Rx15 pdmp wed_300_1_stripp_2lev-lucas

PDMP Track:Combining PDMP and Other Data

to Combat Rx Drug AbusePresenters:

• Richard Stripp, PhD, Chief Scientific and Technical Officer, CordantHealth Solutions

• Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital Emergency Department, and Chair, San Diego County (CA) Rx Drug Abuse Medical Task Force

• Jonathan Lucas, MD, Chief Deputy Medical Examiner, San Diego County (CA)

Moderator: Connie M. Payne, Executive Officer, Statewide Services, Administrative Office of the Courts, and Member, Operation UNITE Board of Directors

Disclosures

• Richard Stripp, PhD – Employment: Cordant Health Solutions (formerly Sterling Healthcare Services)

• Roneet Lev, MD; Jonathan Lucas, MD; and Connie M. Payne have disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– Kelly Clark – Employment: Publicis Touchpoint Solutions;

Consultant: Grunenthal US– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center– Carla Saunders – Speaker’s bureau: Abbott Nutrition

Learning Objectives

1. Identify reasons and methods for combining PDMP data with other data.

2. Evaluate the effectiveness of combining laboratory and PDMP data to identify patients who are not taking Rx medication responsibly, based on a nationwide study.

3. Describe a San Diego collaborative project that combines PDMP and medical examiner data.

Combining PDMP and Other Data to Combat Rx Drug Abuse

Disclosure

• Richard Stripp, Chief Scientific & Technical Officer, wishes to disclose he is an employee of Cordant Health Solutions. He will present this content in a fair and balanced manner.

Learning Objectives

1. Identify reasons and methods for combining PDMP data with other data.

2. Evaluate the effectiveness of combining laboratory and PDMP data to identify patients who are not taking Rx medication responsibly, based on a nationwide study.

The Problem: Isolated Pharmacy and Laboratory Databases

• Tens of millions of urine drug tests are performed annually in the United States, but when and if drug tests are performed often is based on little data beyond the prescribers "feel" for the patient.

Kelly, S. (2014, October 8). Survey: 50% of Physicians Never Check the PDMP when Prescribing Controlled Substances. Retrieved from Imprivata: http://www.imprivata.com/blog/survey-50-physicians-never-check-pdmp-when-prescribing-controlled-substances

A recent survey shows 50% of physicians never check the PDMP when prescribing controlled substances

The Problem: Not all patients are created equal

• Without guidance based on patient-specific data on who and when to test, physicians struggle with drug testing.

The downstream effects of this are:

• Underutilization• Overutilization• Inflated drug testing

costs


Laboratory Pharmacy

Lacks visibility of all

medications prescribed to

the patient

Cannot

communicate if

medications came

from multiple

sources

Cannot always differentiate

if medication was

prescribed or illegally

acquired


Laboratory Pharmacy

Cannot determine

adherence to drug

therapy

Lacks visibility of illicit

drug use

Does not identify use of

non-prescribed

medications

Patient Case Study #1

• Prescription– Oxycodone– Alprazolam

• Prescriptions were filled per PDMP– Report shows 30 day supplies of both oxycodone and alprazolam filled

every month at one local pharmacy• Oxycodone – 30 MG, TAB (filled 11/04) 30 day supply• Oxycodone – 15 MG, TAB (filled 11/04) 30 day supply• Alprazolam – 1 MG, TAB (filled 11/04) 30 day supply

• PDMP results: High Risk– Combining prescriptions totaled 180 MEDs– Prescribed benzodiazepines in combination with an opioid

PDMP data tells one story while the lab results tell another


• Combined Report Review:– By combining both PDMP data and toxicology results, we

know the prescriptions were filled and have been filled consistently over the past year, but are not being taken.

– Additionally, the other non-disclosed medications were not in the PDMP report. Meaning the patient is most likely getting them from an illegal source.

What PDMP Identified What Drug Test Identified

Oxycodone

Alprazolam

Lorazepam

Buprenorphine


• Prescription– Oxycodone

• Prescriptions were filled per PDMP– The patient is taking more than one opioid from more than

one prescriber• Oxycodone – 10 MG, TAB (filled 11/18) 28 day supply• Oxycodone – 15 MG, TAB (filled 11/04) 15 day supply

• PDMP results: High Risk– >1 opioid filled within 4 weeks from more than one

prescriber

PDMP review helps complete the story of the lab test


• Combined Report Review:– With the combination of drug test results and PDMP data, the

prescriber can see that the unexpected medication (alprazolam) is not being prescribed and can discuss with the patient about the source and need for the medication.

– A drug test alone would not have supplied enough information for the physician.

– Having combined access to PDMP data and lab data allows the provider to have a more informed conversation with the patient.

