arizona Rx Drug Misuse and Abuse Initiative

The Arizona Rx Drug Misuse and
Abuse Initiative
A Multi-Systemic Approach for Addressing Arizona’s
“Silent Epidemic”
Arizona Criminal Justice Commission
Statistical Analysis Center
Conceptual Framework
Targeted Increases (+) and Decreases (-)
SUPPLY
+
+
Attitudes &
Awareness
-
Use of the
PDMP
Scripts & Pills
Dispensed
Health
Availability
ED visits
Deaths
NAS
Tx Admissions
-
-
Misuse and
Abuse
Consequences
Crime & Delinquency
DEMAND
Attitudes &
Beliefs
Social Acceptance
Perceived Low Risk
Expectations of Health
Consumer
Antecedent
Behavior
Unsafe Storage & Disposal
Sharing Scripts
Lack of Resistance Strategies
Lack of Parent-Child Communication
Rx Drug Investigations
DUI-D
School Suspensions
Drunk/High @ School
Youth Arrests
Lack of
LE
Training
The Opioid Influx
 A 4 fold increase in the quantity of Rx Pain Relievers sold in the
U.S. in the last decade
 The United States makes up 4.6% of the world’s population, but
consumes 80% of its Rx opioids
 ~46 deaths per day!!!!!!!!!!
 Rx Pain Reliever deaths are greater than heroin and cocaine
combined
The Problem?
Percentage of Pills by Drug Type in Arizona (2013)
• ~ 575 million Class II-IV pills were
prescribed in Arizona in 2013
•Pain Relievers had the highest % of
scripts, pills and average number of
pills per day; accounting for 57.4% of
all pills prescribed
•Hydrocodone and Oxycodone
accounted for 82.6% of all pain
relievers prescribed in Arizona
•Why it matters = probability and
access!
All Other Rx Drugs
14.5%
Oxycodone
24.8%
Benzodiazepine
24.3%
Hydrocodone
22.6%
Other Rx Pain
Relievers
10.0%
Volume:Access Ratio
Enough Rx pain relievers were dispensed last year to medicate every adult
in Arizona around-the-clock for 2 weeks straight
WHO IS IT AFFECTING?
Past 30 Day Rx Drug Misuse Among Arizona Youth (2014)
10%
9%
Percentage of Youth Reporting Rx Drug Misuse
8%
7%
Arizona= 6.3%
6%
5%
8.9%
4%
7.8%
7.7%
7.6%
7.6%
7.1%
6.8%
3%
6.4%
6.3%
6.1%
6.1%
5.6%
5.5%
5.2%
2%
1%
1.9%
0%
Greenlee
Pinal
Mohave
Pima
Gila
Cochise Apache
Santa Coconino Maricopa La Paz
Cruz
*Y-axis altered for visual purposes; accurate representation is out of 100%
Navajo
Yavapai
Yuma
Graham
Rx Misuse and Abuse Among Arizona Adults (2010)
45%
40%
Percent (%) of Reported Use
35%
Arizona 33%
30%
25%
20%
39%
34%
15%
26%
Arizona 13%
10%
5%
30%
29%
13%
24%
25%
13%
12%
15%
5%
0%
Apache, Coconino, Cochise, Graham,
Mohave, Navajo, Greenlee, & Santa
& Yavapai
Cruz
Gila & Pinal
Past 12 Months (but not past 30 days)
La Paz & Yuma
Maricopa
Past 30 Days
Pima
What Is It Costing Us?
 Mortality & Morbidity
 9,860 cases of opioid-related abuse and dependency cases in the ED – a 50% increase
between 2008-2013
 Hospitalizations and emergency department visits for poisonings (Rx drugs are a
leading cause) cost Arizona nearly a half a million dollars per day in 2012.
 1,099 drug-related deaths in AZ in 2013 – 41% involved Opioids/Opiates
 Increase in Crime
 Narcotic drug possession increased 15% between 2010-2012
 Increase in DUI-D
 4,073 DUI-D arrests in AZ – a 99.4% increase over the past decade
 Increase in babies born with NAS
