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CDC: Major Disparities in Opioid Prescribing Among States

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Medical News & Perspectives

CDC: Major Disparities in Opioid Prescribing Among States Some States Crack Down on Excess Prescribing Bridget M. Kuehn, MSJ

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he first few months of 2010 marked a dramatic turn in Florida’s efforts to curb rampant “pill mills,” clinics that inappropriately prescribe large quantities of opioids for nonmedical reasons. The state required all pain clinics within its borders to register no later than January 2010. In that year, federal, state, and local law enforcement began a major crackdown, called Operation Pill Nation. ByFebruary2011,undercoverofficershad made 340 purchases of medication from 60 physicians at more than 40 pain clinics without showing evidence of a valid medical complaint, according to the US Drug Enforcement

Administration.Ultimately,officialsarrested22 people and seized $2.2 million in cash as well as 70 vehicles (http://1.usa.gov/1qnV9UV). In a recent publication, Florida public health leaders credited this law enforcement effort and a slew of recent laws with reducing drug overdose deaths in the state. From 2003 to 2009, the number of overdose deaths increased 61%, from 1804 to 2905, driven mostlybyoverdosesinvolvingpainkillersorthe antianxiety medication alprazolam (Johnson H et al. MMWR Morb Mortal Wkly Rep. 2014; 63[16]:347-351). Most of the deaths involved morethan1drug,accordingtothereport.Since the crackdown began, however, the state has

Painkiller Prescriptions per 100 People by State: United States, 2012.

WA MT

VT

ND

MN

OR ID WY UT

AZ

CO

NY

MI IA

NE

NV CA

WI

SD

PA IL

KS OK

NM TX

OH

IN

MO

KY

WV VA NC

TN MS

AL

AK

NH MA RI CT NJ DE MD DC

SC

AR LA

ME

GA FL

HI

No. of painkiller prescriptions per 100 people 52-71

72-82.1

82.2-95

States in Crisis 96-143

Data Source: IMS National Prescription Audit (NPA), 2012. Source: Centers for Disease Control and Prevention Vital Signs. http://www.cdc.gov/vitalsigns/opioid-prescribing/infographic.htm/#infographic1. Accessed July 21, 2014.

Many southern states have disproportionately high rates of opioid painkiller prescribing.

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begun to see a decline in deaths, from 3201 in 2010 to 2666 in 2012, based on data from state medical examiners. Despite some progress in certain states, a new report from the US Centers for Disease Control and Prevention (CDC) finds that nationwide prescribing rates for narcotic medications remain high and worrisome variations persist among states (Paulozzi LJ et al. MMWR Morb Mortal Wkly Rep. 2014; 63[26]:563-568). Clinicians in the United States wrote 259 million opioid prescriptions in 2012, enough for every adult to have a bottle, noted CDC director Thomas Frieden, MD, MPH, during a press briefing July 1. “Prescription opiates can be an important tool for doctors to use, and some conditions are best treated with opioids,” Frieden said. “But they are not the answer every time someone has pain.” The CDC found that in 2012, for every 100 people in the United States, US clinicians wrote 82.5 prescriptions for opioid painkillers and 37.6 prescriptions for benzodiazepines, a class of antianxiety drugs that has a long history of abuse. State-by-state differences in prescribing were large and difficult to explain. Hawaii had the lowest prescribing rate for painkillers—just 52 per 100, compared with 143 per 100 in the 2 top prescribing states, Tennessee and Alabama.

Florida’s crackdown followed widespread publicity about rampant pill mills in the state fueling opioid abuse there and in other southern states. News articles documented the rise of pill mill empires (http: //buswk.co/1jc2iJ0), where people showed

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up at pain clinics without appointments, paid cash, and left with a month’s supply of pills. Florida had become a haven for physicians who were prescribing and dispensing a high volume of oxycodone in their clinics, with 98 of the nation’s top 100 opioiddispensing prescribers in 2010. In 2011, the state’s top public health official declared an emergency. Since 2009, Florida legislators have passed a raft of laws intended to curb highvolume prescribing. The new legislative provisions include the following: • A ban on physicians dispensing narcotics • Tighter controls of drug wholesalers • Registration and inspection of pain clinics • Mandated reporting of data to a prescription monitoring program • Tougher penalties for those illegally prescribing The legislative efforts seek to reduce diversion and doctor shopping, explained Hal Johnson, MPH, lead author of the MMWR report on the reductions in opioid deaths in Florida. The state’s new prescription drug monitoring program has seen increasing use among physicians, said Johnson, who is a behavioral health epidemiology consultant working with the Florida Department of Health. Some efforts are under way to further increase physicians’ use of data from the prescription monitoring program prior to prescribing. Still, Johnson noted that prescription monitoring alone is not enough; it has been necessary for Florida to increase regulation of drug wholesalers and pain clinics, too. “It has to be a multifaceted approach,” he said. One of several other states to place new limits on prescribing is Tennessee, which the CDC ranked as having the second-highest per capita rate of painkiller prescribing, with 143 prescriptions per 100 people, just behind Alabama. The state has seen dramatic increases in drug overdose deaths, with the number more than doubling from 422 in 2003 to 1059 in 2010. To get a better sense of how risky prescribing was contributing to the deaths, Timothy F. Jones, MD, state epidemiologist at the Tennessee Department of Health, and colleagues from the CDC and other research institutions compared the prescription-related habits of those who died from overdose in 2009 and 2010 with matched controls. They found an increased risk of dying from overdose for individuals who were prescribed opioids by 4 or more physicians,

