“An Epidemic That Starts in the Medicine Cabinet”
BY ROBYN ALIE
MMS PUBLIC HEALTH MANAGER
This is the first of a two-part Vital Signs interview with Michael Botticelli, director of the White House Office of National Drug Policy, who will keynote the Massachusetts Medical Society’s April 8 Public Health Leadership Forum on opioids.
Mr. Botticelli has been in Washington since November 2012, previously serving as deputy director of National Drug Control Policy. Prior to his federal appointment, Mr. Botticelli spent many years at Massachusetts Department of Public Health, most recently as the director of the Bureau of Substance Abuse Services.
VS: What does the opioid issue look like at the national level?
Botticelli: We’ve made significant progress in reducing alcohol, tobacco, and other drug use in the United States. I think it’s tremendously hopeful as we think about the prescription drug and heroin issue, the opioid issue. We [have seen] some significant reductions in prescription drug use, particularly among young adults.
While we are the federal government, we fully acknowledge that if we’re going to have success, it’s really about federal, state, and local entities working in partnership to make sure that we have a comprehensive response around drug issues, particularly around the opioid epidemic.
There’s a huge variation in the number of pain prescriptions that are being issued on a state-by-state basis and actually Massachusetts was on the low end of that when [CDC] looked at the number of prescriptions per 100 adults. And, no surprise, we do see significant state level variations as we look at the number of opioid related overdoses, both prescription drugs and heroin.
VS: How would you explain these regional differences?
Botticelli: There are probably multiple factors…. It could be a function of not having standard clinical guidelines as it relates to pain prescribing. I think it might relate to the variability — although that’s changing — around the sophistication and utilization of Prescription Drug Monitoring Programs [PDMPs]. It might be a function of state legislation and state support for this kind of comprehensive prescription drug abuse strategy that Massachusetts has implemented.... There are a significant number of states that don’t have a robust treatment program or haven’t significantly expanded Medicaid and insurance status like Massachusetts has.
VS: How is the prescription opioid problem similar to or different from other substance abuse?
Botticelli: Unlike other drugs —heroin, cocaine, marijuana — that are illegal and are driven by an illegal drug trade, prescription drugs are not. These are legally prescribed substances. We’ve known for a long time that people — particularly kids and young adults — are less likely to see prescription drugs as dangerous because they are prescribed by physicians. As you move into why people start misusing pain medication, we know diversion from legitimate prescriptions is a huge factor. About 70 percent of people who start misusing pain medications get those free from family and friends who have gotten that prescription from just one doctor…. This is an epidemic that starts in the medicine cabinet.
VS: What do you feel are the interventions that work? What more is needed to address those unique issues?
Botticelli: In 2010, our office issued a strategy to reduce the epidemic of prescription drug misuse in the United States. It has four main pillars. The first one is education: it primarily speaks to educating the prescriber community on safe and effective opioid prescribing. When you look at the significant health consequences that we’ve had around prescription pain medication, there’s a direct correlation to just the volume of pain medication that’s being prescribed. Our office has always been trying to promote a balanced plan around prescribing. We don’t want people to suffer needlessly in pain. But we also want prudent and responsible prescribing, to understand where we do not necessarily have to prescribe. The automatic response to pain shouldn’t be prescribing opioids. We want to make sure that there’s a comprehensive assessment going on about whether or not alternatives to opioids can be used. Chronic opioid prescribing may not be having the intended health benefits that people thought. Massachusetts was actually one of the first states — and one of the few states — that implemented mandatory continuing medical education for prescribers.
The second component is monitoring. A main pillar of our plan is having good usable PDMPs across the country. In 2006, I think we had 26 states that had [PDMPs]. Some of those didn’t keep up with the number of schedules, may not have been providing real-time data, so a big push at the federal level is to make sure all states have a [PDMP]; to make sure those programs have good, reliable, as close to real-time data as possible; that they’re easy to use. We’ve been working… to make sure that these programs are linked to electronic health records. We understand that physicians are working within busy practices. The other issue that we heard from the medical community — that we are attending to — is interstate operability.
VS: How far away do you think we are from those reliable, almost real-time PDMPs across the country?
Botticelli: I think we’re getting there. I think of this as looking at the next generation of prescription drug monitoring programs — PDMPs 2.0. It was a big push just to get prescription drug monitoring programs online. The next piece is how do we use that information not only for identification of high utilizers, but also as a clinical intervention to get people into treatment? We’re seeing states looking at how might physicians partner with treatment programs, or [how to] get physicians good information about creating opportunities to identify those folks and creating a referral to treatment.
This is where we’ve begun to see some really good outcomes coming from the development and implementation and utilization of [PDMPs]. Tennessee… [passed] a state law where prescribers have to check the PDMP when they’re first prescribing. So, over the past two years they’ve seen a 47 percent reduction in the number of high utilizers in prescription drug monitoring programs.
There was probably no more outlier state than Florida. Because of lax legislation and regulation, Florida was the state with the highest number of opioid pain prescriptions. One county, Broward County, accounted for something like 50 percent of all the prescriptions in the United States. It was huge. Through legislative action and the development and utilization of a [PDMP], they actually saw a significant reduction in opioid-related overdoses associated with prescription pain medication. So, we’re beginning to see, in states that have good, reliable [PDMPs], and where physicians and other prescribers access that information, that we really can make significant changes.
Coming in April’s Vital Signs, Mr. Botticelli will speak about treatment and the evolving role of physicians and others in the opioid addiction epidemic.