PDMP Track

Prescriber Viewpoint: How Mandating Compliance is Working

Presenters:

• Ryan A. Stanton, MD, FACEP, Emergency Room Physician, Baptist Health Lexington

• John “Rett” Blake, III, MD, Medical Director, Specialists in Pain Management

• Kelly S. Ramsey, MD, MPH, MA, FACP, Clinical Director of Special Programs, Hudson River Health Care, Inc.

Moderator: John L. Eadie, Director, Prescription Drug Monitoring Program (PDMP) Center of Excellence, and Member, Rx Summit National Advisory Board

Disclosures

Ryan Stanton, MD, FACEP; John E. “Rett” Blake, III, MD; Kelly S. Ramsey, MD, MPH, MA, FACP; and John L. Eadie 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. Evaluate the impact on opioid prescribing by state mandates that prescribers use the PDMP prior to issuing opioid prescriptions to a new patient and periodically thereafter.

2. Compare prescriber attitudes toward such mandates before and after they were implemented.

3. Advocate states adopt mandates that prescribers use the PDMP prior to issuing opioid prescriptions to a new patient and periodically thereafter.

PDMP Track: Prescriber Viewpoint: How Mandating Compliance is Working Dr. Ryan A. Stanton MD, FACEP

Public Relations Chairman ACEP/KACEPMedical Director- Lexington Fire/EMS

Disclosure

• Ryan Stanton, MD FACEP,

has disclosed no relevant,

real or apparent personal

or professional financial

relationships with

proprietary entities that

produce health care goods

and services.

Objectives

• Review the “problem” in Kentucky

• Outlines the details of “Pill Mill” Legislation

• Look at the effects of the legislation

• Review key aspects of legislation from the ER

provider standpoint

Background

The 4-1-1

• Addiction is typically caught late in the disease process

• "Addiction is a brain disease"

• Substance abuse cost 467.7 billion annually(2005) to

governmental entities

• 1 out of 14 hospital stays are related to addiction(2004)

• Approx 30% of patient encounters(2009)

The DAWN Report(samhsa.gov)

The 4-1-1(USA)

• 8,400 new drug users every day

• 51% of new users under age 18

• Marijuana represents more than half of new drug users

• 23.8% of people age 18-20 reported using an illicit drug in the last month

• Estimated 22.5 million Americans over age 12 used an illicit drug in the last month(8.7%)(more people addicted than Type I Diabetes Mellitus)

drugabuse.gov

The DAWN Report(samhsa.gov)

Kentucky Drug Overdoses

Drug Overdose Deaths

Opioids

• Over 16,000 deaths annually

• WV- 550% increase in 10 years(All OD deaths)

• KY- 282%(All OD deaths)

• USA- 160%(All OD deaths)

• Women- 400%(Rx opioid deaths)...6,600 in 2010

• Men- 265%(Rx opioid deaths)...10,000 in 2010

• Methadone made up 1/3rd of opiate deaths as of 2009

Drug Overdose Morbidity and Mortality, 2000-2010

Nation View

Kentucky Takes Action

• 2012 House Bill 1- “Pill Mill Bill”

• 2013 House Bill 217

• Physician ownership of pain clinics

• Limited prescriber dispensing

• Requires daily reporting of controlled substances to KASPER

• Designated “institutional” accounts for KASPER

• Requires 7.5% of CME to be approved pain/addiction related

• Mandates KASPER registration and use

American College of Emergency Physicians(ACEP)

Kentucky Takes Action

– KASPER Query Exemptions

• Emergency

• Within 14 days of surgery(3 days dental/oral)

• Patients in hospital/long term care

• Hospice/Cancer

• Single doses of anxiolytic prior to procedure

Kentucky Takes Action

– Results• KASPER accounts up 340%

• KASPER queries increased from about 1 million

annually to about 5 million annually

• 2013 controlled substance prescriptions declined for

the first time since KASPER started in 1999

• 2013 2.47 prescriptions per person…about 2008 level

• Heroin numbers way up

• Decreased ER “doctor shopping” visits(subjective)

Kentucky Takes Action

– Early Lessons• Engage stakeholders early

• Consider methods to decrease provider workload– Delegates

– Institutional accounts

• Allow implementation time

• Make information and training easy and available

• Obtain feedback and adjust

• Make KASPER reports up to date and available

• Reports must be reviewed

ER MD Key Points– Reports must be…

• Fast

• Accurate

• Timely

• Interstate

• Easy to obtain

– Delegates

– Institutional accounts

– Can’t take time away from the bedside

• Easy system

ER MD Key Points– Also…

• Providers aren’t law

enforcement

• Must have administrative

support for refusal– Patient satisfaction

– Pain as “vital sign”

