1. health and fitness
2. drugs

PRESCRIPTION NATION
A D D R E S S I N G A M E R I C A’ S P R E S C R I P T I O N D R U G A B U S E E P I D E M I C
from the National Safety Council
WORKING TOGETHER TO ADDRESS THE
PRESCRIPTION DRUG OVERDOSE EPIDEMIC
As the National Safety Council celebrates 100 Years of Safety, the Council has been examining how it can better address the
urgent and emerging issues that are confronting our nation today and into the future. Drug overdoses have now surpassed
traffic crashes as the leading cause of injury death in America. More than 38,000 people died of drug overdoses in 2010.
The class of drugs that contributed to the largest number of these deaths is prescription pain medications. Prescription pain
reliever abuse is now a national epidemic, affecting millions of Americans and killing more than 16,000 in 2010. Since 1999,
the number of people who have died from prescription drug overdoses each year has more than doubled. Forty-five people die
every day from overdoses of prescription pain relievers. This is about twice the number of fatal overdoses from illegal drugs.
At NSC, we have taken on this issue as one of our five strategic initiatives, with a goal of substantially reducing injuries and
deaths associated with it. We are confronting this epidemic nationally and in states and communities. We ask you to learn more
about this issue and join us.
This report documents the current status of laws and practices in the states and makes recommendations, based on research
evidence, for additional actions. This comparison of current laws and practices with research evidence suggests:
•
•
•
•
c oordinated state action is needed to optimize prescription drug monitoring programs (PDMP)
to identify misuse and fraud;
education of prescribers is necessary to support responsible prescribing practices;
enhanced enforcement should be undertaken to reduce pill mills, doctor and pharmacy shopping; and
programs should be expanded to treat opioid drug overdoses by increasing access to naloxone, a safe effective
treatment to reverse an overdose.
Countless lives have been lost and many more will be lost in this epidemic without concerted action. I invite you engage with us
on this important issue so together we can save lives and prevent injuries.
Sincerely,
Janet Froetscher
President & CEO
National Safety Council
2 | Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic
Table of Contents
America’s Prescription Drug Epidemic ................................................................................................................ 1
Rating the States ...................................................................................................................................................... 9
Detailed Review of the Rating ............................................................................................................................... 14
Additional Related Reports available by download:
Summary by State
Prescription Drug Abuse, Addiction and Diversion:
Overview of State Legislative and Policy Initiatives
About the National Safety Council
The National Safety Council is a nonprofit organization whose mission is to save lives by preventing injuries and
deaths at work, in homes and communities and on the road through leadership, research, education and advocacy.
NSC advances this mission by partnering with businesses, government agencies, elected officials and the public to
make an impact where the most preventable injuries and deaths occur, in areas such as workplace, distracted driving,
teen driving, prescription drug overdoses and Safe Communities.
Founded in 1913 and chartered by Congress, the National Safety Council relies on research to determine optimal
solutions to safety issues. Its educational efforts aim to change behaviors by building awareness, providing training
and sharing best practices. The Council recognizes organizations that have focused on safety as a critical part of their
operational excellence with the Robert W. Campbell Award®, safety’s most prestigious honor. The NSC Congress
& Expo is the world’s largest annual event dedicated to safety and Safety+Health® magazine is a leading source of
occupational safety and health information. Offering a variety of learning options, NSC is a world leader in Defensive
Driving, First Aid and Workplace Safety training. Each year the Green Cross for Safety® medal from NSC salutes
a company and its CEO for exceptional safety leadership. NSC is the International Support Center for the Safe
Communities America® program, guiding community stakeholders to reduce injuries and promote safety for the
residents of their communities.
The National Safety Council is committed to helping its members and the public prevent unintentional injuries and
deaths through a wide variety of benefits that advance them on their Journey to Safety Excellence. This Journey
outlines a process of continuous improvement in leadership and employee engagement, safety management systems,
risk reduction and performance measurement. With local Chapters and global networks, NSC is the leading advocate
for safety and promotes June as National Safety Month.
National Safety Council | 3
AMERICA’S GROWING
PRESCRIPTION DRUG
EPIDEMIC
Prescription pain medications, including opioid pain
relievers, are commonly used in an effort to improve
lives by reducing pain and suffering. Prescription
pain medications are used to help in recovery and
rehabilitation from injuries, surgeries and various
ailments. Along with the pain relieving benefits are the
risks of misuse, addiction and death when the use of
these drugs is not carefully prescribed and monitored by
health professionals.
The Centers for Disease Control and Prevention (CDC)
reports year-over-year increases in prescription drug
overdoses for the past 11 years.1 In 2010, 38,329 people
died from drug overdoses.2 The majority of these
deaths involved prescription medications. Opioid pain
relievers, alone or in combination with other prescription
medicines or alcohol, were involved in 16,651 deaths3
— approximately 45 deaths per day. In fact, more people
died from opioid pain reliever drug overdoses than from
heroin and cocaine combined.
Admissions for opioid treatment in emergency rooms and
rehabilitation centers also have increased substantially in
recent years.
