Professional Documents
Culture Documents
Prescription Opioids
Nathaniel Katz, MD, MS
Tufts University School of Medicine
Analgesic Research
Opioid Prescribing to Adolescents in Dental Settings
National Institute of Drug Abuse
February 23, 2009
Outline
1. Define and characterize diversion
2. Present what is known about sources
of diverted prescription opioids
3. Speculate about role of dentists
4. Describe potential solutions
1
Define and Characterize
Diversion
Definition of Diversion
The transfer of a controlled substance from a lawful
to an unlawful channel of distribution or use.
Section 309, Diversion Prevention and Control
Uniform Controlled Substances Act
National Conference of Commissioners on
Uniform State Laws, 1994
Diversion Examples
Diversion
Sharing
Selling, buying
Stealing
Prescription forgery
Doctor shopping
Illegal internet Rx
Criminal prescribing
Not Diversion
Using your own
legitimately
prescribed
medication to get
high
(~20% of NMU)
2
What is Known About Sources of
Diverted Prescription Opioids
Percentage
Primary Diversion
Manufacturers
Distributors
706,558
Pharmacies
2,633,098
Hospitals/Clinics
Internet
Illegal Internet
Practitioners
Internatl Smuggling
Nursing Homes
Forgery
Hospices
Patients
Doctor Shopping
Patient Sells/Gives
TOTAL
Tens of millions?
Tens of millions?
175,000,000?
?
1,000,000,000?
Estimated percentage
63,000
scripts
3
2
1
0
96
97
98
99
00
01
02
03
3.5 million
doses
04
05
Fiscal yr
*Questionable activity = obtained Schedule II opioid prescriptions from
4 pharmacies & 4 physicians during the specified yr
Quantifying Diversion:
Research Agenda
Clean up NSDUH data:
3
Speculate About the Role of
Dentists in Prescription Opioid
Diversion
199
8
MD Specialty
%
Prescriptions
200
2
MD Specialty
%
Prescription
s
DENTISTRY
15.5%
FAMILY PRACTICE
13.0%
FAMILY PRACTICE
14.6%
ORTHOPEDIC SURGERY
11.5%
DENTISTRY
12.2%
INTERNAL MEDICINE
11.1%
INTERNAL MEDICINE
12.2%
10.2%
OSTEOPATHIC MEDICINE
6.7%
ORTHOPEDIC SURGERY
EMERGENCY MEDICINE
5.5%
OSTEOPATHIC MEDICINE
7.8%
GENERAL SURGERY
4.2%
EMERGENCY MEDICINE
6.1%
OBSTETRICS/GYNECOLOGY
3.5%
GENERAL SURGERY
3.6%
OBSTETRICS/GYNECOLO
GY
3.2%
ALL OTHERS
28.9%
ALL OTHERS
30.2%
Dentists likely prescribe about a billion doses per year of opioids, mostly
immediate-release combination products
14
Source: IMS Health, National Prescription Audit PlusTM, Year 1998 to 2002, Excluding Long-Term Care & Mail Order
4
Potential Solutions
Web-based
training
REMS
registry
Explains
Med Guide
Patient
Patient
trainingenrollment
Data
Client
Switch
company(ies)
Enrollment
verified
Prescription filled
Prescription brought
Retail
Pharmacy
Closed
Distribution
Solutions
Problem
General Approach
Dentists
Poor pt selection,
monitoring,
treatment
REMS-based mandatory
training
(Not education)
Guidelines
Mandatory training
Research
Poor monitoring
Sharing/selling
Universal pt
education/training
Natl awareness campaign
Lockboxes
Forgery
Tamper-proof scripts
Tamper-proof scripts
Doctor shopping
Prescription monitoring
Prescription monitoring
Theft
Rational disposal