 3 out of every 1,000 babies born between 2008-2013
CONTRIBUTING FACTORS
i.e., What is Amplifying this Problem and What Can We Change?
Difficult Balancing Act
Prescribers struggle with balancing the legitimate pain needs of their
patients while ensuring their safety
 Prescribers were told over a decade ago that they weren’t
accessing pain well enough – Pain became the 5th Vital Sign
 Inconsistent Guidelines
 Unrealistic Expectations of the Health Consumer
 Uninformed Patients and lack of education tools/resources
 The Role of the CSPMP
Percentage of Arizona Prescribers Signed Up to Use the
CSPMP
100
90
80
Percent Signed Up
70
60
50
40
81.3
Arizona= 32.5%
30
49.4
20
10
44.0
41.5
37.8
36.8
35.5
34.5
31.7
31.2
29.8
23.9
20.0
15.0
0
14.9
Easy Access
78.9% of Arizona youth who have misused prescription drugs in the past
30 days report getting them from friends, family or right out of the home
Percent (%) Youth Reporting Reasons
8.9
8.7
4.1
2.9
1.5
Lose weight
Fit in
Get back at
parents
Be more
grown up
Be like a
famous person
12.0
20.3
To focus
Because I
needed it
21.0
Something
new
13.9
23.5
Other
Feel normal
23.9
Stop boredom
33.8
39.9
Deal with
stress
Keep from
feeling sad
41.4
0
Get high
10
44.4
20
Have fun
Reasons Past 30 Day Arizona Youth Rx Misusers Gave for Using
(2014)
100
90
80
70
60
50
40
30
Diversion as a Business
Oxy and Hydro generate between $20-$80 a pill “on the street”
depending on dose and formulation
FINDING A SOLUTION
The Arizona Rx Drug Misuse and Abuse Initiative
A Multi-Systemic Approach:
Medical/Treatment, Law Enforcement and Prevention
Initiative Ontology
 ASAP
 Leveraging existing resources and partners
 Data-driven-decision-making
 Expert Panel
and
 Public Health vs. Public Safety: a multi-systemic approach
 Coalitions, Task Groups and Local Champions
 The vehicles of change
 “Home Grown” or “Backyard” approach
The Strategies
1.
Reduce Illicit Acquisition and Diversion of Rx Drugs
2. Promote Responsible Prescribing and Dispensing Policies and
Practices
3. Enhance Rx Drug Practice and Policies in Law Enforcement
4. Increase Public Awareness and Patient Education about Rx Drug
Misuse
5. Enhance Assessment and Referral to Treatment
Reduce Illicit Acquisition and
Diversion of Rx Drugs
Install and Promote
Permanent Drop Boxes
Safe Storage
Promote Responsible
Prescribing and Dispensing
Raise Awareness and Educate
 Provide education and resources to balance
legitimate pain needs with patient safety (i.e., minimize highdose opioids, dangerous drug combinations and “doctor shopping”)
 Self-monitoring of individual prescribing habits (e.g., report cards)
 Use of the PDMP
 Adopt statewide clinical guidelines for prescribing and dispensing
controlled substances
 Opioids in smallest dose possible and shortest time necessary
 Encourage non-narcotic alternatives and/or combination of therapies
Enhance Rx Drug Practice and
Policies in Law Enforcement
HIDTA
Rx Diversion Crimes Training
 Strategies and step-by-step guidelines for helping law
enforcement officers conduct pharmaceutical drug diversion
investigations
 Topics include