In 2011, 1.4 million emergency
department visits were related
to the misuse or abuse of
prescription medicines —
an increase of 114%
since 2004.4
Drug treatment admissions for prescription opioids
increased seven-fold between 1998 and 2010, from 19,941
to 157,171.5 The CDC has termed our current problem
with opioid abuse an epidemic. There are nearly 2 million
people in the United States who are currently addicted
to opioid pain relievers.6 One in six teens have misused
or abused prescription pain relievers in their lifetime
according to a recent study.7
The rapid increase in opioid deaths and opioid treatment
admissions correspond with the increase in sales of
opioid pain relievers (see figure 2). Further underscoring
this connection, states with the highest drug overdose
death rates also have among the highest sales per capita of
prescription pain relievers.8
A number of factors have contributed to the increase and
widespread availability of these powerful medications. In
the mid 1990s, several professional medical organizations
reported that physicians were not adequately treating
pain and recommended that physicians be more attentive
in identifying pain and more aggressive in treating
it.9 New extended-release opioid pain relievers were
introduced and approved by the FDA for the treatment of
moderate to severe pain. Deemed to have a higher abuse
potential which may lead to psychological or physical
4 | Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic
STATES WITH THE LARGEST SALES OF OPIOID
PAINKILLERS ALSO HAVE THE HIGHEST MORTALITY RATES
Kg of NPR used per 1M
3.7 - 5.9
6.0 - 7.2
7.3 - 8.4
8.5 - 12.6
Age-adjusted rate per 100,000
5.5 - 9.4
9.5 - 12.3
12.4 - 14.8
14.9 - 27.0
Figure 1: States with highest rates of drug overdose fatalities also reported higher sales of opioid pain relievers.
dependence10 opioid pain relievers such as oxycodone
and hydrocodone gained widespread acceptance by the
medical community.
Through the latter half of the 1990s and into the last
decade, doctors, dentists and other providers prescribed
opioid pain relievers more frequently as a part of
patient care. From 2000 to 2009, the number of opioid
prescriptions per 100 people increased by 35.2 percent
and the number of morphine milligrams equivalents
(MME) prescribed doubled.11 Now, approximately, 1 in 25
adults are receiving treatment of chronic pain with opioid
pain relievers.12
It is clear that the increase and availability in opioid
prescribing parallels an increase in addiction and
overdose deaths. 13 There are many factors related to the
increase in opioid addiction and why some people may
be at greater risk than others. We do know that opioids
have very powerful antidepressant and antianxiety
properties. 14 People with depression who receive a
prescription for an opioid medication are much more
likely to misuse it. 15 There are others who are genetically
predisposed to addiction and can easily have problems
with the pain pills. One study showed that as many as 43
percent of those being treated for chronic back pain with
opioids may also have a substance use disorder. 16
National Safety Council | 5
RATES OF OPIOID OVERDOSE DEATHS,
SALES AND TREATMENT ADMISSIONS,
US 1999 - 2010
8
Opioid Sales KG/10,000
7
Opioid Deaths/100,000
6
Opioid Treatment Admissions/10,000
5
4
3
2
1
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Figure 2: As opioid sales increased, the rates of opioid deaths and opioid treatment admissions also increased.
The increases in prescriptions for pain medications
resulted in many more of these medicines being kept in
home medicine cabinets. The accessibility to these drugs
has increased the opportunity for theft or misuse.
Nearly, 70 percent of
people who misuse
prescription medicines report
getting the drugs or taking
them without asking from family
members or friends.17
As a person falls more deeply into addiction, he or
she begins to seek the medications from multiple
doctors and/or purchase drugs from friends and illegal
dealers. A person who tries to obtain medications from
multiple doctors, without the prescriber’s knowledge
of the other prescriptions, is considered to be engaged
in “doctor shopping”. This is illegal in 16 states. In
addition, 34 states have general provisions that ban
the use of deceit, misrepresentation or fraud to obtain
controlled substances.18
Another source contributing to the over-supply of
prescription opioid pain relievers are “pill mills”.19 At
6 | Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic
Methods and sources for obtaining pain relievers
HOW DIFFERENT MISUSERS OF
PAIN RELIEVERS GET THEIR DRUGS
9%
17%
KEY
13%
28%
17%
Bought from friend/
relative, dealer, or
internet
Prescribed from 1
or more doctors
26%
68%
Obtained from
friend/relative for
free or w/o asking
64%
41%
Recent Initiaters
Occasional Users
Figure 3: Most people who misuse
prescription medicines get them from
a friend or family member.
Frequent/Chronic Users
Types of past-year users
pill mills, which provide little or no medical care, clinic
physicians issue prescriptions for large quantities and high
dosages of opioid pain relievers and other prescription
drugs frequently abused. People seeking drugs willingly
traveled hundreds of miles to purchase a supply of pills to
use for themselves and sell to others. Largely unregulated,
these facilities minimally adhere to accepted standards of
medical practice. Florida, Kentucky and 8 other states have
enacted legislation that significantly reduced or eliminated
pill mills in those states.20 However, many of these
businesses have moved to other, less regulated, states.
