PRESCRIPT

ION DRUG

ABUSE/MISUSE IN

OKLAHOMA

Avy Redus, MSProject Coordinator

AvyD@health.ok.gov

Claire Nguyen, MSInjury EpidemiologistClaireN@health.ok.go

vOklahoma State Department of Health

Injury Prevention Service405-271-3430

http://poison.health.ok.gov

BACKGROUNDPoisoning Ingestion, inhalation, absorption, or contact with a substance resulting in a toxic effect or bodily harm.

Unintentional Individual did not intend harm to themselves or someone else

May intentionally take a drug, but did not intend to harm themselves

METHODSOffice of the Chief Medical ExaminerCentralized systemIPS receives ME reports for all non-natural deathsNarrativeAutopsyToxicology

Manner of death

SCOPE OF T

HE PROBLEM

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

0

2

4

6

8

10

12Ra

te p

er 1

00,0

00 P

opul

atio

n

Source: Centers for Disease Control and Prevention, 2013*Deaths are those for which poisoning by drugs (illicit, prescription, and over-the-counter) was the underlying cause.

Unintentional drug overdose death rates in the U.S. have more than tripled since 1990.

MAGNITUDE OF THE PROBLEM, U.S.

• 15,000 deaths annually• In 2010, 1 in 20 used pain killers for nonmedical purposes

• Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month.

Source: Centers for Disease Control and Prevention, 2012

UNINTENTIONAL POISONING DEATH RATES, OKLAHOMA AND THE UNITED STATES, 1999-2010

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

5

10

15

20

25

Oklahoma US

Rate

per

100,0

00 P

opul

atio

n

Source: WISQARS, Centers for Disease Control and Prevention

UNINTENTIONAL POISONING AND MOTOR VEHICLE CRASH DEATH RATES, OKLAHOMA, 1999-2010

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

5

10

15

20

25

Unintentional Poisoning MVC

Rate

per

100,0

00 P

opul

atio

n

Source: WISQARS, Centers for Disease Control and Prevention

MORTALITY RATES BY AGE GROUP* AND GENDER, UNINTENTIONAL POISONING, OKLAHOMA, 2007-2012

15-24 25-34 35-44 45-54 55-64 65-740

5

10

15

20

25

30

35

40

45

MalesFemales

Age Group

Rate

per

100

,000

Pop

ulat

ion

*Decedents under age 15 and over age 74 were excluded due to small number of cases (<1% of all UP deaths)

Source: OSDH, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports)

DEATHS INVOLVING PRESCRIPTION DRUGS, ILLICIT DRUGS, OR ALCOHOL BY YEAR OF DEATH, UNINTENTIONAL POISONING, OKLAHOMA, 2007-2012

2007 2008 2009 2010 2011 20120

100

200

300

400

500

600

700

800

All poisoningsPrescriptionAlcoholMethamphetamineCocaine

Year of Death

Num

ber o

f Dea

ths

Source: OSDH, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports)

Source: OSDH, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports)

SUBSTANCES INVOLVED IN UNINTENTIONAL POISONING DEATHS, OKLAHOMA, 2007-2012

MEDICATIONSMedication Type Number RatePrescription medication 3075 13.7 Narcotic analgesic 2677 12.0 Anti-anxiety 1007 4.5 Muscle relaxant 305 1.4 Antidepressant 252 1.1 Tri-cyclic antidepressant 186 0.8 Non-narcotic analgesic 186 0.8 Antipsychotic 47 0.2 Respiratory 52 0.2 Hypnotic/sedative 39 0.2 Antiemetic 31 0.1 CNS stimulant 25 0.1 Other** 60 0.3Over the counter 143 0.6

Most common medications (number of deaths); Oxycodone (791) Hydrocodone (787) Alprazolam (733) Methadone (628) Morphine (463)

Unintentional Poisoning Death Rates by County of Residence1, Oklahoma, 2007-2012

CimarronTexas

BeaverHarper

Ellis

Beckham

Woodward

Woods Alfalfa

Major

Dewey

Custer

Washita

Kiowa

Blaine

Caddo

Grant

Garfield

Kingfisher

Kay

Noble

Logan

Canadian Oklahoma

Cleveland

Grady

Osage

McClain

Jackson

Tillman

Comanche

Cotton

Stephens Murray

Bryan

Pushmataha

Choctaw

Muskogee

Ottawa

Washington

Nowata

Craig

Mayes

Harmon

Top 5 counties21.1 – 34.217.9 – 21.012.6 – 17.87.6 – 12.5<5 deaths

Roger Mills

Greer

Tulsa

Okmulgee

Creek

Okfuskee

Payne

Lincoln

WagonerCherokee

Adair

RogersDelaware

Carter Johnston

Jefferson

Garvin

Love Marshall

Le Flore

Atoka

Hughes

McIntosh

Latimer

Haskell

Sequoyah

SeminolePotta-watomie

Rates per 100,000 population

State rate2: 17.5

1County of residence was unknown for 31 persons.