Rx drug trends
Drug identification
PDMP
Internet Pharmacies
Forged prescriptions
Doctor Shopping
Diversion in a medical facility
Over-prescribing cases
Increase Public Awareness and
Patient Education
Raise Awareness and Educate
 Create a sense of urgency about the Rx drug misuse problem
 Educate patients and the public about risks of misuse




Taking more than prescribed
Mixing with other drugs and/or alcohol
Not sharing scripts with others and why
Proper storage and disposal – especially if kids are present in the
home
 Get parents talking to their kids about risks, expectations and
resistance strategies
The Rx360 Curriculums
 Research-based curriculum adapted from DrugFreeAmerica’s
Pact360 modules and localized to specific communities and
populations in Arizona
 Raises awareness of the Rx problem, the risks of misuse,
resistance strategies and methods of proper storage and
disposal
 3 modules: Youth (middle and high school); Parent;
Community (e.g., senior citizens and childless adults)
Messaging & Patient Education
Increase Access and Referral to
Substance Abuse Tx
Resource Information
 Screening, Brief Intervention and Referral to Treatment
(SBIRT)
 Additional screening tools: SOAPP; Opioid Risk Tool
 Decision-trees (RHBA) for navigating Tx options and type
 Accessing Tx through AHCCCS and the Affordable Care Act
 MAT Training
 Promotion of the SAMHSA Tx Locator Tool
Did it WORK?
Evaluation Highlights
Breadth, Depth and Efficacy
Did We Change Knowledge, Attitudes, Awareness,
Beliefs and BEHAVIOR?
Process Evaluation Highlights
Cumulative Initiative Counties
 The initiative counties have 40 Rx drug drop boxes and have held 46 take back events
 7 of 9 hospitals are implementing the ED Guidelines or equivalent
 Over 1,500 prescribers are receiving quarterly report cards
 163 professionals have received comprehensive Best Practice training
 Over 300 Law Enforcement Officers have received the Rx Diversion Crimes curriculum
 13,198 youth and 1,328 adults have received the Rx360 curriculum
 Over 26,000 people have been reached via community events
 Over 900,000 people have been reached via public messaging and media methods
Impact Evaluation
Strategy 1:
Reduce Illicit Acquisition and
Diversion of Rx Drugs
Goal: Install and Promote
Permanent Drop Boxes
 15,000 lbs. of unused, unneeded and expired medication are no
longer available for potential diversion.
 117 Rx drug boxes are now available in Arizona – a 485% increase
since June, 2012
Goal: Increase Knowledge and Awareness
of Proper Disposal and Storage Methods
 There has been a 76.7% increase in community awareness of
drop box locations in the pilot counties
 There has been a 55.6% increase in community awareness of
take-back events in the pilot counties
 There has been a 64.7% increase in knowledge of proper
storage methods in the pilot counties
 There has been a 179.3% increase in knowledge of proper
storage methods in the pilot counties
Goal: Limit Youth Access
 Arizona has seen a 10% reduction in youth obtaining Rx drugs
from the home.
 The “Friends and Family” plan has significantly decreased in
Yavapai, Graham/Greenlee Counties and Casa Grande for past
30 day youth Rx drug misusers (range 29-68% reduction)
Strategy 2:
Promote Responsible Prescribing
and Dispensing
Goal: Encourage Sign Up and
Use of the CSPMP
 Arizona has seen a 118% increase in prescribers signed
up to use the CSPMP system
 14.9% June 1, 2012
 32.5% January 1, 2014
 Arizona has seen a 317% increase in pharmacists