Federal agencies, in coordination with the White House
Office of National Drug Control Policy (ONDCP), have
mobilized to reduce overdoses from opioid pain relievers
and other prescription medications. ONDCP published
a national strategy Epidemic: Responding to America’s
Prescription Drug Abuse Crisis in 2011 that outlines specific
tactics to reduce by 15 percent the non-medical use of
prescription drugs among people 12 years of age and older.
The plan outlines specific actions to be taken by federal
agencies, including the CDC, Drug Enforcement Agency
(DEA), Bureau of Justice Assistance (BJA), Substance
Abuse and Mental Health Services Administration
(SAMHSA), and Food and Drug Administration (FDA) to
achieve this goal.21
Strategies identified in the ONDCP plan include:
•
e ducation of patients, prescribers and the
general public;
•
e xpansion of prescription drug monitoring
programs (PDMP) to identify misuse and fraud;
•
e nforcement initiatives to reduce pill mills,
doctor and pharmacy shopping, criminal
prescribers and drugged driving; and
•
programs to encourage proper medication disposal.
National Safety Council | 7
CDC reported that “wide variation among states in
the nonmedical use of opioid pain medications and
overdose rates cannot be explained by underlying
demographic differences in state populations but is
related to wide variations in opioid prescribing.”22
States with the highest sales
of opioid pain relievers report a
greater number of drug
overdose deaths.
The presence of high-volume prescribers and “pill mills”
within a state can contribute to increased drug overdose
deaths. Differences between states laws and regulations
might also contribute to this national epidemic. State
leadership and action is needed to implement many of
these strategies and promising approaches. As evidenced
in this report, states have begun to take action but more
work is needed in order to save lives.
In this report, the National Safety Council examines
state progress in four areas:
•
state leadership and action,
•
prescription drug monitoring programs,
•
responsible opioid prescribing and
•
overdose education and prevention programs.
NSC recognizes that access to substance abuse treatment
is an important part of a comprehensive strategy to
address this problem, however, it is not addressed in this
report. For this report, NSC established standards for
performance in each of these four areas, based on the
best available research evidence.
8 | Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic
STATE LEADERSHIP
AND ACTION
• State plan addressing prescription drug misuse
and overdoses
• State taskforce or workgroup addressing
prescription drug misuse and overdoses
The Association of State and Territorial Health Officials
(ASTHO) in summary findings from a multistate
meeting “Preventing Prescription Drug Abuse Across
the Continuum”26 and a National Governors Association
(NGA) issue brief “Six Strategies for Reducing
Prescription Drug Abuse”27 identified that “high level
state leadership” is essential in order to “develop and
implement a coordinated and effective state response to
prescription drug abuse.”
PRESCRIPTION
DRUG MONITORING
PROGRAMS
PDMPs are state operated databases that collect prescription
information from pharmacies and dispensers of controlled
substances. The Prescription Drug Monitoring Program
Center of Excellence at Brandeis University (COE) identified
in its white paper 35 recommended best practices.28 The
research base supporting these practices is developing. The
scientific support includes research evidence, cases studies
and a consensus of expert opinion. The National Alliance
of Model State Drug Laws (NAMSDL) conducted a review
of recommended practices promoted by NAMSDL, COE
and four other organizations.29 The report identifies areas
of agreement and compares states, current implementation
of those practices. NSC examines how states have enacted
legislation authorizing five of these recommended practices.
• PDMP data can be accessed by a variety of
professionals and state agencies including:
- Prescribers and dispensers
- L aw enforcement, coroners or medical
examiners and licensing boards with
probable cause or active investigation
- State insurance programs such as
Medicaid, etc.
• PDMP allows dispenser and prescriber delegates
• PDMP moving towards realtime data collection
and, at a minimum, collects data from dispensers
at least weekly
• State PDMP shares data with other states
• PDMP proactively alerts following user groups:
prescribers, dispensers, law enforcement and
licensing boards.
Insufficient data exist for a comparison of states on a
number of recommended practices such as prescriber
utilization of the PDMP or integration of PDMP data
with electronic health records.
RESPONSIBLE OPIOID
PRESCRIBING
Based on recommendations identified in ONDCP
national strategy, Institute of Medicine report30 and
experiences of states leading the effort to reduce
prescription drug overdoses, this report examined states’
efforts to support responsible prescribing practices.
• State has regulations that deter the formation of
pill mills and interstate trafficking of opioid pain
relievers.
• State medical boards and licensing agencies
provide rules or guidance to all prescribers on
responsible prescribing of opioid pain relievers.
• State medical boards and licensing agencies require
or recommend education regarding responsible
prescribing of controlled substances, pain
management, screening for substance use disorders
and state prescription monitoring program. A
number of states are requiring certain prescribers
such as pain management professionals and other
high volume prescribers of opioid medications to
obtain mandatory education.
• State PDMP use by requiring prescriber utilization
of the state PDMP. A number of states are requiring
certain prescribers such as pain management or
other high volume prescribers to utilize the PDMP.
National Safety Council | 9
OVERDOSE
EDUCATION AND
PREVENTION
PROGRAMS
The ONDCP, American Medical Association (AMA),
Harm Reduction Coalition and others recommend
increased access to naloxone. Studies have shown that
programs that provide overdose education and increase
access to naloxone are safe and cost effective.31
A report by the Network for Public Health Law32
compiling relevant state law supplemented by a review
of recent state legislation was used as basis for the
state rating.
