The mission of the Indiana Attorney General's Prescription Drug Abuse Prevention Task Force is to significantly reduce the abuse of controlled prescription drugs and to decrease the number of deaths associated with these drugs in Indiana.
The Indiana Attorney General's Prescription Drug Abuse Prevention Task Force was established in September 2012. It is made up of approximately 100 members including state legislators, law enforcement, health and medical professionals, pharmacists, federal, state and local government agencies, educators, advocates and treatment providers. In addition, a significant number of working-group volunteers have contributed to the efforts of the task force. The Rx Task Force is composed of the following core committees:
- Education - Developing education materials about appropriate prescribing and use of controlled substances for medical providers and the public
- Enforcement - Targeting criminal prescribing and diversion
- INSPECT - Ensuring sustainability and access to Indiana’s Prescription Drug Monitoring Program
- Take Back - Increasing availability of disposal sites for unused controlled substance
- Treatment & Recovery - Improving access to treatment for those suffering from addiction
Education is a key component in addressing all levels of this epidemic. The education committee of the Task Force works to develop clinical education materials about appropriate prescribing and use of controlled substances for medical providers and the public at large.
First Do No Harm: The Indiana Healthcare Providers Guide to the Safe, Effective Management of Chronic Non-Terminal Pain developed by the Education Committee under the leadership of Dr. Deborah McMahan was launched at the symposium on November 1, 2013. The guide provides a set of best practices to help providers work toward more sound management of patients with chronic non-cancer pain. This user-friendly publication geared toward clinicians and medical facility staff provides guidelines on compliance on Indiana laws governing the prescribing of opioids to manage chronic non-terminal pain patients.
The committee also provided outreach around the state to not only prescribers such as physicians, advanced practice nurses and physician assistants but also office staff and hospital executives to educate them on the MLB rules and proper prescribing guidelines. The task force, along with the Indiana State Medical Association, has provided outreach opportunities in a variety of settings around the state at annual conferences, medical association meetings, and physician offices.
The Task Force also launched a FREE online CME video course on The Opioid Epidemic and Indiana’s Opioid Prescribing Laws. This program is designated for a maximum of 1.0 AMA PRA Category 1 Credit and was presented by presented by Task Force Members, Palmer MacKie, M.D., Clinical Assistant Professor of Medicine at Eskenazi Health and Amy LaHood, M.D., Family Medicine Physician at St. Vincent Health Network.
A public awareness campaign was developed and implemented to educate consumers about the dangers of prescription drug abuse. There is a common misconception that narcotics are safe because they are prescribed by doctors – not pushed by drug dealers on the streets. The reality is that painkillers now take the lives of more Americans than heroin and cocaine combined.
The BitterPill website was launched in conjunction with the statewide awareness campaign to increase public awareness of the dangers of prescription drug abuse. This campaign included television, radio, outdoor, digital, print, cinema and sponsorship campaigns across the state. In addition, the campaign engaged in collaboration with elected officials and law enforcement, with the OAG leveraging relationships with officials across the state to promote the program in local markets.
The Indiana Prescription Drug Abuse Prevention Task Force also teamed up with the Indianapolis Colts to heighten awareness of Indiana’s prescription drug abuse epidemic. The sponsorship is being paid for utilizing funds the Attorney General’s Office receives from court-ordered settlements of pharmaceutical litigation involving illegal off-label marketing.
A train the trainer program was developed to educate the community on prescription drug awareness. Over 50 individuals have been trained to make presentations and we have partnered with at least 10 organizations, such as Purdue Extension, Keep Rx, Safe, Indiana Prevention Resource, Indiana Collegiate Action Network, and Department of Education, to collaborate with outreach. Each program produces a ripple resulting in more outreach and new partnership opportunities. Education has extended in many varieties of events such as school convocations, high school health courses, back to school nights for parents, drug awareness weeks on college campuses, health fairs, rotary/Kiwanis club meetings and other community events. One common core PowerPoint presentation exists, but every outreach program has been customized for each audience.
Prescription drug diversion most commonly occurs through doctor shopping and through illicit drug prescribing at clinics known as pill mills. The enforcement committee targets the criminal prescribing and diversion of prescription drugs.