signed up to use the CSPMP system
 14.7% June 1, 2012
 61.2% January 1, 2014
Prescribers Signed up for the CSPMP
Pilot Period
140
Cumulative
% Prescribers Signed Up
120
100
80
131.96
60
97.67
82.38
40
51.00
20
33.90
18.59
14.93
43.12
29.52
22.55
0
CSPMP % Signed Up
(pre)
CSPMP % Signed Up
(post)
Pilot
CSPMP % Signed Up
Increase (pilot)
CSPMP % Signed Up
Current
Non-Pilot
CSPMP % Signed Up
Increase (current)
Arizona CSPMP Queries
2,000,000
1,800,000
82.51% INCREASE
between 2012-2013
1,600,000
1,400,000
Queries Run
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
2009
2010
2011
2012
2013
Pilot CSPMP Queries
25000
Start of Yavapai Pilot
116.7% Increase
(Pre to Current Quarter)
Start of Pinal Pilot
230 Prescribers
Made Queries
Start of Graham/Greenlee Pilot
20000
Queries
15000
31.4% Increase
(Pre to Post Quarter)
10000
178 Prescribers
Made Queries
134 Prescribers
Made Queries
5000
0
Q1 2012
Q2 2012
Q3 2012
Q4 2012
Q1 2013
Q2 2013
Q3 2013
Q4 2013
Q1 2014
Q2 2014
Goal: Provide Education and
Training and Increase Awareness
of Individual Prescribing Habits
Rate of Controlled Substance Prescriptions in Arizona
Noted Decreases are Between 2012-2013
45,000
40,000
6.3% Decrease
Prescriptions Dispensed per 100,000 People
35,000
8.8% Decrease
30,000
5.5% Decrease
25,000
20,000
2.3% Decrease
15,000
10,000
16.3% Decrease
5,000
0
2009
Oxycodone
2010
Hydrocodone
2011
Other Rx Pain Relievers
2012
Benzodiazepine
2013
Carisoprodol
Rate of Controlled Substance Pills in Arizona
Noted Decreases are Between 2012-2013
Pills Dispensed per 100,000 People
3,000,000
2,500,000
5.7% Decrease
2,000,000
8.0% Decrease
5.7% Decrease
1,500,000
4.8% Decrease
1,000,000
500,000
16.6% Decrease
0
2009
Oxycodone
2010
Hydrocodone
2011
Other Rx Pain Relievers
2012
Benzodiazepine
2013
Carisoprodol
Rates of Controlled Substance Prescriptions in Pilot Counties
Noted Decreases are Between 2012-2013
250,000
9.4% Decrease
Prescriptions per 100,000 People
200,000
6.2% Decrease
150,000
6.4% Decrease
0.5% Decrease
100,000
50,000
0
2009
Graham/Greenlee Counties
2010
2011
Pinal County
2012
Yavapai County
2013
Non-Pilot Counties
Rates of Controlled Substance Pills in Pilot Counties
Noted Decreases are Between 2012-2013
16,000,000
14,000,000
10.0% Decrease
12,000,000
12.3% Decrease
Pills per 100,000 People
10,000,000
7.3% Decrease
8,000,000
2.4% Decrease
6,000,000
4,000,000
2,000,000
0
2009
Graham/Greenlee
2010
2011
Pinal
Yavapai
2012
2013
Non-Pilot Counties
Awareness and Education
 Provide education and resources to balance
legitimate pain needs with patient safety (i.e., minimize highdose opioids, dangerous drug combinations and “doctor shopping”)
 Adopt statewide clinical guidelines for prescribing and dispensing
controlled substances
 Opioids in smallest dose possible and shortest time necessary
 Encourage non-narcotic alternatives and/or combination of therapies
 CME opportunities for opioid-prescribing education
 Self-monitoring of individual prescribing habits (e.g., report cards)
PDMP Prescriber Report Card
Strategy 3:
Enhance Rx Drug Practice and
Policies in Law Enforcement
Goal: Increase Knowledge,
Awareness and Use of the CSPMP
 Law Enforcement PDMP sign up has increased 115% in Arizona
and 140% in our Initiative counties
 Awareness of the Rx problem significantly increased for
officers who completed the Rx Drug Diversion Crimes
training
 Beliefs that law enforcement officers play an important role
in prescription drug diversion significantly increased