• State has an overdose education and prevention
program to increase access to naloxone or allows
licensed healthcare professionals to prescribe naloxone
for third party use to prevent drug overdose.
• G ood Samaritan provisions protecting first
responders and others from criminal and/or civil
liability for possessing and administering naloxone.
• L aws providing immunity or special consideration
at sentencing for bystanders who call 911 or
provide medical assistance.
SUMMARY OF
STATE ACTION
•
wenty-three states were identified as partially
T
meeting the standard but needing improvements
in at least one areas.
•
ourteen states met the standards in two or
F
more of the four areas.
The one area in which many states require improvement
is in supporting responsible prescribing practices.
•
wenty-five states did not meet the standards for
T
responsible prescribing practices.
•
hile 16 states require or recommend education
W
for prescribers on the treatment of pain,23 only
13 states have strengthened their laws to deter
pill mills24 or to establish rules addressing
responsible prescribing.
States with the most
overdose fatalities
and/or highest rates of
prescription drug misuse
were more likely to have
to implemented changes
in laws, regulations
and programs.
Following the lead of New Mexico, 13 states have
increased access to naloxone, a drug that reverses opioid
overdoses or passed laws to encourage bystander action.25
Overall, states had conducted the most work in areas of
state leadership and action and establishing prescription
drug monitoring programs.
•
wo states, Kentucky and Washington, met
T
the standards in all four areas. Vermont
provisionally met the standards, pending the
outcome of the state’s rule-making process for
legislation passed in 2013.
•
en states partially met the criteria,
T
demonstrating progress, by meeting or partially
meeting the standards in all four areas.
10 | Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic
STATE OVERVIEW
RATING INDICATORS
Meets Standards
Partially Meets Standards, Making Progress
Partially Meets Standards, Improvements Needed
Does Not Meet Standards
RATING THE STATES
The attached table lists each state’s overall rating and its rating for each area using the described criteria on page 9 and 10. To
receive a meets rating, the state met all indicators for an area; partially met if the state met at least one of the indicators and
does not meet if the state met none of the indicators. States were rated based on best available information as of April 30, 2013.
new or pending state legislation or changes to programs after this date may not be reflected in these ratings. The District of
Columbia and other U.S. territories are not included in this report.
National Safety Council | 11
OVERALL STATE RATINGS
OVERALL RANK
STATE ACTION &
LEADERSHIP
PRESCRIPTION
DRUG MONITORING
RESPONSIBLE
PRESCRIBING
OVERDOSE
PREVENTION
Kentucky
Washington
Vermont
Massachusetts
New York
Tennessee
California
New Mexico
Colorado
Florida
North Carolina
Virginia
Rhode Island
Illinois
Montana
North Dakota
Wisconsin
Connecticut
Minnesota
New Jersey
Oregon
West Virginia
Oklahoma
Maryland
NR
Indiana
Alabama
Arkansas
This report provides a detailed review of the four areas examined. See report appendix for a summary by state of report
findings and recommendations.
12 | Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic
OVERALL RANK
STATE ACTION &
LEADERSHIP
PRESCRIPTION
DRUG MONITORING
RESPONSIBLE
PRESCRIBING
OVERDOSE
PREVENTION
Louisiana
Michigan
Mississippi
Ohio
Texas
Utah
Nevada
Alaska
NR
Georgia
NR
Arizona
New Hampshire
Idaho
Kansas
Missouri
Delaware
NR
Iowa
Maine
South Carolina
Wyoming
Hawaii
NR
Nebraska
Pennsylvania
South Dakota
NR
RATING INDICATORS
Meets Standards
Partially Meets Standards, Making Progress
Does Not Meet Standards
NR Not Reported
Partially Meets Standards, Improvements Needed
National Safety Council | 13
DETAILED REVIEW OF
FOUR RATINGS
STATE ACTION AND
LEADERSHIP
State action and leadership is necessary to effectively
address prescription drug misuse and overdoses.
Coordination across state agencies and the ability to bring
together diverse stakeholders is required.33 A 2012 survey
of state alcohol and drug addiction directors reported that
most states had a state plan that addressed prescription
drugs and/or convened a taskforce to address the issue.34
In addition, several states reported previously convened
taskforce that is no longer active. It should be noted that
states may have convened a taskforce for a specific purpose
such as a study or to develop a plan. That taskforce may be
dismissed upon completion of the task.
Forty-one states were rated as meets or partially meets by
having a state plan and/or an active task force. Three states
did not meet the standard. Six states could not be rated as
meeting the standard as data were not available.
As this report shows, while many states have plans
or taskforces addressing prescription drug misuse
and overdoses, more work is needed to save lives
from drug overdoses and reduce the nonmedical
use of prescription drugs. ASTHO and NGA have
learning collaboratives in fifteen states to develop
comprehensive, coordinated strategies to prevent
injuries and deaths, prescription drug misuse and
abuse.35 These efforts led by governors, the chief state
health officials and other key state leaders (i.e. state
agency directors, public safety and Attorney General)
ensure that the strategies identified have the support
necessary to be implemented across state government.