who filled prescriptions at 4 or more pharmacies, or who were prescribed mean daily doses greater than 100 morphine milligram equivalents per year. More than half (55%) of those who died had 1 or more of these 3 risk factors. In January 2013, Tennessee passed a law mandating that physicians check the state’s prescription monitoring program before prescribing narcotics. Although pharmacies— particularly large chain stores—had been using the system, which had been in place since 2006, use had been spotty among physicians, Jones said. The system can enable physicians and pharmacies to identify patients who are at high risk or who may be diverting drugs. For example, prior to the mandate, there were 3200 people in the system who had received more than 25 prescriptions in a year and about 5000 who’d gotten the drugs from 10 or more physicians. Some physicians using the system have been shocked to find their patients are in these high-risk groups, Jones noted. Requiring physicians to look at the prescription monitoring data dramatically reduced the number of patients whose prescription behaviors place them at high risk of overdose. From mid-2011 to mid-2013, the state saw a 50% decrease in patients using 5 or more prescribers or 5 or more dispensers in the preceding 90 days, Jones said. “Making [prescription monitoring program]usemandatoryisreallythekey,”hesaid. “That’s what really turned the corner for us.” Similarly, in 2012, New York State began requiring physicians to consult its prescription monitoring data before prescribing narcotics. By 2013, the state had documented a 75% decline in the risky use of multiple prescribers, according to the CDC report. Jones said he and his colleagues hope to see more reductions in risky prescribing. He noted that Tennessee has passed several additional measures, including mandatory public health department inspections of the top 50 prescribers, a 30-day cap on opioid prescriptions, and a ban on physician dispensing. The state also passed a law granting immunity for those who administer naloxone to reverse an opioid overdose. This prevents individuals who assist someone during an overdose from being charged with drug-related crimes. Without such protection, some individuals may be afraid to intervene or call an ambulance.

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Prescribing Patterns Overall, the CDC data suggest disproportionately high prescribing of opioids and benzodiazepines in the South. The agency has also documented disproportionately high rates of overdose in other US regions, especially in Appalachia and parts of the West and Southwest (Chen LH et al. MMWR Morb Mortal Wkly Rep. 2014:63[26]:577). But these death rates include overdoses from illicit drugs and may not correspond with opioid prescribing rates. Len Paulozzi, MD, a medical officer in CDC’s injury center, said in an interview it’s not clear why opioids and benzodiazepines are prescribed more in the South. The prevalence of pain or the number of older individuals is not higher in the region than others. The South does have a higher population of black people, but these individuals are less likely to be prescribed opioids. In fact, Tennessee’s data suggest that high-risk users are disproportionately white males. Paulozzi noted that prescribing rates for other drugs, such as medications for attention-deficit/hyperactivity disorder and antibiotics, are also disproportionately high in the South. Again, the reasons aren’t clear, although poverty and differences in health care delivery may be factors, Paulozzi suggested. Federal agencies have been working for years to try to reduce prescription overdose death rates, which in 2009 eclipsed car crashes as the leading cause of accidental death. The US Food and Drug Administration has approved abuse-resistant formulations of opioid medications and required manufacturers of some products to develop safety plans. The Substance Abuse and Mental Health Services Administration has worked to expand access to office-based buprenorphine treatment to make it easier for patients to receive help for opioid addiction. The CDC has issued numerous alerts and recommendations for clinicians and is currently evaluating state-level programs to identify interventions that work. The latest data available suggest that although overdose deaths have continued to increase, the rate has slowed. Nationally, there were 16 917 deaths involving painkillers in 2011, a 2% increase over the 16 651 that occurred in 2010. From 2009 to 2010, painkiller overdoses increased 8%, from 15 597 to 16 917. Paulozzi said there is agreement about the need to do more at the federal level to “bend the curve of overdose deaths.” JAMA August 20, 2014 Volume 312, Number 7

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One worry is that rising heroin use may be a sign that individuals are shifting from prescription opioid abuse to other opioid drugs. From 2010 to 2012, Florida saw a 24% decrease in oxycodone prescribing but a37%increaseinmorphineprescribing.The state also saw an increase in heroin overdose deaths during the same period, from 48 to 108 (0.3 to 0.6 per 100 000 people in the state). Johnson said this increase, although concerning, is small compared with the simultaneous reductions in prescription overdoses, which decreased from 2722 in 2010 to 2116 in 2012. This reduced the prescription overdose rate to 11 per 100 000, the lowest in the state since

2007, according to the report on Florida’s efforts. Paulozzi said economic factors and greater availability of heroin may be driving some opioid users to heroin, as has been reported in some surveys. But there aren’t clear data explaining why heroin use has increased in the northeastern United States. For now, the CDC is focusing on preventing prescription opioid abuse. “We are interested in upstream interventions,” said Paulozzi. “We want to get ahead of the problem before people become dependent and prevent them from turning to heroin because of its lower price and high availability.”

