states of preparedness: health agency progress, second edition

i States of Preparedness: Health Agency Progress, Second Edition

Prescription Drug Overdose:

State Health Agencies Respond
Prescription Drug Overdose: 

State Health Agencies Respond
Acknowledgments 

ASTHO thanks the following individuals for their invaluable assistance in conceiving, 

developing, and producing this report: Ileana Arias, Amy Harris, Paul Halverson, Jerry 

Jones, Jodiane Tritt, Charles McGrew, Rich Weismann, Ana Viamonte Ros, Bill James, Lisa 

VanderWerf-Hourigan, Judith Monroe, William Hacker, Todd Harwell, Bobbi Perkins, Roger 

Citron, Steven Helgerson, Leah Devlin, Marcus Plescia, Mike Crutcher, Shelli Stephens 

Stidham, Bob Rolfs, Chris Curtis, Jim Kaplan, Aron Hall, Danae Bixler, and John Wilkinson. 

This brief was made possible through funding from the Centers for Disease Control and 

Prevention National Center for Injury Prevention and Control. (Cooperative Agreement # 

U50/CCU313903) ASTHO is grateful for their support. The contents of the brief is solely the 

responsibility of the authors and does not necessarily represent the official views of CDC. 

This document was written for the Association of State and Territorial Health Officials by Stuart 

Berlow, MPP, MHSA, Director, Injury Prevention, ASTHO; Len Paulozzi, MD, MPH, Medical 

Epidemiologist, National Center for Injury Prevention and Control, CDC; and Shane Diekman, 

PhD, MPH, Behavioral Scientist, National Center for Injury Prevention and Control, CDC. 

To download an electronic version of this report, visit the ASTHO Web site listed below. For 

reprint requests or to obtain permission to reproduce this report, please contact publications@

astho.org.

Association of State and Territorial Health Officials

2231 Crystal Drive, Suite 450

Arlington, VA 22202

Tel 202-371-9090 Fax 571-527-3189

www.astho.org
Table of Contents

Executive Summary ................................................................................................. 1

The Rising Tide ......................................................................................................... 3

Public Health Implications ........................................................................................ 4

The Assessment Process ........................................................................................... 6

Findings .................................................................................................................... 7

State Health Agency Awareness ................................................................................ 7

State Health Agency Responses to the Problem ............................................................ 9

Barriers to Addressing the Problem .......................................................................... 14

Future Needs — What Should Health Agencies be Doing? ........................................... 15

Discussion ............................................................................................................... 16

Recommendations ................................................................................................. 19

References .............................................................................................................. 20

Prescription Drug Overdose: 

State Health Agencies Respond
Executive Summary 

This report presents health agency leadership and infrastructure to respond adequately 

perspectives from nine states on how to this emerging threat. Nonetheless, State 

prescription drug overdose has emerged and Territorial Health Officials (SHO) 

as a national public health problem. It also clearly recognize this problem and have 

shows the increasing awareness of the demonstrated leadership in responding to and 

problem, which prevention and monitoring the planning for this threat. 

strategies have shown promise, and the 

To assess the knowledge, response, and infrastructure, technology, prevention, 

planning regarding prescription drug misuse partnership, and leadership required to 

and overdose, in late 2007 the Association combat comprehensively and to reverse this 

of State and Territorial Health Officials rising trend. 

(ASTHO) and the Centers for Disease Control 

Since 1999, abuse, misuse, and overdose and Prevention (CDC) conducted interviews 

of prescription drugs have significantly with SHOs and other senior leaders in nine 

increased. Each year more than 20,000 states. This report outlines the knowledge, 

persons in the United States die from drug perceptions, partnerships, recommendations, 

overdose. Those with the highest rates are policies, and other issues that are fundamental 

adults ages 35–44 and persons living in the to understanding and responding to drug 

South and West regions of this country. misuse. The following states are included 

Opioid drugs, commonly prescribed to relieve in this report: Arkansas, Florida, Indiana, 

pain, are the most common source of drug Kentucky, Montana, North Carolina, 

overdose deaths. Oklahoma, Utah, and West Virginia.

This increase in drug overdoses has created 

a considerable public health burden, and 

many states lack the capacity, personnel, 

ASTHO © 2008 Prescription Drug Overdose: State Health Agencies Respond 1
Key Interview Findings: Recommendations: 

 Most State Health Agencies (SHA)  SHAs should routinely track all 

recognized that prescription drug major causes of injury. To increase 

overdoses were a growing issue but public and professional awareness 

in some cases only recently realized of the drug problem, states should 

its magnitude. Most agencies emphasize its magnitude and 

became aware of the overdose rapid growth—the many young 

problem through mortality data. lives that are cut short and the 

mounting costs for state programs,  States rely heavily on measures law enforcement, Medicaid, and such as interagency task forces substance abuse treatment. and prescription monitoring 

programs to address the problem.  State governments should identify 

Less common are educational and a “home” for coordinating the 

regulatory initiatives. response to the drug overdose 

problem. Prevention, surveillance, States cited insufficient data, and response are often too privacy and confidentiality fragmented across agencies and concerns, and lack of state- divisions of state government. based injury prevention capacity 

as barriers to implementing a  States should build their capacity 

response. by using cost savings from 

reducing fraud and abuse involving  States recognized the need to prescription drugs to fund overdose increase the visibility of the prevention as part of SHA injury prescription drug overdose prevention. They should address problem. privacy, confidentiality, and other 