State Leadership
and Action Criteria
• State plan addressing
prescription drug misuse
and overdoses
• State taskforce or
workgroup addressing
prescription drug misuse
and overdoses
It is important that these learning collaboratives’ work
be expanded to more states. One of the more troubling
aspects of the current prescription drug epidemic is
how quickly it has expanded from one or two isolated
states to become a regional problem and now, a national
epidemic. The well-documented experiences of states
such as Florida and Kentucky demonstrate how the
movement of prescription drugs across state lines can
contribute to problems in nearby states. Unless all
states have in place similar controls and the ability
to share critical data - such as PDMPs - and strong
standards guiding the prescribing and dispensing of
scheduled II, III and IV substances, states risk becoming
a safe harbor for those engaged in the trafficking of
prescription medications. ASTHO, NGA and other
national organizations have identified state leadership
and coordinated a comprehensive approach essential to
reducing prescription drug overdose deaths.
14 | Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic
IMPROVE STATE
PRESCRIPTION DRUG
MONITORING PROGRAMS
Prescription
Monitoring Programs
Experts from the field and research have identified PDMPs
as an effective tool in preventing the misuse and diversion
of prescription medications.36 PDMPs are state operated
databases that collect prescription information from
pharmacies and dispensers of controlled substances. Fortynine states have operating PDMPs or have enacted PDMP
legislation to establish their program. Missouri is the lone
state without legislation authorizing PDMP.
1. P
DMP data can be
accessed by a variety of
professionals and state
agencies including:
-P
rescribers and
dispensers
- L aw enforcement,
coroners or medical
examiners and licensing
boards with probable
cause or active
investigation
-S
tate insurance
programs such as
Medicaid, etc.
The PDMP Center for Excellence at Brandeis University
identified more than 35 best and promising practices for
state prescription monitoring programs.37 The scientific
support includes research evidence, case studies and a
consensus of expert opinion. The National Alliance of Model
State Drug Laws conducted a comparison of published
PDMP best-practice recommendations and existing state
PDMP legislation and policies. Based on this report,
the National Safety Council rated state PDMPs on five
recommended practice indicators.
1
2. P
DMP allows dispenser and
prescriber delegates
3. P
DMP moving towards
realtime data collection
and collects data from
dispensers at least weekly
ake the PDMP Easy to Access by
M
Adding Authorized Users
Each state determines who is authorized to access the PDMP
database. Nearly all states allow pharmacists and prescribers
access to the PDMP. Other authorized users may include
officials from other state agencies such as the Medicaid,
Medicare and health insurance programs, health department
and workers compensation boards. Most states allow access
to PDMP data to aid law enforcement officers or medical
licensing boards in their investigations. Forty-seven states
require a court order, probable cause or active investigation
in order for law enforcement officials to access PDMP
information. To protect patient privacy, thirty-five states
have laws prohibiting unlawful access and/or disclosure of
patient information. An analysis revealed that some states
very narrowly define who is authorized to use the PDMP.
In many cases, restrictions written into state law prevent
professionals and state agencies that need PDMP data from
carrying out their responsibilities. For example, a coroner
may find it helpful to check the PDMP when conducting an
investigation to determine cause of death. State Medicaid
programs could use PDMP information to detect suspicious
activity indicating fraud or doctor shopping.
4. P
DMP shares data with
other states
5. P
DMP proactively alerts
following user groups:
prescribers, dispensers,
law enforcement and
licensing boards
2
Allow Prescribers and
Dispensers the Ability to Delegate
PDMP Access
Many states limit access to the PDMP only to the licensed
prescriber or pharmacist who is registered with the state
PDMP. This adds an unnecessary obstacle for prescribers
and dispensers that may significantly decrease utilization
of the PDMP. The ability to delegate PDMP access allows
prescribers and dispensers to assign the task of checking
National Safety Council | 15
the PDMP to other medical professionals making it a
part of their clinical and office workflows. Further, state
PDMPs which allow delegation and the creation of
institutional accounts report higher utilization rates by
prescribers and dispensers.
3
Move to Real-Time Data Collection
Prescribers and pharmacists need easy-to-use reports
with real-time information. Most state PDMPs collect
prescription information from pharmacies weekly, a few
PDMPs collect bi-weekly or monthly. The Oklahoma
PDMP is the first to offer real-time data reports to
pharmacists and physicians to assist them in making
clinical decisions on whether to issue a prescription or
dispense medication to a patient. Today, an Oklahoma
emergency department physician can use his or her
PDMP to identify a patient who recently received
prescriptions from multiple doctors or pharmacies from
anywhere in the state, or to obtain a more accurate list
of recent prescriptions for a patient confused about
their medication and the amounts he or she is taking.
Recently, New York, Minnesota and Kentucky began the
first steps towards real-time data by enacting legislation
to collect prescription data within 24 hours.
Since many who obtain
prescription drugs illicitly
will utilize providers in multiple
states, it is important that
those providers have
access to the PDMP
in other states.