What PDMP Identified What Drug Test Identified

Oxycodone

Alprazolam

Of course the results of one or two case studies cannot predict the behavior of an entire population.

How does combining pharmacy & laboratory data work to identify high risk patients everywhere?

The Study

• Scope

– In April through June 2014, Cordant conducted 257 toxicology screens on 237 injured workers across 48 states.

– Test subjects were selected from the pool of patients meeting key risk identifiers according to PBM data.

The Study

• The Process– Cordant applied the several parameters to the study

group using their pharmacy data to identify potential risk.

– Risk criteria identified about 1/4th of the injured worker population as potentially “high risk”.

– Once patients were identified as potentially high risk, urine samples were collected at the doctor’s office during their next visit and sent to one of Cordant’s five laboratories for testing.

The Results70.9% of patients tested in the study produced

inconsistent results

The Results

• Of patients tested, 45.6% were deemed high risk due to meeting one or more of the following criteria:– Prescribed medication not detected– Detection of an illicit drug or alcohol– Exhibiting other aberrant results or

behavior

• Patients were deemed medium risk if non-reported prescription medications were detected

• Low risk if tests showed the expected results.

The Results

• Toxicology testing revealed high degrees of inconsistent test results among the tested claimants who fit these parameters:

– Prescribed a high medication dosage: 70.9%inconsistent test results.

– On the prescribed opioid for more than two months: 73.8% inconsistent test results.

(Claimants in this group were often prescribed higher doses and for a longer duration than claimants in other groups.)

Conclusion

• Combining pharmacy and laboratory data is extremely effective in identifying high-risk opioid users.– Reduces inflated drug testing costs by identifying those most

likely to abuse or misuse medications.– Improves patient outcomes by giving the physician a more

complete picture

• Getting the right medication to the Patient at the right time, in the right dose, and with the right monitoring requires a combination of:– care coordination– lab and prescription data integration– and clinical expertise

Thank You

Medical Examiner and CURES Correlations

San Diego 2013

Roneet Lev, MD Scripps Mercy HospitalSean PetroOren Lee

Jonathan Lucas, MD San Diego Medical Examiner

24

Disclosures

• Roneet Lev, MD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

• Jonathan Lucas, MD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

About the Data

• ME Data– 254 deaths with

prescriptions as cause of death

– Could be with alcohol, illicit, over the counter

• CURES Data (aka PDMP)– Outpatient pharmacies– Does Not Include

• VA• Balboa Naval Hospital• Methadone Clinics• Inpatient hospitals

186

68

254 Prescription Related Deaths in San Diego 2013

CURES Data

No CURES

26

Medical Examiner Data

Prescription 154

Prescription+Illicit 44

Prescription+Alcohol 39

Prescription+Illicit+Alcohol 10

Prescription+OvertheCounter(OTC) 4

Prescription+Alcohol+OTC 2

Prescription+Illicit+OTC 1

Prescription+Illicit+Alcohol+OTC 1

Total 254

27

“Death Diaries”

CURES Report

28

Death Diary: 56 Year Old Female

23 Scripts10 Providers

29

February, March No MedsApril ER#1: Hydrocodone #10

Dr. R: Codeine#40, Lorazepam #42May Dr. P: Hydrocodone #15, Lorazepam #20June ER#2: Hydrocodone #20, Lorazepam #20August ER#3: Oxycodone #20, Lorazepam #21

ER#4: Oxycodone #21, Lorazepam #20September ER#5: Oxycodone #20, Lorazepam #6

Dr. L: Methadone #120October Dr. L: Methadone #120

ER #6: Hydrocodone #15Dr. W: Lorazepam #8

November ER #3: Oxycodone #5, Lorazepam #4Dr. L: Methadone #120

December Dr. L: Methadone #120January ER #7: Lorazepam #4February 1, 2013 Dr. L: Methadone #30Death: February 7, 2013

Methadone, Clonazepam, Phenytoin, Carbamazepine, Gabapentin

Population Demographics

• Age Range 15 – 73

• Male predominance, especially for No CURES

• Average Age 46.5

254

6446.6

186

60 46.46876.1

46.6

Total %Male Average Age

ME Total

CURES

No CURES

30

275 Pharmacies

2013 By the Numbers

Average Scripts Per Patient - PDMP Match, No Illicit, Doctor Shopper

23.5

Highest Number of Scripts for 1 patient 123

Average Number of Pharmacies 3.12

Highest Number of Pharmacies for 1 Patient 21

Percent of Pharmacies With a Single Death- 1 Pharmacy had 12 deaths

54.2%

31

Specific Medications on CURES(Number of Patients)

• 33 Medications; 4366 RxOpioids Benzodiazepines SleepAid Stimulants OtherHydrocodone(123) Clonazepam(44) Zolpidem(43) Amphetamine(7) Carisoprodol(30)