 States also identified the potential concerns about prescription-drug 

effectiveness of evidence-based monitoring programs (PDMP) by 

guidelines for prescribers and emphasizing to physicians the value 

for policy and programmatic of knowing which of their patients 

tools. Although many states have are abusing medications and the 

implemented responses, their value of prosecuting unscrupulous 

effectiveness is unclear. providers.

 SHAs should rigorously evaluate 

the effect of prevention and control 

efforts on health outcomes.

2 Prescription Drug Overdose: State Health Agencies Respond ASTHO © 2008
ASTHO © 2008 Prescription Drug Overdose: State Health Agencies Respond 3

The Rising Tide 

Between 1999 and 2005, the annual number 

of unintentional drug overdose deaths in 

the United States more than doubled—from 

11,155 to 22,448. Drug overdose became 

the second leading cause of unintentional 

injury death in the nation in 2002, just behind 

motor-vehicle injuries. The 35–44 age group 

had the largest increase.1

A 2006 CDC report showed that the rise in 

drug overdose mortality was due to increasing 

deaths from prescription 

drugs rather than from 

illicit drugs such as heroin 

and cocaine. The primary 

problem was a class of 

prescription drugs known 

as opioid analgesics.2

These drugs are powerful 

painkillers with a potential 

for abuse because of 

their heroin-like effect. 

Physicians increasingly 

prescribed these drugs 

during the 1990s to treat moderate and severe 

pain. However, their potential for misuse 

was underestimated, and opioid analgesics 

quickly became the most popular category of 

abused drugs. By 2007, more teenagers used 

opioid analgesics recreationally than used 

marijuana.3

 

 In 2000, publicity about prescription drug 

abuse focused on OxyContin®, a powerful 

opioid painkiller. Today, however, the most 

common opioid involved 

in drug overdose deaths 

has become the pill form 

of methadone, which 

is increasingly used as 

a painkiller because 

it costs twenty times 

less than drugs such as 

OxyContin®.4

 From 

1997–2006, the sales of 

Oxycontin®, methadone, 

and other opioids increased 

substantially.5

Total Unintentional and 

Undetermined Intent Drug 

Overdose Deaths, 2005
This drug overdose epidemic hit some parts Public Health Implications

of the country particularly hard. More than 

half of the country—particularly Southern Within the public sector, law enforcement 

and Midwestern states—saw their drug agencies have traditionally been responsible 

mortality rates double. West Virginia’s rate for preventing and responding to drug abuse. 

increased over 500 percent, while rates in SHAs have typically served supporting roles, 

Oklahoma, Montana, and Arkansas tripled. such as providing mental health and substance 

Increases were generally greater in more rural abuse treatment programs. With the change 

states.1 to a drug abuse problem that is increasingly 

related to prescribed pharmaceuticals, the 

Rates of both use and misuse of opioid role of SHAs has expanded. At the same 

analgesics are highest in low-income time, state drug control offices have shifted 

populations that likely rely on Medicaid, emphasis from illegal drug control to 

so the social costs of this problem are preventing prescription drug misuse. 

significant. One national evaluation of insured 

populations found that opioid abusers had The problem impacts SHAs in numerous 

mean annual direct health care costs eight ways. It affects state Medicaid and workers’ 

times higher than nonabusers.6

 Another compensation programs, which pay for 

study estimated that the total costs for opioid both the prescription drugs and the medical 

abuse was $8.6 billion in 2001 dollars. Direct care necessary to treat overdoses among 

healthcare costs accounted for $2.6 billion, low-income and disabled populations. The 

and lost productivity totaled $4.6 billion. prescriptions for these drugs are written 

The costs in 2005 dollars would be $9.5 by physicians and dentists and dispensed 

billion.7

 Given the substantial increase in drug by pharmacists, all of whom are licensed 

overdose in recent years, economic costs are 

expected to be significantly higher in 2008.

4 Prescription Drug Overdose: State Health Agencies Respond ASTHO © 2008
State Health Officials and Other Interview Participants by state licensing boards, which 

frequently sit within SHAs. These 

Arkansas: Paul Halverson, DrPH, FACHE, Director and State agencies are also often the home of Health Officer; Jerry Jones, Pharmacy Director; Jodianne Tritt, JD, 

Director of Community Support; Charles McGrew, Deputy Director prescription monitoring programs, 

and Chief Operating Officer, Arkansas Department of Health which track prescriptions for 

Florida: Ana Viamonte Ros, MD, MPH, Secretary of Health and controlled substances, including 

Surgeon General; Rich Weismann, Poison Control Director, opioid painkillers and sedatives. 