4
Share PDMP Data with Other States
State boundaries present an opportunity for those
actively seeking prescription drugs to misuse or
divert to others. The Kentucky Attorney General’s
office reported that 60 percent of the prescription
medications seized by law enforcement were
prescribed, dispensed and brought to Kentucky from
Florida and neighboring states. 38
16 | Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic
Since many who obtain
prescription drugs illicitly
will utilize providers
in multiple states, it is
important that those providers
have access to the
PDMP in other states.
Forty-four states currently authorize their PDMPs to share
data either with other state PDMPs and/or their authorized
PDMP users.39 Although changing state laws may be a
difficult task amid individual concerns about the privacy and
security of personal information, states should allow other
states to access their PDMP. By doing so, it will be easier for
states to monitor and stop the movement and diversion of
prescription drugs across state lines.
5
Issue Proactive Alerts
PDMP officials analyze prescription data to look for
suspicious patterns that may indicate “doctor shopping”
or “pill mill” operations and in some states may issue
alerts to prescribers, dispensers, law enforcement and
licensing officials. Studies have shown that prescribers
and dispensers who receive proactive alerts and are
prompted to review the patient record, may change
clinical decisions regarding the prescribing of controlled
substances and more likely to utilize the state PDMP
after receiving an alert.40 State PDMPs should be
authorized to issue proactive alerts to prescribers,
dispensers, drug diversion officers and licensing officials.
States should allocate the necessary funding to support
staffing to conduct these analyses and to make revisions
to PDMP software.
RESPONSIBLE OPIOID
PRESCRIBING
The amount of prescription painkillers sold to
pharmacies, hospitals, and doctors’ offices was four times
larger in 2010 than in 1999. Enough pain killers were
prescribed in 2010 to medicate every American adult
with a 5mg dose of hydrocodone, four times a day for a
month.41 Yet, according to a recent Institute of Medicine
(IOM) report, the overall treatment of pain in the United
states has not improved. Based on recommendations
identified in ONDCP national strategy and experiences
of states leading the effort to reduce prescription drug
overdoses, NSC examined states efforts to support
responsible prescribing practices.
Responsible Opioid Prescribing
1. S
tate has regulations that deter the formation of pill mills and interstate trafficking of
prescription pain medications.
2. State medical boards and licensing agencies provide rules or guidance to all prescribers
on responsible prescribing of opioid medications and/or schedule II, III and IV controlled
substances.
3. S
tate medical boards and licensing agencies require or recommend education regarding
responsible prescribing of controlled substances, pain management, screening for
substance use disorders and state prescription monitoring program. At a minimum,
certain prescribers such as pain management professionals and other high volume
prescribers of opioid medications are required to obtain mandatory education.
4. S
tate increases PDMP use by requiring prescriber utilization of the state PDMP. At a
minimum certain prescribers such as pain management or other high volume prescribers
are required to utilize the PDMP.
National Safety Council | 17
Pill mills are clinics that overprescribe pharmaceuticals inappropriately for nonmedical use.
Ohio: a case study in what happens when pill mills are reduced
Prior to 2011, Ohio was above the national
prescription drug overdose death rate.
Following the passage of Ohio’s “Pill Mill
Bill,” 13 illegal pill mills were closed
in the first year. The bill was a success,
as it drastically reduced prescriptions in
counties that had the biggest problems.
REDUCTION OF PRESCRIPTION
PAINKILLERS
SOLD IN
PERCENTAGE
OF PRESCRIPTION
PAINKILLER
HARDEST HIT COUNTIES
REDUCTION
IN HARDEST-HIT COUNTIES
1
Adams County
-5.3%
2
Scioto County
-19.6%
3
Jackson County
-8.65%
4
Gallia County
-11%
1
1
2. Support safe prescribing.
Pill Mills
2
4
predominantly serving drug-seeking consumers. Primary
care physicians and hospital emergency departments are the
and
other
need clear
guidelines
to determine the appropriate amount of painkillers needed.
Florida,Doctors
Kentucky
and
Ohioprescribers
have seen success
with pill
mill
first place those in acute pain turn to for treatment.
legislation that regulates pain clinics and pain management
services. Ohio and Florida saw
significant decreases
Washington:
responsible prescribing
Primary care physicians have a difficult job balancing
in the amount of opioid pain relievers prescribed after
their efforts to provide adequate pain relief with their
implementing pill mill regulations. After passage of Ohio’s
In 2007, the state of Washington issued
voluntary
prescribing
guidelines.
desire
to prevent
drug diversion,
addiction and death. It is
law, 13 pill mills closed in the
first year.
In Scioto
Passed
into
law inCounty,
2010, the guidelines
reversed
a
decade-long
trend
of
often difficult to keep up with the latest recommendation
one of Ohio’s hardest hit counties,
nearly fatal
2 million
fewer
increasing
prescription
opioid overdoses.
and tools available to help them in this challenging task.
doses were prescribed, a 19.6 percent decrease.42 Pill mill
Washington has seen success in reducing overdose deaths
legislation
typically
Number
of regulates
deaths pain or wellness clinics not
23% prescribed through
and the amounts of opioid pain relievers
covered under other state medical practice statutes, defining
the implementation of prescribingreduction
guidelines. In 2007,
600 requirements and establishing educational
ownership
in deaths
voluntary guidelines were introduced
in Washington to
qualifications and the clinical oversight responsibilities of
guide physicians on responsible opioid prescribing for
the medical
500 director. Eleven states have enacted these laws.
non-cancer pain. Following introduction of the guidelines
Pill mill legislation frequently require use of the state PDMP
it reported increases in prescriber awareness of safer
prior to prescribing controlled substances to patients.