Oxycodone(84) Alprazolam(39) Lunesta(4) Phentermine(4) Testosterone(6)

Morphine(32) Lorazepam(37) ChloralHydrate(2) Lisdexamfetamine(1) Lyrica(4)

Codeine(27) Diazepam(26) Zaleplon(2) Methylphenidate(1) Phenobarbital(3)

Oxymorphone(3) Chlordiazepoxide(17) Dronabinol(2)

Hydromorphone(20) Temazepam(17) Estrogen(1)

Methadone(14) Triazolam(6) Fentanyl(13) Oxazepam(3) Buprenorphine(11) Clorazepate(1) Naloxone(9)

32

Types of Rx

190

93

173 10

157

122

49

930

Number of Patients with MedicationsME vs PDMP

ME

PDMP

33

Specific Medications

34

Number of Medication on ME Report

35

20%

80%

Single Medication(51)

Multiple Medication(203)

Single Medications on ME Report

36

34 4

5

7

12

OTHER SINGLE MEDICATIONSDiazepam (1)Fluoxetine (1)Ketamine (1)Opioid (1)Quetiapine (1)Acetaminophen (2)Clonazepam (2)Hydrocodone (2)Tramadol (2)Venlafaxine (2)

PDMP MatchRx 2 months before death matches ME report

• PDMP Match, No Alcohol, No Illicit, No Doc Shop (42 patients)– 64% Female– 51 years Ave (older) – More Rx– Less Providers– Less Pharmacies– More Single Rx– More Opioids, Sleep

Aids, High Morphine Equivalents, Long Acting

254Total Deaths

100 (40%)PDMP Match

68 (27%)

Match + No Alcohol or Illicit

42 (16.5%) Match +

No Illicit + No Shoppers

37

Rx Types and PDMP MatchBy Number of Patients

75

77

38

Opioids - 190

PDMP Match

PDMP No Match

No PDMP

32

38

23

Benzodiazepines - 93

1

2

Stimulants - 3

5632

24

Other - 112

No one died of Rx for ADD/ADHD

38

Opioids + Benzodiazepines

• All PDMP Reports – 54% (100 patients)

• ME Deaths – 21% (55)

• ME/PDMP Match – 71% (39)

39

16

ME Reports – 254 patients21% = Opioids + Benzodiazepines

Combination

PDMP Match

No Match100

86

PDMP Reports - 186 patients55% = Opioid + Benzodiazepine

Combination

Opioid + Benzo

No Combination

39

Chronic Use3 or More Consecutive Months For Same Rx

Total

Population

Patientswith

PDMPreports

Patientswith

ChronicUse

Chronic

Use%ofPatients

SanDiegoData2013 3.2million 816,372 13,567 1.6%

CaliforniaData2013 38.3million 7,057,000 200,080 2.8%

SanDiegoPrescriptionDeathsin

2013(ME/PDMPdata)

254deaths 186 128 68.8%ofpatients

95.81%ofRx

69% of Deaths were Chronic Users; 96% of all Rx

2.8 1.6

68.8

California San Diego San Diego Deaths

Chronic Users

40

Methadone Deaths46 total; 7 from CURES; 39 or 85% outside CURES

41

PDMP Match (3)

6%

PDMP Match + Doctor Shopper (3)

7% PMDP Match + Doctor Shopper + Illicit (1)

2%

No Recent Methadone Rx

(3)7%

No Methadone on PDMP (24)52%

No PDMP Data (12)26%

PDMP Match (3)

PDMP Match + Doctor Shopper (3)

PMDP Match + Doctor Shopper +Illicit (1)

No Recent Methadone Rx (3)

No Methadone on PDMP (24)

No PDMP Data (12)

Methadone Deaths: Many Chemical Combinations

42

4 4 4 4 4 4 4 5 5 5 69

12

46

Drugs included with Methadone Deaths

OTHER SINGLE MEDICATIONSLamotrigine (1)Amitriptyline (1)Benzodiazepine (1)Carbamazepine (1)Codeine (1)Doxepin (1)Nortriptyline (1)Phenytoin (1)Sertraline (1)Cocaine (2)Fluoxetine (2)Hydromorphone (2)Trazodone (2)Alprazolam (3)Venlafaxine (3)

Doctor Shopping4 providers + 4 pharmacies in 12 months

• 52 Patients (28% of all PDMP Reports)were Doctor Shoppers

• “The Heavy Half” = Received 51% of all Rx

• 50/50 Male/Female

28%

72%

% Doctor Shoppers

Doctor Shopper

Regular Patient

43

Doctor Shopper v PDMP Deaths

61.550

41.5

9.1 6.817.3

96.2

54

37

23.5

4.5 3.1

27.4

69

% PDMPMatch

% PDMPMatch, NoIllicit, NoAlcohol

Ave NumberRx

AverageNumber

Providers

AverageNumber

Pharmacies

% Single RxDeath

% ChronicUse

Doctor Shoppers vs. PDMP DeathsDoctor Shoppers (52)

Total PDMP Deaths (186)

44

Providers at-a-Glance

Total Number of Providers 713

Average # of Providers per patient 4.5

Maximum providers per patient -PDMP Match, No Illicit, Doctor Shopper

36

Percentage of Providers With Single Death- 3 Providers had 4 Deaths

85%

45

Who are the Prescribers?