Florida Department of Health; Bill Janes, Director, Florida Office 

Finally, SHAs are leaders and of Drug Control 

experts in collecting relevant data Indiana: Judith A. Monroe, MD, FAAFP, State Health 

Commissioner, Indiana State Department of Health about mortality, hospitalization, 

Kentucky: William Hacker, MD, FAAP, CPE, Commissioner of and emergency department 

Public Health, Kentucky Cabinet for Health and Family Services visits for problems such as drug 

Montana: Todd Harwell, MPH, Chief, Chronic Disease Prevention overdose. 

and Health Promotion Bureau; Bobbi Perkins, EMT-B, Injury 

Prevention Program Manager; Roger Citron, RPh, Medicaid SHAs play a growing role in Pharmacist; Steven Helgerson, MD, MPH, State Medical Officer, 

Montana Department of Public Health and Human Services addressing the rise in prescription 

North Carolina: Leah Devlin, DDS, MPH, State Health Director; drug overdoses through disease 

Marcus Plescia, MD, Chief of Chronic Disease and Injury Section, surveillance and data collection, 

North Carolina Division of Public Health education and outreach, policy 

Oklahoma: Mike Crutcher, MD, MPH, Commissioner of Health; development, and coalition 

Shelli Stephens Stidham, Chief, Injury Prevention Service, 

building. As leaders of these Oklahoma State Department of Health

agencies, State and Territorial Utah: Bob Rolfs, MD, MPH, State Epidemiologist, Utah 

Department of Health Health Officials (SHOs) play 

West Virginia: Chris Curtis, MPH, Acting Commissioner; Jim a critical role in determining 

Kaplan, MD, Chief Medical Examiner; John Wilkinson, Director, the scope and effectiveness of 

Office of Health Facilities Licensure; Aron Hall, DVM, MSPH, CDC 

their agencies’ responses to this Epidemic Intelligence Service Officer; Danae Bixler, MD, MPH, 

Bureau of Public Health, West Virginia Department of Health & problem. 

Human Resources

ASTHO © 2008 Prescription Drug Overdose: State Health Agencies Respond 5
6 Prescription Drug Overdose: State Health Agencies Respond ASTHO © 2008

To better understand the prescription 

overdose problem at the state level, CDC 

funded ASTHO through an existing 

cooperative agreement to conduct interviews

with nine SHOs during the fall of 2007. 

The Assessment Process

The goals of the interviews were to:

 Understand SHOs’ awareness about 

the problem of prescription drug 

overdoses.

 Learn about state responses to the 

problem. 

 Identify perceived barriers to 

addressing the problem. 

 Identify SHOs’ perceived needs 

to better address their state’s 

prescription drug overdose 

problems. 

Participants were selected from 19 states 

with at least 50 nonsuicidal drug overdose 

deaths in 2004 and overdose rates that at lea

doubled from 1999 to 2004. Care was taken 

to include geographic and social diversity 

among the sample in addition to including 

 those states that had expressed an interest in 

participating.

SHOs from the nine states were encouraged 

to invite a small group of program experts, 

leaders from partner agencies, and others to 

attend the interview and to provide expertise 

and perspectives. Interviews were conducted 

by telephone in October and November 2007, 

and lasted for about 30 minutes. Respondents 

could review the transcripts for accuracy and 

clarity. Participants’ quotes in this report are 

typically, but not always, verbatim.

Seven SHOs were interviewed. In addition, 

interviewees included state epidemiologists, 

state injury prevention directors, leaders of 

state drug control offices, and other relevant 

state health and substance abuse staff. 

st 
ASTHO © 2008 Prescription Drug Overdose: State Health Agencies Respond 7

Findings

This section describes the .ndings from 

the SHO interviews, which are organized 

according to the specific study goals. 

Themes are presented when appropriate and 

illustrative quotes are used to reinforce key 

points.

Interview Guide

CDC and ASTHO developed a semi-structured 

interview guide that included a series of openended questions:

• Tell me what you know about prescription 

drug overdoses in your state. 

• When did you become aware of the prescription 

drug overdose problem in your state? How 

did you become aware of this problem?

• Please describe in detail your agency’s response 

to the prescription drug overdose problem. 

• What in your opinion have been the most 

effective approaches to dealing with this 

problem in your state? How would you define 

success in terms of your agency’s response? 

• What has motivated or facilitated your 

agency’s response to addressing the current 

prescription drug overdose problem? 

• What barriers have reduced the 

effectiveness of your response? 

• Historically, what has been your 

agency’s response to prescription drug 

overdose problems in your state? 

• Talk about what you think your agency’s 

role should be in addressing this and future 

prescription drug misuse problems.

State Health Agency Awareness 

When asked how they became aware of the 

prescription overdose problem, interviewees 

typically had a general sense of the overall 

numbers of deaths and other health outcomes 

associated with drugs or prescription drugs. 