400
opioid prescribing practices and subsequent decreases in
overdose deaths.43 In 2010, Washington state law required
all licensing boards to establish rules and adopt one set of
300
Prescribing Guidelines
evidence-based prescribing guidelines. The state developed a
number of tools and resources to support responsible opioid
Pill mill
legislation only addresses one part of the
200
prescribing practices. In addition, it increased training and
prescribing problem: that of high volume prescribers
2
100
18 | Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic
0
support for prescribers to recognize substance abuse and
make referrals to treatment. Following Washington State’s
efforts, it reports a 23 percent reduction in drug overdose
death rate since 2008.44 Vermont and Indiana recently
passed legislation that requires licensing boards to develop
and adopt evidence-based prescribing guidelines.
3
Prescriber Education
IOM report recommends that all healthcare providers keep
their knowledge of pain management current by engaging
in continuing education programs. Licensure, certification,
and recertification examinations should include assessments
of providers’ pain education.45 A Johns Hopkins review of
medical school curricula determined that pain education
was limited and that the risks of opioid treatment were
underrepresented.46
Sixteen states currently require or recommend education for
physicians and other professionals who prescribe controlled
substances to treat pain.47 State medical boards and medical
societies should increase medical education offerings and
resources to support responsible prescribing.48
Washington has created a number of resources to support
prescribers including pain assessment tools and continuing
medical education (CME) on pain management and
addiction. Project ECHO offers CMEs for participation
in weekly TelePain video conferences with University of
Washington specialists that provide case consultation and
answer prescriber clinical and practice based questions.49
In addition to state efforts, the National Institute on Drug
Abuse (NIDA) and the AMA have also released free online
training courses for prescribers to address this need.
4
Increase Utilization of State PDMP
State PDMPs provide prescribers with additional
information about a patient’s prescribing history and
assist prescribers in making prescribing and other
treatment decisions. However, PDMPs are underutilized
by most prescribers. The majority of state PDMPs
report low utilization rates. Seven states, Kentucky,
Massachusetts, New Mexico, New York, Tennessee,
West Virginia and Vermont - have all moved to increase
utilization of the PDMP by requiring prescribers to
access the PDMP prior to prescribing a schedule II,
III or IV controlled substance and at specified time
intervals (6 or 12 months) if treatment is on-going.
Since implementing this legislation, KASPER, the
Kentucky PDMP, saw prescriber’s registrations triple
and information requests increase from 3,000 to 18,000
each day. In order to increase prescriber utilization of
these systems, PDMPs need to simplify the registration
process and make querying the PDMP easy for medical
professionals to incorporate into their clinical workflows.
Kentucky PDMP processes the majority of PDMP queries
within 15 seconds or less.50 This report was unable to rate
state PDMPs on ease of use and prescriber utilization
- two key metrics to ensure widespread adoption of
PDMPs by prescribers and dispensers.
OVERDOSE EDUCATION
AND NALOXONE TO
DISTRIBUTION
Opiate overdoses, typically from opioid pain relievers or
heroin, are reversible with the timely administration of
the drug naloxone. Naloxone, available by prescription,
can be administered as an injection or nasal spray. It is
not a controlled substance and has no abuse potential.
Physicians can provide a prescription for naloxone to
a person at risk of overdose similar to prescribing an
EpiPen for people with severe allergies. However, unlike
in some types of allergic reactions, with an opioid
overdose, it is unlikely the person at risk would be
responsive and able to self-administer this medication.
States have increased access to and use of naloxone by
amending medical practice laws and regulations to allow
a licensed healthcare professional to presribe naloxone
for use by a third-party such as a family member.
Massachusetts allows community programs to provide
naloxone to trained individuals with a standing order
from the health department.51 These programs provide
naloxone to the people most likely to witness and
intervene in an overdose, law enforcement officers, users
of drugs and their friends and family members.
Other policy interventions which support increased
naloxone access are two categories of laws loosely termed
Good Samaritan provisions. The first category protects
first responders and other bystanderes from criminal or
civil liability for possessing and administering naloxone.
The second category provides limited immunity from
prosecution or mitigation at sentencing fro crimes such
as possession of drugs or drug paraphernalia to overdose
bystanders who call 911 or provide medical assistance.52
National Safety Council | 19
Overdose Education and
Prevention Criteria
• State has an overdose
education and prevention
program to increase access
to naloxone or allows licensed
healthcare professionals to
prescribe naloxone for 3rd party
use to treat drug overdose.
• Good Samaritan provisions
protecting first responders and
others from criminal and/or
civil liability for possessing and
administering naloxone.
• Laws providing immunity
or special consideration at
sentencing for bystanders,
often also drug users, who call
911 or administer naloxone.