Investigative/Prosecutorial Curriculum and Training
With diversion occurring at epidemic proportions – it was critical that we built support for law enforcement efforts that reduces the prevalence of prescription drug diversion. The committee developed a curriculum on the investigation and prosecution of prescription drug diversion for law enforcement and prosecutors and to provide this training statewide. The seminars were held in key markets around the state and educated on a variety of topics such as:
- Drug Identification
- Recognizing Chronic Abusers
- Investigating Drug Overdose Deaths
- Overview of Drug Statutes and Case Law
- INSPECT Training
- Doctor Shopping 101
The committee continues to address the lack of drug diversion being reported within healthcare facilities – especially long-term care facilities and home health agencies. Diversion occurs along all points in the distribution process including physicians, nurses, nurses-aids, home health agencies and pharmacies although much of the diversion goes unrecognized or unreported. The committee plans to study how to identify and correct the problem of drug diversion in Indiana healthcare facilities. After conducting more research on this subject, the committee plans to explore possible policy or regulatory strategies to address it. They will work to build recommendations that could be taken to the legislature, boards, and health facilitates for further implementation.
Senate Enrolled Act 227: Enhanced Lifeline Law
The Rx Task Force worked with Senator Merritt to update the Lifeline Law to provide immunities for first responders – including law enforcement and firefighters – to carry and administer Naloxone, a medication that counteracts the effects of an opioid drug overdose. This law removed legal barriers for first responders to have the ability to utilize the antidote to save patients’ lives.
The Rx Task Force also worked to support the passage of Senate Bill 406, also known as Aaron’s Law. This bill allows lay persons (the general public) to administer naloxone to a friend or family person who is experiencing an opioid overdose. A person may obtain a prescription for naloxone from their family physician and get it filled at their local pharmacy.
The Enforcement Committee plans to collaborate with Education Committee to develop educational material such as a training toolkit and video for first responders and other non-medical laypersons regarding the use of naloxone in the field. The committee will also actively engage with police departments to provide training on the law that offers them immunity. Additionally, the committee will research grant opportunities for funding naloxone kits.
The INSPECT Committee works to ensure sustainability and access to Indiana’s Prescription Drug Monitoring Program. The committee hit the ground running to propose a legislative funding solution in the 2012 legislative session. HB 1465 passed into law and provides a long-term funding solution for INSPECT by moving all of the funds generated by the CSR back into the program.
With the passage of HB 1465, the committee conducted research to determine the effectiveness of INSPECT and made recommendations on additional technological capabilities or features as needed to improve the user functionality of the database. The goal was to provide better and more seamless access to electronic prescription drug information with prescribers. An interim study committee for INSPECT was formed the summer of 2012 which assisted with the following 2013 legislative initiatives:
- HB 1218 requires that INSPECT reporting by pharmacies to go from 7 days to 3 days beginning July 1, 2015 and 24 hours beginning January 1, 2016.
- Requires methadone clinics to check INSPECT before prescribing.
- Requires a committee to weigh the benefits and disadvantages of collecting all legend drugs. These findings will be presented to a legislative council by October 2014. Several of the Task Force members served on this committee.
The Medical Licensing Board’s chronic pain rules require a physician to run an INSPECT report at the onset of a treatment plan and annually thereafter. Further studies should be done to evaluate the feasibility of requiring practitioners to use INSPECT to check for patient controlled substance prescription histories before generating any prescriptions for such substances, every time they are prescribed. The 2013 IPLA INSPECT Knowledge and Use Survey indicates that prescribers and dispensers have made modifications in their prescribing and/or dispensing habits because of INSPECT with most stating that they have reduced the number of controlled substances that they prescribe and/or dispense.
Increasing availability of disposal sites for unused controlled substances has been the work of the take back committee. In the fall of 2014, the DEA announced new guidelines that will give consumers more options to dispose of prescription drugs safely and conveniently by allowing pharmacies and other health-care facilities will be able to register as collectors and accept controlled substances year-round. Additionally, reverse distributors may now register to serve as collectors, easing the earlier concerns of transportation issues.