All were aware that they had a growing 

problem in their states. A wide variation 

existed in when they became aware of the 

problem, ranging from the mid-1990s to 

2007, the year of the interviews. 

Several states indicated that data from state 

medical examiners were the primary source 

of their information. Other sources included 

media reports and national reports in public 

health literature.

KENTUCKY – William Hacker: “The 

prescription drug overdose problem 

has grown consistently over the past 10 

years. We became more aware of the 

problem due to better data. Although no 

single event raised our awareness, over 

the years several anecdotal stories of 

overdoses both accidental and intentional 

have been shared in the media.”
8 Prescription Drug Overdose: State Health Agencies Respond ASTHO © 2008

NORTH CAROLINA – Leah Devlin: “We 

lose over 700 people from unintentional 

overdoses each year. The big ones 

are methadone and OxyContin. It’s a 

multifactorial problem.”

UTAH – Bob Rolfs: “Somewhere around 

2000, the medical examiners noticed a 

trend. Previously, there were about 30-40 

deaths per year in prescription opioid use. 

That jumped to somewhere around 250.” 

WEST VIRGINIA – Jim Kaplan: “We began 

to see an upward trend in toxicology 

fatalities around 1997-1998. We began 

to see general trending of the methadone 

problem in 2002-2003.” 

* Official 2005 drug overdose mortality data for West Virginia is incomplete.

0

5

10

15

20

2005

2004

2003

2002

2001

2000

1999

AR FL IN KY MT NC OK UT WV* US

Rate per 100,000

Unintentional and undetermined intent drug poisoning mortality 

rates by year, selected states and the U.S., 1999-2005
State Health Agency Responses to creating task forces in which members were 

the Problem drawn from mental health and substance 

abuse agencies, law enforcement, offices Although SHA responses to the problem 

of drug control, pharmacy boards, coroner/ varied, certain activities were frequently 

medical examiners, workers’ compensation, reported. They included state task forces, 

Medicaid, public employees’ insurance implementing state prescription drug 

programs, medical licensing boards, medical, monitoring programs (PDMPs), and linking 

dental, and pharmacist associations, and state-managed databases. 

other non-governmental stakeholders. West 

Creating State Task Forces Virginia’s “Controlled Substance Advisory 

In many cases, either the SHA or another Board Workgroup” similarly convenes key 

state agency had convened representatives statewide stakeholders to identify priorities 

from various components of their respective and to develop strategies. 

governments—and in some instances 

members of the community. For example, Some participants thought that forming a task 

force was a critical early step: Bill Janes, Director of Florida’s Office 

of Drug Control, described a drug control NORTH CAROLINA – Leah Devlin: “In 

advisory council with members from 2002, our Epidemiology Officer and the 

public health, law enforcement, other state Secretary of the Department helped 

create a 25-member task force to help 

agencies, the community, and the Governor’s deal with the issue. They came up with 48 

office. William Hacker noted that in 2004, recommendations of what we should do. 

Kentucky created the Governor’s Office The task force was key. It brought together 

law enforcement, mental health and 

of Drug Control Policy within the Justice public health. This was the first time the 

and Public Safety Cabinet to coordinate issue was addressed with a collaborative 

state agency efforts. Several states reported approach.” 

ASTHO © 2008 Prescription Drug Overdose: State Health Agencies Respond 9
10 Prescription Drug Overdose: State Health Agencies Respond ASTHO © 2008

Implementing State Prescription Drug 

Monitoring Programs

States frequently cited prescription 

drug monitoring programs as tools to 

monitor prescription sales of controlled 

substances, such as opioid analgesics and 

benzodiazepines (see inset).

Some SHAs are making extensive use of their 

PDMP data for surveillance and evaluation:

KENTUCKY – William Hacker: “Ten years 

ago the Department of Public Health 

established an electronic reporting system, 

Kentucky All Schedule Prescription 

Electronic Reporting (KASPER) to track 

controlled substances dispensed within 

the state. KASPER is designed to provide 

information to physicians and pharmacists 

and serve as an investigative tool for law 

enforcement. For example, if a physician 

sees a patient that exhibits drug seeking 

behavior, he/she can access KASPER 

online or by phone to find out if any other 

provider or pharmacist has prescribed 

narcotics and when. The system’s benefits 

also include that high quality care is 

provided to those patients who truly need 

prescription drugs. The KASPER program 

is now housed in the Cabinet’s Office 

of Inspector General and continues to 

be the primary data source that guides 

prescription drug overdose prevention 

efforts of the Department of Public Health.” 

State Prescription Drug Monitoring 

Programs

Prescription Drug Monitoring Programs 

(PDMP), have been implemented in 26 

states and nine more are in the development 

phase according to the U.S. Department of 

Justice. PDMPs create statewide databases 

to monitor prescriptions and to identify 

patients who may “doctor shop” or forge 

prescriptions to illegally obtain large amounts 

of drugs. They can also identify physicians 

who are prescribing especially large quantities 

of drugs. Most programs provide patientspecific drug information upon request of the 

patient’s physician or pharmacist. Some state 

programs proactively notify physicians when 

their patients are seeing multiple prescribers 

for the same class of drugs. 