Overdose education and prevention programs distribute
naloxone overdose prevention kits and provide training. The
people most likely to witness an overdose - law enforcement
officers, people who use drugs and their friends and family
members - may be in the best position to intervene and treat
an overdose by administering naloxone.
Education includes how to recognize the signs of an
overdose, when and how to administer naloxone and the
importance of rescue breathing until 911 first responders
arrive. State program requirements may include logging
distribution of kits, educating kit recipients and requiring
hospital emergency departments to report if naloxone
was administered prior to arrival at ER and record
patient outcomes.
Studies have shown that
programs that provide
overdose education
and increase access to
naloxone are safe and
cost-effective.
The use of naloxone has reversed more than 10,000
overdoses.53 This report rates state efforts to expand access
to naloxone.
Following the lead of New Mexico, 13 states have increased
access to naloxone by amending state law. Sixteen states
have added Good Samaritan provisions to provide
protection from civil or criminal liability for possessing
or administering naloxone and offer limited immunity
or special consideration at sentencing to bystanders who
provide medical assistance. North Carolina recently
authorized creation of a state-wide program that would
increase access to naloxone and extend Good Samaritan and
limited liability provisions. Thirty-four states have to yet to
change laws to increase access to naloxone or begin these
life-saving programs. States should allocate the necessary
resources and funding to support effective implementation
of overdose prevention programs.
CONCLUSION
Drug overdose is a national epidemic, contributing to the
deaths of more than 300,000 people from 1999 to 2010. The
leading class of drugs responsible for these deaths is opioid
prescription pain relievers, which were involved in more
than 16,000 deaths in 2010, or about 45 deaths every day of
that year.54 This report demonstrates that many states have
made great strides in addressing this problem. However,
evidence-based practices, documented by multiple sources
and presented in this report, indicate that preventing
prescription drug misuse and overdose deaths requires
significant state actions that are far more extensive than
most states have engaged thus far.
The ultimate success of state actions is also linked to
improved support for individuals affected by addiction.
Although not addressed in this report, improved access to
substance abuse prevention, treatment and recovery services
is critical to states efforts to effectively address prescription
drug misuse and prevent further drug overdoses. NSC looks
forward to working with the treatment, prevention and
recovery service community as this work moves forward.
The National Safety Council is hopeful that governors,
legislators, public health officials, the medical community
and the pharmaceutical industry, among many interested
parties, will find this report useful in identifying the needs
that exist in each state and the evidence-based strategies that
should be considered to stop this national epidemic and save
thousands of lives each year.
20 | Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic
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National Safety Council | 21
REFERENCES
29
(continued)
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N
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30
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31
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22 | Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic
ACKNOWLEDGEMENTS
The National Safety Council wishes to acknowledge and thank the NSC Board of Directors and Delegates who have led
the Council’s entry into this issue. In addition, NSC wishes to thank these volunteers and organizations that comprise the
Expert Panel that has reviewed and provided feedback on NSC strategies and this report:
Rodney Bragg
State of Tennessee, Department of Mental Health,
Division of Alcohol and Drug Abuse Services
Terry Cline
State of Oklahoma
Department of Health
Steve Haught
Employee Assistance Professionals Association
Paul Jarris, MD, MBA
Association of State and Territorial Health Officials
Rene Hanna
Office of National Drug Control Policy
Thomas MacLellan
National Governors Association
Brian Rosen
Pharmacuetical Research and Manufacturers Association
Purdue Pharma
Robert Cowan
National Association of Boards of Pharmacy
Elizabeth Walker Romero
Association of State and Territorial Health Officials
David Hopkins
Kentucky Office of Inspector General, Cabinet for Health and
Family Services
Sharon Moffat
Association of State and Territorial Health Officials
Constantine Gean, MD, MBA, MS, FACOEM
Liberty Mutual Insurance
William Reay, Pharm.D., MS, MHA
Darci Beacom
CNA Insurance
Sherry Green
National Alliance of State Model Drug Laws
Christopher Jones, PharmD, MPH, LCDR
Centers for Disease Control and Prevention
Leonard J. Paulozzi, MD, MPH
Centers for Disease Control and Prevention
Clarion Johnson, MD
Exxon Mobil, Medicine and Occupational Health
Brian Richard
Walmart
Michael Ayotte, R.Ph.
CVS Caremark
Tasha Polster
Walgreens Company
Kathryn Mueller, MD, MPH
Colorado Division of Workers Compensation
John Klimek, R.Ph.
National Council for Prescription Drug Programs
Barry Dickinson, Ph.D.
American Medical Association
Lucy Gee, MS
Florida Department of Health
Robert Forney, Ph.D., DABFT
NSC Alcohol, Drugs and Impairment Division
Chief Toxicologist, Office of Lucas County Coroner
Brenda Gray, RN
Marriott International, Inc.
John Eadie
PDMP Center of Excellence
Rob Morrision
National Association of State Alcohol and Drug Abuse Directors
Whitney Englander
Harm Reduction Coalition
Corey Davis
Harm Reduction Coalition
Sharon Stancliff, MD
Harm Reduction Coalition
Cheryl Wittke
Safe Communities of Madison-Dane County
Adam Pomerleau, MD
Emory University
National Safety Council | 23
0813 900002199
©2013 National Safety Council