CDC: Ebola Risk to US Patients Is Low, But Clinicians Should Be on Alert Joan Stephenson, PhD

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s the number of cases and deaths increases in West Africa in the largest-ever outbreak of Ebola virus disease (EVD), the US Centers for Disease Control and Prevention (CDC) has issued a health alert to health care workers to take steps to help prevent the spread of the virus in the United States. Although the risk of the virus spreading outside of Africa is low, the agency said, it advised clinicians to obtain good travel histories of their patients to identify those with recent travel (within 21 days) to affected countries, to be aware of the symptoms of Ebola infection, and to “consider isolation of those patients meeting these criteria, pending diagnostic testing” (http://1.usa.gov /1lavRXd). The report was issued just days after confirmation of a diagnosis of EVD in a man who reportedly collapsed after a flight from Liberia to Lagos, Nigeria, a city of 21 million, and died in the hospital where he was taken and isolated. Health authorities also reported confirmation of Ebola virus infection in 2 US citizens working in a hospital in Monrovia, Liberia. “These recent cases, together with the continued increase in the number of Ebola cases in West Africa, underscore the potential for travel-associated spread of the disease and the risks of EVD to health care workers,” the advisory noted.

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According to the CDC, symptoms of Ebola infection, which can appear from 2 to 21 days after exposure to the virus (most commonly 8-10 days after exposure), typically include fever, headache, joint and muscle aches, weakness, diarrhea, vomiting, stomach pain, and lack of appetite (http://1.usa.gov/1rzF4O4). Patients also may experience rash, red eyes, hiccups, cough, sore throat, chest pain, difficulty breathing or swallowing, and bleeding. The infection, which is not contagious until the onset of symptoms, is spread through contact with blood and bodily fluids of infected individuals. Clinicians who have a patient with Ebola symptoms should isolate the patient and follow infection control precautions—particularly avoiding contact with blood and bodily fluids, according to the health alert. Some 1201 cases and 672 deaths in Guinea, Liberia, and Sierra Leone have been tallied since the first cases from the West Africa outbreak were reported in March, said Stephan Monroe, deputy director of the CDC’s National Center for Emerging and Zoonotic Infectious Diseases, at a July 28 briefing. “It’s a rapidly changing situation and we expect there will be more cases in these countries in the coming weeks and months,” he said.

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Kidney stones

Kidney stone

Climate Change May Increase Kidney Stone Risk Increases in global temperatures and greenhouse gas emissions may put more people at risk of developing kidney stones, according to a new study. Researchers analyzed medical records for more than 60 000 adults and children treated for kidney stones between 2005 and 2011 in 5 US cities. They then compared the records with weather data from the National Climatic Data Center. The investigators found that the risk of developing kidney stones increased during the study period when mean daily temperatures rose above 50°F (10°C) in all the cities except Los Angeles. Mean daily temperatures reaching 86°F (30°C) were linked with risk increases of 38% in Atlanta, 37% in Chicago, 36% in Dallas, and 47% in Philadelphia compared with 50°F (10°C). Higher temperatures contribute to dehydration, which leads to higher concentrations of calcium and other minerals in the urine, which promotes kidney stone development. http://jama.md/UqBARh Using Teaspoons May Result in Dosing Errors Physicians can help make the process of doling out a dose of liquid medication more error free for parents giving liquid medication to their child by simplifying dosing directions, according to a new study. Parents may fumble to find the right dosing device, struggle to understand the dosing directions, and have difficulty getting their child to take the medication. Many organizations have suggested switching to metric-only dosing for liquid medications to reduce dosing errors. A team of researchers compared dosing error rates among 287 parents whose children were prescribed a liquid medication in either teaspoons or milliliters after visiting 1 of 2 emergency departments. Parents who had been given a prescription in teaspoons were more likely to make a measurement error than parents given a metric measurement (42.5% vs 27.6%). Many of these errors occurred because parents given a prescription in teaspoons used a kitchen spoon or other nonstandard device. Parents with low health literacy and non-English speakers were particularly prone to errors when teaspoons were used as a measure. http://jama.md/WyJYQb

For more on these stories and other medical news, visit http://newsatjama.jama.com.

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CDC: Major disparities in opioid prescribing among states: some states crack down on excess prescribing.

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