The Take Back Committee has offered to help develop, implement, and measure the pilot take back program in partnership with interested retail pharmacies. The Attorney General’s Office could also help promote the program with earned media efforts and other educational material. If successful, we could pitch this model program to other pharmacies to illustrate the benefits it provides to Indiana communities and the public at large.
Yellow Jug Old Drug
Started by the Great Lakes Clean Water Organization (GLCW) in 2008, the Yellow Jugs Old Drugs Program partners with local pharmacies and the Indiana Prescription Drug Abuse Task Force to provide secure and responsible drug disposal. The Yellow Jugs Old Drugs program addresses the fact that there are very limited ways to dispose of unwanted drugs. Now, consumers can take their unwanted medication to any participating pharmacy year-round for a safe disposal option while reducing the amounts of chemicals showing up in our water. Currently pharmacies can only accept non-controlled drugs, but once the DEA regs go into place, they will be eligible to collect controlled drugs also. There are currently 4 pharmacies in Indiana that are involved in this program. GLCW is very close to having a local chain come on board and they are continuing to provide outreach to pharmacies and community leaders on the program. He has also spoken to some corporations about providing sponsorship/grant funding to pharmacies for their yellow jugs.
The treatment and recovery committee works to improve access to treatment and recovery for those suffering from addiction. Opiate addiction is a brain disease. Understanding the neurobiology of this disease translates into development of successful methods of treatment. The two primary barriers to treatment services include the workforce shortage of addiction treatment professionals and lack of adequate insurance coverage for addiction treatment services and medications.
There is a significant workforce shortage of professionals in our state that understand how to properly treat this addiction. There are 40 counties in our state designated as mental health professional shortage areas and 50 counties have no addiction psychiatrists working within them. The shortage will be further exacerbated when additional requirements of ACA go into effect in January of 2014. Many more individuals will become eligible for coverage of addiction treatment. A wide range of individuals have been found to abuse prescription drugs, although the highest rate of death in 2006-2008 was for 45-54 year-olds. This is the target age for adult addicted individuals seeking treatment services.
HB 1360, the Workforce Development Bill, created a committee that will oversee the student loan forgiveness program for health care providers that are willing to work in the field of addictions. The initial meeting was held on August 28th. Family and Social Services Agency (FSSA) will provide the administrative support. The Office of the Attorney General agreed to donate seed money for the first year to get this program up and running. Additional funding will be needed to continue this program indefinitely.
Expansion of Medicaid Eligible Drugs
The team successfully sought an expansion of the scope of the medications that the Mental Health Quality Advisory Committee reviews to include consideration of addiction medications. They also plan to recommend that the Indiana General Assembly engage in further study of including medications used for the treatment of addiction in the preferred Medicaid drug list for the Indiana Medicaid program and the possibility of inclusion under private insurance coverage, both with continuous coverage irrespective of episodes of relapse.
According to an issue in the Journal of the American Medical Association, the number of babies experiencing what is called "neonatal abstinence syndrome" (NAS) increased by 330 percent across the nation between 2000 and 2009. During the 2013 legislative session, the treatment committee worked with stakeholders to get SEA 408 passed, which the Indiana State Department of Health (ISDH) to: (1) meet with representatives of certain associations to study and make recommendations on issues concerning NAS; and (2) report, before November 1, 2014, on certain issues concerning NAS to the legislative council for distribution to the appropriate interim study committee. This law has forced us to think about what we are going to do with these addicted pregnant women. Through a collaborative effort, all women of childbearing age will receive risk appropriate health care before, during and after pregnancy.
The Indiana Perinatal Quality Improvement Collaborative (IPQIC) was originally initiated by ISDH to address NAS and serve as the committee to make recommendations to the legislative council. Several task force members serve on this committee.
The treatment committee also plans to address this issue by working with other advocacy groups to research best practices for treating pregnant mothers with addictions to prescription medications. We will also collaborate with these groups to examine the impact of prescription misuse during pregnancy on babies and requirements for successful recovery before making any recommendations for pre and perinatal substance abuse and treatment services. More education needs to be done on the use of methadone treatment for pregnant women.
The medical licensing board rules also have language that requires physicians to inform “women of child bearing age” about the dangers of prescription drugs.