The number of states with prescription 

monitoring programs has grown rapidly 

in recent years, driven in part by financial 

support from the Department of Justice 

through the Harold Rogers Program. Among 

the nine states included in this report, PDMPs 

operate in six: Indiana, Kentucky, North 

Carolina, Oklahoma, Utah, and West Virginia. 

Only Indiana and Oklahoma’s PDMPs were 

enacted prior to 1990; the others were all 

enacted in 1995 or later.
FLORIDA – Ana Viamonte Ros reported, WEST VIRGINIA – John Wilkinson, 

in 2007, that Broward County began to reported data sharing within the Bureau 

pilot a local database that could then be for Public Health: The Office of Health 

used statewide. Advocates hope that Facility Licensure and Certification has 

a pilot in such a populated county will shared information on participation in state 

demonstrate both the effectiveness and narcotics treatment programs by people 

confidentiality of the PDMP and make dying of drug overdoses with the Office of 

future implementation possible. the Chief Medical Examiner.

WEST VIRGINIA – Danae Bixler: “Our WEST VIRGINIA – Aron Hall, CDC 

(PDMP) data suggest that the problem Epidemic Intelligence Service Officer, 

is mixed: a substantial proportion of fatal mentioned a recent collaborative 

cases had prescriptions for the drugs that investigation of drug overdose deaths 

killed them—often from multiple physicians in West Virginia. The investigation 

and multiple pharmacies. In other cases, involved the CDC, West Virginia Office 

many decedents did not have prescriptions of Epidemiology and Health Promotion, 

for at least one drug identified in post- Office of the Chief Medical Examiner, 

mortem toxicology. This suggests that Board of Pharmacy, and statewide opiate 

a substantial proportion of decedents treatment programs. Investigators from 

are getting prescriptions directly from CDC abstracted data in collaboration with 

physicians and the others are getting drugs each of these entities to describe risk 

through diversion [to nonpatients].” factors for fatal drug overdose and patterns 

of prescription drug abuse. 

Other Data Collection and Sharing Efforts

MONTANA – The state is currently 

Respondents mentioned several data linking medical examiner records on drug 

collection or sharing efforts. overdose deaths with Medicaid files to 

examine the prescribing patterns, coUTAH – The state is trying to link data from morbidities, and costs associated with 

the state prescription monitoring program such deaths.

with the state medical examiner’s and 

emergency department databases.

ASTHO © 2008 Prescription Drug Overdose: State Health Agencies Respond 11
Public and Provider Education FLORIDA – Bill Janes described an 

electronic prescribing initiative that 

State health departments have also taken passed the Florida Legislature in 2007. 

advantage of their existing contacts with the “While we continue to work to implement 

a prescription drug monitoring database, community: I believe e-prescribing is the system 

of the future. It is more timely and less 

FLORIDA – Bill Janes: “There are many expensive. The problem is most doctors 

(statewide) coalitions and community do not e-prescribe and this solution is 

efforts to increase awareness, but we must probably not achievable in the immediate 

do a better job of reaching our families.” future.” Florida’s e-prescribing legislation 

requires a state agency to 

INDIANA – In Indiana, law enforcement 

• Create a clearinghouse of maintains issue jurisdiction, but the Indiana information on electronic 

State Department of Health has offered prescribing, 

outreach and education to healthcare 

• Create a Web site to provide providers who prescribe drugs, and to healthcare providers with 

statewide media to encourage responsible information about the process 

and educational reporting. and advantages of electronic 

prescribing, software availability, 

WEST VIRGINIA – The West Virginia and state and national initiatives 

University School of Medicine offers two on electronic prescribing.

CME courses entitled, “Clinical Challenges • Convene quarterly meetings 

in Prescribing Controlled Drugs.” The of stakeholders to assess 

implementing e-prescribing. courses present provider education to help 

guide the judicious use of controlled drugs, In Palm Beach County, a Good Samaritan 

balancing the needs of patients with the law protects citizens who help anyone who 

risks of abuse and diversion. is overdosing. 

Regulatory or Legislative Initiatives MONTANA – The state requires Medicaid 

clients to obtain preauthorization for certain 

States have rules and laws that might affect drug prescriptions. Medicaid only covers 

the use of controlled prescription drugs and preauthorized prescriptions.

related overdoses. 