Source: OSDH, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports)

Pawnee

Coal

Pontotoc

McCurtain

Pittsburg

CONSEQUEN

CES

ASSOCIATED W

ITH

PRESCRIPT

ION DRUG

ABUSE/MISUSE

LEGAL CONSEQUENCES

HEALTH CONSEQUENCES

SOCIAL CONSEQUENCES

FINANCIAL CONSEQUENCES

WHY HAS PRESCRIPTION DRUG

ABUSE/MISUSE BECOME SO PREVALENT?

WHAT CAN YOU DO?

SAFE USE• Never take prescription

medication that is not prescribed to you

• Never take your prescription medication more often or in higher doses than prescribed

• Never drink alcoholic beverages while taking prescription medications

• Never share your prescription medications with anyone

• Taking prescription pain medications with other depressants such as sleep aids, anti-anxiety medications, or cold medicine can be dangerous

• Tell your healthcare provider about ALL medicines and supplements you take

SAFE STORAGE•Keep your prescription

drugs in a secure location to make sure kids, family, and guests don’t have access to your medications

•Know where your prescription medications are at all times

•Keep prescription pills in the original bottle with the label attached, and the child resistant cap secured

•Keep track of how many prescription pills are in your bottle so you are immediately aware if any are missing

SAFE DISPOSAL• Please take your medications

to a permanent collection site (drop box) or a special community take-back event• Call your city or county law

enforcement professionals• Do not flush prescription

drugs down the toilet unless information on your prescription label or FDA specifically instructs you to do so.

• Follow FDA guidelines when throwing the drugs in household trash

WHAT CAN COMMUNITIES DO?•Engage in community take-back events•Get involved• Town hall meetings• Community coalitions

•Community-based prevention education•Support groups•Promote safe use, storage, and disposal•Promote the use of the PMP•Naloxone

WHAT CAN BUSINESSES DO?•Active promotion of a referral to treatment hotline (211)•Provide educational information of prescription drug

abuse/misuse•Explanation of substance abuse services in new

employee orientation•Onsite support services

(employee benefits, employee assistance program, counselor, clinician, etc.)

WHAT CAN BUSINESSES DO?Adopt workplace prescription drug policies• Prohibited behavior• Major medical insurance• Pharmacy benefit program• EAP• Crisis intervention• Assessment, referral• Short-term and follow-up counseling • Treatment monitoring

WHAT SHOULD PARENTS DO?Educate yourself• Defining• Risks• Signs and Symptoms • PreventionCommunicate the risks of

prescription drug abuse/misuse to your kids

• Children who know the risks of drugs at home are up to 50% less likely to use drugs than those who do not get the education

Safeguard your medicine cabinet

• Keep prescription medicine in a secure location; lock them up• Count and monitor the number

of pills you have• Ask your friends and family

members to do the sameGet help• 211• 1-855-DRUGFREE (1-855-378-4373)

SIGNS AND SYMPTOMS OF A DRUG OVERDOSE EMERGENCY

• Won’t awaken when aroused • Bluish purple skin tones for lighter skinned people and grayish or

ashen tones for darker skinned people • Slow, shallow, erratic, or absent breathing • Snore-like gurgling or choking sounds • Elevated body temperature • Vomiting • Irrational behavior or confusion Signs and symptoms of drug overdose may differ depending upon the type of drug consumed.

Emergency: If you suspect someone is experiencing a drug overdose, you must react to this true medical emergency by calling “911” without delay.