 Knowledge of specific information around Rx fraud
investigation procedures significantly increased*
Strategy 4:
Increase Public Awareness and
Patient Education
The Demand Side
 Public Awareness of the Rx problem increased
 Awareness of the risks of Rx misuse and abuse increased
 Knowledge of proper storage and disposal increased
 Parents became more aware of the importance of talking to
their kids about Rx misuse and developing resistance strategies
 Parents felt more equipped to have conversations with their
kids about Rx misuse and developing resistance strategies
Goal: Increase Youth Perception
of the Risks and Consequences of
Rx Drug Misuse
Reasons Non-Rx Youth Users in Yavapai County Gave for Not Using
100
Percentage of Youth Reporting Reason for Not Using
90
80
70
60
6.9% Increase
8.7% Increase
50
7.1% Increase
40
30
20
43.6
47.4
46.6
49.8
43.7
46.8
10
0
Physical Harm
External consequences
2012
Parent Disapproval
2014
Outcome Evaluation
Rates of Misuse, Non-Fatal Poisonings and
Opioid-Related Deaths
Past 30 Day Rx Drug Use Among Arizona Youth
100
90
80
Percent (%) Use
70
60
50
40
30
20
10.7
10.4
10
7.9
20.25%
REDUCTION
2012=-2014
6.3
0
2008
2010
2012
2014
Arizona Youth Past 30 Day Rx Drug Misuse: Pilot vs. Non-Pilot
14
12
Percentage of Youth Reporting Misuse
10
8
11.0% Decrease
19.2% Decrease
6
36.8% Decrease
4
36.7% Decrease
2
0
2008
2010
Yavapai
Pinal
Note: scale reduced for visibility; accurate depiction is out of 100%
2012
Graham/Greenlee
2014
Non-Pilot
Non-Fatal Poisoning-Related Inpatient Hospitalizations in Arizona
140
120
8.21%
REDUCTION
Age adjusted rate per 100,000 people
100
80
17.97%
REDUCTION
60
40
20
0
2008
2009
Pilot Counties
2010
2011
2012
Non-Pilot Counties
2013
Opiate/Opioid Related Deaths in Arizona
10
9
8
4.09%
INCREASE
Cases per 100,000 people
7
6
28.29%
REDUCTION
5
4
3
2
1
0
2008
2009
Pilot Counties
2010
2011
2012
Non-Pilot Counties
2013
Accomplishments
 Almost 500 new prescribers signed up for the CSPMP in MC
 Toolkit completed and dissemination has started
 Statewide Summit – consensus and adaptation
 Coalition buy-in session
 Community Learning Collaborative
 Identifying Champions
 Pharmacy/Law Enforcement Partnership in progress
Future Plans
 Expansion of drop boxes in local
pharmacies
 Sign up to Save Lives Campaign –
Promote Delegates
 Leveraging AHCCCS Health Plans
 Report cards and regulatory boards
 Key Stakeholders Group
 Hot-Spot Mapping to target resources
Contacts
For additional information, please visit our website http://www.azcjc.gov/acjc.web/rx/default.aspx or contact:

Karen Ziegler (initiative co-chair): [email protected]

Sheila Sjolander (initiative co-chair): [email protected]

Shana Malone (county-level strategies): [email protected]

Dean Wright (PDMP specifics): [email protected]

Shelly Mowrey (prevention): [email protected]

Tomi St. Mars (prescriber education): [email protected]

Sara Salek (AHCCCS): [email protected]

Jenna Jones (AZ D.O. Board): [email protected]

Carlena Orosco (coordination & TA): [email protected]

Danielle Dandreaux (coordination & TA): [email protected]

Kelly Charbonneau (DBHS): [email protected]

Kenneth Steel (Maricopa County Public Health): [email protected]

Kyle Gardner (Maricopa County Public Health): [email protected]

Tracy Cruickshank (Maricopa County Public Health): [email protected]

Jeanene Fowler (Maricopa County Public Health: [email protected]

Adonis Deniz Jr. (Mercy Maricopa): [email protected]

Heather Brown (Mercy Maricopa): [email protected]