12 Prescription Drug Overdose: State Health Agencies Respond ASTHO © 2008
Creating Programs Tracking State Health Agency Actions 

States provided many examples of Most respondents acknowledged that, while 

government programs that addressed aspects awareness is growing within their agencies, 

of population-based services and patient care. the response to the problem has not matched 

the extent of the burden. Furthermore, states 

ARKANSAS – The Arkansas Department 

could not conduct enough formal prevention of Health is working with the state 

coroners’ association and others to get programs to permit critical assessment and 

prescription opioids and other drugs out evaluation. Therefore, much of what is known 

of the homes of people who have recently 

is anecdotal or incomplete. died at home so they do not fall into the 

hands of drug abusers. Arkansas also has 

INDIANA – Judith Monroe noted that a drug destruction program to ensure that 

Indiana State Department of Health’s the drugs are properly disposed of when 

outreach to statewide media and providers found in homes.

has increased awareness and discussions 

about drug overdose—but unfortunately, KENTUCKY – The Kentucky Department 

this awareness has not translated to a of Mental Health and Mental Retardation 

decrease in mortality rates. received a grant to address substance 

abuse. One of its programs uses clinicians 

KENTUCKY – The state is evaluating the and other professionals to focus on 

results of its community outreach program. outreach to communities with high rates 

Initial results show promise. Final results of substance abuse. Initial results show 

should be available next year. Kentucky promise. Data will be available next year. 

also noted promising research on the In addition, Kentucky created a public 

effectiveness of substance abuse courts health program that screens all pregnant 

ordering treatment and close monitoring women for substance abuse.

rather than incarceration for drug-related 

crimes. MONTANA – The state created a casemanagement program within Medicaid. 

Clients who use multiple pharmacies 

and prescribers are designated to one 

physician and one pharmacy for all 

controlled substance prescriptions.

ASTHO © 2008 Prescription Drug Overdose: State Health Agencies Respond 13
Barriers to Addressing the Problem to ensure that databases are used only to 

maintain the public’s health. PDMPs are 

SHOs noted many barriers to addressing the obliged to consider stakeholder privacy and 

drug overdose problem. Limited awareness of confidentiality concerns. SHOs emphasized 

the extent of the unintentional drug overdose their agencies’ histories of protecting sensitive 

problem was a common theme: health information and that SHAs have the 

ARKANSAS – Paul Halverson: “We have appropriate education, policy, and technical 

terrible statistics, but no one talks about it.” infrastructure to be responsible data stewards.

NORTH CAROLINA – Leah Devlin: “I don’t FLORIDA – Privacy concerns are common 

think people are aware of this as an issue. barriers that prevent implementing 

We’ve been trying to get this through for PDMPs. As Florida’s Ana Viamonte Ros 

ten years.” reported in 2007, Broward County began 

to pilot a local database that could be 

When discussing data collection and sharing used statewide. Advocates hope that 

a pilot in such a populated county will issues, particularly PDMPs, privacy and 

demonstrate both the effectiveness and 

liability concerns were a common theme. con.dentiality of the PDMP and facilitate 

Patients and their advocates are concerned future implementation. 

that their medical information may be 

NORTH CAROLINA – Leah Devlin: “There 

scrutinized without permission by persons is a huge privacy issue. It does seem very 

other than healthcare providers, such as ‘big brother,’ where drugs are put in a 

database. It freaks people out.” law enforcement. Healthcare providers are 

concerned that their medical decision will 

An additional barrier regarding PDMPs 

be second-guessed by law enforcement was convincing pharmacists that the burden 

or by malpractice attorneys. However, all of reporting prescription information was 

respondents indicated that the most stringent small and justified given the importance of 

privacy protections are implemented at preventing drug misuse. 

SHAs to protect patient confidentiality and 

14 Prescription Drug Overdose: State Health Agencies Respond ASTHO © 2008
Also, respondents raised concerns that state. It’s embarrassing that we, state and 

attention to this issue might cause physicians nationally, don’t have staff to work on the 

to cut back on prescribing opioid painkillers number one issue for 1 to 44 year-olds—

to the point where some people’s pain might unintentional injury.”

be undertreated. 

Montana staff also noted that their state did 

UTAH – Bob Rolfs: “We under-treat pain, not have a well-organized injury prevention 

but now there is a push to treat pain more. 

program. In other states with injury programs, (Prescription misuse) could be an offshoot 

of that. But we don’t necessarily want to participants noted that drug overdoses still 

scale back and go back to under-treating had to compete for attention with other injury 

patients. We need to find the balance 

priorities. between treating the people who need 

more and preventing overuse.” 

Future Needs — What Should 

Health Agencies be Doing? With respect to mounting a response to 

prescription misuse, the most common Respondents noted many potential areas 

obstacle cited was lack of funding both to where prevention efforts have been suggested, 

identify the sources of the problem and to proposed, or implemented. SHOs and others 

provide treatment for people with substance laid out their priorities in addressing future 

abuse problems. In North Carolina, it issues:

was noted that substance abuse treatment 

ARKANSAS – Paul Halverson: “What 

programs were not readily available, I would like is a good, efficient drug 

especially in rural areas. monitoring program. We have to stop 

doctor shopping and inappropriate 

The theme of lack of capacity within SHAs prescriptions. Doctors should know whom 

else the patient is seeing. Building the 

for injury prevention in general is also related database to prevent abuse is critical. It is 

to this issue. As Paul Halverson of Arkansas not intended as a police mechanism—it 

put it, “We have no injury capacity in this is truly to enhance the public’s health by 

being an informational tool.”