• 713 total

Pain3%

Dentistry4% Surgery

8%

Psychiatry11%

Emergency/Urgent Care

20%

Primary Care54%

PRIMARY CARECardiologyEndocrinologyFamily Practice (17%)

General PracticeGastroenterologyGYNInfection DiseaseInternal Medicine (22%)

NephrologyNeurologyNurse Practitioner (2.6%)

OncologyPhysician Assistant (6.3%)

PM&RRheumatology

PAINAnesthesiaPain

SURGERYENTGeneralNeurosurgeryOphthalmologyOrthopedicsPlasticsPodiatryRadiologyUrologyVascular

46

Where do Doctor Shoppers Go?

• Neurology 17.1 Rx per Doctor Shopper v 3.1

• Urology 100% to Doctor Shoppers

0 0 07

20 2335

43 44 44 47 48 50 50 51 53 56 5662 64 64 67 67 69 71 73 76 81

100 100 100 100

End

ocr

ino

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(1

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GI (

1)

Op

hth

alm

olo

gy (

1)

GY

N (

6)

ID (

3)

An

est

hes

ia (

7)

Surg

ery

(15

)

Fam

ily P

ract

ice

(1

18

)

Ge

ner

al P

ract

ice

(3

)

Pai

n (

13

)

PA

(5

9)

Inte

rnal

Med

icin

e (

14

1)

Pla

stic

s (1

)

Rad

iolo

gy (

2)

AV

ERA

GE

(71

3)

PM

&R

(1

1)

Den

tist

ry (

33

)

Psy

chia

try

(77

)

Ne

uro

logy

(8

)

Eme

rge

ncy

(1

40

)

Nu

rse

Pra

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(22

)

ENT

(2)

Vas

cula

r (1

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Rh

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Ne

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(3

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On

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Ort

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Po

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Car

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(1

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Ne

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Uro

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(5

)

Un

kno

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(3

)

47

Who is Prescribing the Most?

6265

1814

711.5

6 7.65

1.51.8 0.45

%Total Rx %Total Pills

Rx by Specialty

Primary Care

Psychiatry

Surgery

Pain

Emergency

Dentistry

How many pills do you need?

1923

58

7579

97

123

Dentistry Emergency Psychiatry Average Primary Care Pain Surgery

Pills/Rx

Specialists and Medication Types

Emergency6%

Primary Care69%

Surgery11%

Dentistry3%

Psychiatry3%

Pain8%

Opioids (63%) Emergency

Primary Care

Surgery

Dentistry

Psychaitry

Pain

Emergency3%

Primary Care47%

Surgery2%

Dentistry1%

Psychiatry47%

Benzodiazepines (25%)

Emergency0%

Primary Care62%

Surgery0%

Dentistry1%

Psychiatry35%

Pain2%

Sleep Aids (3%)

Primary Care34%

Psychiatry66%

Stimulants (1%)

50

Who is Prescribing Hydrocodone?

• 95,821 pills

• 990 Rx

• 123 Patients

Emergency

2%

Primary Care63%

Surgery28%

Dentistry

1%

Psychiatry

3%

Pain

4%

51

Take Home Messages“Death Dairy” to Safe Prescribing

1. Providers – Check CURES2. Pharmacies – Check CURES3. Don’t Mix Opioids and Benzos4. Use Medication Agreement5. Subtract ER Doses From Regular Rx6. Functional Assessment verses Pain

Scale7. Escalating dosages? Methadone? or

Addiction Referral8. Insurance Paying?9. DEA Watching?10. ME office giving feedback

52

PDMP Track:Combining PDMP and Other Data

to Combat Rx Drug AbusePresenters:

• Richard Stripp, PhD, Chief Scientific and Technical Officer, CordantHealth Solutions

• Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital Emergency Department, and Chair, San Diego County (CA) Rx Drug Abuse Medical Task Force

• Jonathan Lucas, MD, Chief Deputy Medical Examiner, San Diego County (CA)

Moderator: Connie M. Payne, Executive Officer, Statewide Services, Administrative Office of the Courts, and Member, Operation UNITE Board of Directors

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