CONTACT INFORMATION•Call 211 for treatment referrals•Call OBNDD directly to report diversion

•1-800-522-8031• http://www.ok.gov/obndd/

People

Daughter

Son

Brother

Aunt

Uncle

CASE STUDIESA male in his 40s with a history of knee pain due to years of working laying carpet. He had recently been released from rehab for his prescription pain medication addiction, but was prescribed more pain medications for his knee and back pain. He was home with his wife and not feeling well. His wife was doing laundry and could hear him snoring loudly. She noticed he was no longer snoring, went to check on him, and found him unresponsive. His death was pronounced by EMS. His toxicology report included five different prescriptions medications, two of which were opioids.

CASE STUDIESAn older adult female had recently been to the doctor and prescribed two new medications, fentanyl patches and oxycodone for pain. She was also previously prescribed hydrocodone. She fell asleep on the couch and her husband carried her to the bedroom and put her to bed. She slept most of the day, and her husband woke late that evening and noticed she would not move when he asked her. He called 911 and she was pronounced by EMS.

CASE STUDIESA female in her 30s suffered from arthritis and bipolar disorder. She went to rehab approximately a year before her death after overmedicating several times. Her husband worked out of town, but said she was in great spirits when he came home for the weekend. She complained of some pain from her arthritis, and told her husband she knows her body and doses herself. He woke in the middle of the night to her snoring, and several hours later became concerned when she did not get up to check on their crying baby. She was unresponsive with blue face, lips, and tongue. Her toxicology report included an antidepressant, opioid, and muscle relaxant.

CASE STUDIESA male in his 30s with a history of a work-related back injury 5-10 years previous. He had multiple surgeries on his back and neck since the injury. He was home alone and found unresponsive by family on their arrival to the home. He did not have a known history of substance abuse or mental health problems. He had a prescription for both of the drugs involved in his death.

CASE STUDIESA young adult male veteran had recurring pain from an injury sustained during a tour in Iraq. He suffered from depression and had a history of overmedicating. He was found unresponsive in the middle of the night and pronounced on arrival by a first responder. His death involved multiple prescription drugs, including prescription painkillers and antidepressants. He had a known prescription for almost all of the drugs.

ADDRESSING THE

PROBLEM

STATE PLAN• Community/Public Education• Provider/Prescriber Education• Disposal/Storage for the

Public• Disposal/Storage for Providers• Tracking and Monitoring• Regulatory/Enforcement• Treatment/Interventions

LEGISLATION• HB 1781

Share PMP data• HB 1782

Expand use of naloxone• HB 1783

Limit hydrocodone refills• HB 1491

Notify providers of possible doctor shoppers

CASE STUDY

PROJECT LAZARUS

• Town hall meetings• Task forces/coalitions• Tool kit for primary care

prescribers• Pain management guidelines• Sample patient-prescriber agreement• Patient education materials• Screening, brief intervention, and

referral to treatment information • Support group for pain patients

COMMUNITY ORGANIZATION

• Schools• Colleges• Civic organizations• Churches• Red Ribbon campaign• Media• Billboards

COMMUNITY-BASED PREVENTION EDUCATION

• One-on-one prescriber education on pain management

• Continuing medical education

• Promotion of prescription monitoring program

PRESCRIBER EDUCATION

Enhanced hospital policy• Limit on amount dispensed• Required check of PMP

Take-back events by law enforcement• Fixed disposal sites

Drug detox and treatment programs

REDUCE EXCESS SUPPLY AND INCREASE TREATMENT

More than half of deaths occurred at home• Emergency medical care not called or not able to reach

victim in time to reverse the overdose• Bystanders did not recognize as lethal overdose• Concern for liabilityFree naloxone for high risk patients

NALOXONE PROGRAM

Source: Wilkes Co. Health Department; NC SCHS; CDC Wonder

Results: Opioid Prescribing

The overdose death rate dropped 71% in two years after the start of

Project Lazarus and the Chronic Pain Initiative.

• High prescription opioid unintentional poisoning rates

• Some degree of community awareness

• Coalition building capacity• Motivated community organizer• Support from the medical

establishment• Strong data utilization practices

KEY COMPONENTS

State plan action itemsAssist with local plans• Link with DMH contactsPresentations• Train-the-trainer• Regional provider trainingEducational materialsProvide local data• Death, hospital discharge, PMPTechnical assistance

OSDH SUPPORT

Avy Redus, MSOklahoma State Department of

HealthProject Coordinator

405-271-3430AvyD@health.ok.gov

Claire Nguyen, MSOklahoma State Department of

HealthInjury Epidemiologist

(405) 271-3430ClaireN@health.ok.govhttp://poison.health.ok.gov