ASTHO © 2008 Prescription Drug Overdose: State Health Agencies Respond 15
FLORIDA – Ana Viamonte Ros: “We data. We need to get prospective data to 

need to understand the best practices of get a real understanding of the issue. In 

other states and how they have overcome the meantime, we know enough to keep 

obstacles. We need to strengthen rules going.”

for enforcement and increase availability 

for health insurance and rehabilitation WEST VIRGINIA – Chris Curtis: “We 

services. Unifying mental health and need more prevention efforts. We can’t 

substance abuse is very important, do it ourselves, we need to engage all 

along with the education and awareness the players to work with us. Public health 

message.” needs to validate the extent of the problem 

and work with our partners to educate 

KENTUCKY – William Hacker: “We need and prevent. It’s not only a public health 

to improve collaboration between state issue, it’s a medical care issue because 

agencies and other partners. As linkages these drugs are prescribed by private 

continue to build, partners can share their practitioners.” 

individual passions with one another to 

address community needs at both the 

macro and micro levels. This problem will Discussion

not be solved in a decade, maybe several. 

It is necessary to keep the issue in front of The states chosen for this assessment 

both the general assembly and executive 

represent a cross-section of jurisdictions with branch.”

sharp increases in prescription drug overdose 

NORTH CAROLINA – Leah Devlin: “We’re deaths since 1999. ASTHO and CDC sought 

an aging state. As we get older we’ll see 

to include a geographic, demographic, more in pain. We will have to do more 

prevention.” and cultural mix of states to best capture 

national trends for such an emerging public 

UTAH – Bob Rolfs: “We need to keep this 

health challenge. Not surprisingly, the issue at a high level to continue working 

on things. We need to involve public SHO interviews yielded an impressive 

education, guidelines for physicians that array of needs, priorities, challenges, and 

are evidence based, and we need to 

recommendations—although many common understand the problem better, including 

the epidemiology of it. At a micro-level, themes arose. 

our focus has been analyzing secondary 

16 Prescription Drug Overdose: State Health Agencies Respond ASTHO © 2008
Collectively, SHOs and their leadership teams Many of these issues reach beyond the scope 

identi.ed these most common problems, of this singular issue. Limited capacity 

solutions, and conclusions: within SHAs to address injury prevention 

impedes progress on the nation’s fifth 

 Most states recognize prescription 

drug overdoses as a growing issue, leading cause of death, while also impairing 

although some states only recently opportunities to study, prevent, and educate became aware of its magnitude 

locally. Most states became aware about drug overdose. Privacy concerns 

of the problem through mortality related to prescription drug monitoring data.

programs are common among public health  States rely heavily on measures 

such as interagency task forces issues, yet lessons learned from states with 

and prescription monitoring active PDMPs like Kentucky can be used 

programs to address the problem. 

Less common are educational and to assuage fears and to increase national 

regulatory initiatives. adoption of such programs. Cross-agency 

 States cited lack of awareness partnerships in states like Arkansas, of the problem, insufficient 

data, privacy and confidentiality Montana, West Virginia, North Carolina,

concerns, and lack of state- and Florida present models for responding to based injury prevention capacity 

as barriers to implementing a health threats that can only be overcome by 

response. using multidisciplinary approaches. Creating 

 States cited the need to increase awareness and performing public outreach, the visibility of the prescription 

overdose problem. as is the case in Indiana, demonstrates the 

 States need evidence-based crucial need and effectiveness of health 

guidelines for prescribers and marketing, promotion, and education. effective policy and programmatic 

tools. Although many states have Utah’s mature epidemiology capacity has 

implemented responses, their helped leaders understand, appreciate, and effectiveness is unclear. 

strategically address this emerging health 

threat. 

ASTHO © 2008 Prescription Drug Overdose: State Health Agencies Respond 17
These multidisciplinary responses and State public health is but one necessary 

solutions can reverse such a formidable partner to eliminate drug overdoses; 

trend. As ASTHO’s interviews revealed, Florida’s model partnership with drug 

SHOs are increasingly aware of the growing control and North Carolina’s task force 

problem of drug overdose and are developing creation showcases this clearly. Identifying a 

multifaceted approaches for prevention and “home” for drug abuse in state government, 

control. While prevention infrastructure and delineating clear roles for agencies, providing 

capacity may not match the extent of the adequate surveillance and prevention 

problem, innovation is both necessary and resources, and leaders who appreciate and 

common, as indicated in the interviews. This promote this issue are fundamental for 

report is a step in identifying, promoting, prevention and control. ASTHO hopes 

and ultimately preventing the public health that the findings, recommendations, and 

tragedy of prescription drug abuse and observations included in this report will shine 

overdoses. Continuing education is needed light on the preventable cause of 20,000 

and yields results, as Indiana and West annual deaths. It also hopes to promote 

Virginia demonstrate. Closing infrastructure partnership and collaboration between state 

gaps for injury prevention and control is public health officials and its key internal and 

fundamental, particularly in places like external stakeholders throughout the nation. 

Arkansas. And investing in sound, robust 

surveillance like Utah’s is a crucial step in 

identifying problems and targeting scarce 

prevention dollars. 

18 Prescription Drug Overdose: State Health Agencies Respond ASTHO © 2008
ASTHO © 2008 Prescription Drug Overdose: State Health Agencies Respond 19

Recommendations

Many opportunities for policy, programmatic, 

legislative, or regulatory change emerged 

from the candid responses by SHOs and 

their teams. Though each state has a unique 

policy and bureaucratic environment, there 

are several strategies to address the barriers 

and unmet needs reported by the survey 

participants, all of which may be applied in 

other jurisdictions. 

 State governments should identify 

a permanent home for the response 

to the drug overdose problem. Too 

often, prevention, surveillance, 

and response are fragmented 

across agencies and divisions of 

state government. A task force is a 

useful temporary response, but is 

probably not effective as a longterm solution.

 SHAs should routinely track 

all injury causes including drug 

overdose and track the patterns of 

drug prescriptions in their states 

using data from prescription drug 

monitoring programs. 

 In addition to surveillance, 

prescription drug monitoring 

programs can be valuable as part 

of a comprehensive prevention 

program, but they alone cannot 

solve the problem. To date, none 

of the PDMPs in surveyed states 

have been able to reduce the rate 

of deaths from drug overdoses. 

PDMPs may work best when 

they are proactive and paired 

with aggressive prevention, 

drug treatment, and enforcement 

components.

 To increase public and professional 

awareness, states should emphasize 

the many young lives cut short 

and the mounting costs to state 

programs, law enforcement, 

substance abuse treatment, and 

Medicaid. Medicaid recipients 

are more likely to be prescribed 

narcotics8

 and to die from 

prescription drug overdoses.

 States can address their lack of 

capacity in this area by showing 

that effective prevention measures 

save state dollars being spent on 

potentially unnecessary medication, 

emergency department visits for 

drug overdoses, and prescription 

fraud. Cost savings from such 

measures are greater than those 

realized by preventing illicit drug 

misuse, because the state may itself 

be paying for the drugs. Some of 

those savings could go to the SHA 

to fund an overdose prevention 

component of a state injury 

program.
20 Prescription Drug Overdose: State Health Agencies Respond ASTHO © 2008

 States can address privacy, 

confidentiality and other concerns 

regarding monitoring medical care 

by emphasizing to physicians and 

pharmacists the benefit of knowing 

which of their patients are abusing 

medications and the value of 

prosecuting unscrupulous providers 

in their communities.

 States should seek the assistance of 

schools of public health, medicine, 

and pharmacy to evaluate the effect 

of policy initiatives on health 

outcomes. They should also use 

evidence-based practice guidelines 

such as the “Interagency Guideline 

on Opioid Dosing for Chronic Noncancer Pain,” developed by the 

Washington State Agency Medical 

Directors Group.9

References

1. Paulozzi LJ, Annest JL. Unintentional 

poisoning deaths—United States, 1999–

2004. MMWR 2007;56:93-6.

2. Paulozzi LJ, Budnitz DS, Xi Y. Increasing 

deaths from opioid analgesics in the United 

States. Pharmacoepidemiol Drug Saf 

2006;15:618-27.

3. Substance Abuse and Mental Health 

Services Administration. Results from 

the 2006 national survey on drug use and 

health: national findings. Rockville (MD): 

The Administration, Office of Applied 

Studies; 2007. Report No.: DHHS pub. no. 

SMA 07-4293.

4. Toombs JD, Kral LA. Methadone treatment 

for pain states. Am Fam Physician 

2005;71:1353–8.

5. Department of Justice (US), Drug 

Enforcement Administration. ARCOS: 

Automation of Reports and Consolidated 

Orders System. [cited 2008 Mar 27]. 

Available at URL: www.deadiversion.usdoj.

gov/arcos/index.html

6. White AG, Birnbaum HG, Mareva MN, 

Daher M, Vallow S, Schein J, et al. 

Direct costs of opioid abuse in an insured 

population in the United States. J Manag 

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7. Birnbaum HG, White AG, Reynolds JL, 

Greenburg PE, Zhang M, Vallow S, et 

al. Estimated costs of prescription opioid 

analgesic abuse in the U.S. in 2001;Clin J 

Pain 2006;22:667–76.

8. Raofi S, Schappert SM. Medication therapy 

in ambulatory medical care; United States, 

2003–2004. Vital Health Stat 2006;13. 

9. Washington State Agency Medical 

Directors’ Group. Interagency guideline on 

opioid dosing for chronic non-cancer pain. 

[cited 2008 Mar 31]. Available at URL: 

www.agencymeddirectors.wa.gov. 
2231 Crystal Drive, Suite 450

Arlington, VA 22202

www.astho.org

Prescription Drug Overdose:

State Health Agencies Respond

OCT 2008

Copyright © 2008 ASTHO. 

All rights reserved.