• Strengthen healthcare abuse

laws

• Must bolster recovery resources

• Be ready for heroin

Summary• Know your demons

– What are the substance abuse challenges of your community

• Understand what is fueling prescription abuse and overdoses

• Healthcare’s apathy has led to legislative action

• Attacking Rx opioid abuse is multifaceted– Healthcare– Law Enforcement– Recovery Resources– Community Buy-In– Legislation

Summary

• We must take steps to

curb a healthcare fueled

epidemic

• Providers MUST be part of

the solution conversation

• Solutions must not hinder

quality care/efficiency

• Attack the problems

– “Candyman” Docs

– “Strive for 5”

– Recovery Resources

– Foster EBM

National Drug Summit

Rett Blake, M.D.

Disclosure

• John E. “Rett” Blake, III, MD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Top 5 USA

• Class II Drugs/per capita

a. Oxycodone

b. Morphine

c. Oxymorphone

• Class III

a. Hydrocodone

• Class IV

a. Codeine products

b. Tramadol

c. Benzodiazepine

d. Ambien

Top 10

• Unintended overdose deaths per capita

• NAS babies born dependent on opioids

Neonatal Abstinence Syndrome (NAS)

Corrective Action Plan

• Engage all Stakeholders

• Legislation

– Controlled Substance Monitoring Act 2002- CSMD began

collecting data in 2006

– Prescription Safety Act 2012

• Facilitation

• Implementation

Prescription Safety Act 2012

• Required Registration in CSMD

• Required querying the database for all opioid and benzodiazepine prescriptions over 7

days and annually thereafter with exceptions for hospice care and non-refillable post-

operative medications performed in a licensed facility

• Allows Providers to delegate two other licensed professionals to access CSMD on their

behalf

• Protected, but available to law enforcement only through an active case

Regulation/Legislation

• Requirement for registration and query of CSMD

• Required DOH to create the Chronic Pain Guidelines

finished in 2014.

• Expert Panel

• Symposia

• Pharmacy Conferences

• Law Enforcement

Number of Doctor Shopper Identified in CSMD by Quarter,

2010-2014*

Year

1st

Quarter

2nd

Quarter 3rd Quarter 4th Quarter Total

Change

(%)

2010 1,695 2,005 2,127 1,830 7,657 -

2011 1,950 2,413 2,515 2,352 9,230 20.5

2012 2,246 2,218 2,261 1,940 8,665 -6.1

2013 1,785 1,533 1,533 1,335 6,186 -28.6

2014 1,374 1,404 1,278 1,307 5,363 -13.3

*If patients in CSMD had same date of birth and same result of soundex first name and last name, we took the patients as same person. Data used for above analysis were downloaded on Jan. 5, 2015. Data are subject to change due to database updating and the other reasons. VA pharmacies were excluded from the analysis. Doctor and pharmacy shopper was defined as a person who got his/her prescriptions from 5 or more different DEA prescribers and filled the prescriptions at 5 or more different DEA pharmacies within 3 months.

2010-2014 Number of “Doctor and Pharmacy Shoppers" in CSMD *

2010-2014 Morphine Milligram Equivalents Reported to

CSMD *

*Note: Morphine Milligram Equivalents (MME) were converted based on CDC MME conversion tables . Above numbers were derived from CSMD data downloaded on January 5, 2015. 2014 data are subject to change due to database updating. VA pharmacies were excluded from above analysis.

Number of Prescriptions of Controlled

Substances Dispensed and Reported to

CSMD, 2010-2014

15,500,000

16,000,000

16,500,000

17,000,000

17,500,000

18,000,000

18,500,000

19,000,000

2010 2011 2012 2013 2014

Nu

mb

er o

f P

resc

rip

tio

ns

Year

• Risk assessment-objective tool

• Dose, frequency, previous pain practices, different

pharmacies

• Vitally important tool for opioid prescription

monitoring

Clinical Perspective

Implementation -Enhancement

• Delegates who can check CSMD for provider

• Morphine Equivalents

• Practitioner vs. Peer

• Self Look-up and Extender Look-up Capabilities

• Clinical Risk indicators; patients at risk for overdose diversion, or doctor shopping

a. MEDD

b. Number of Doctors and Providers

c. Number of Pharmacies

d. Child bearing age reminder

Trends off Legislative Report

• MME

• Interstate Sharing

• Doctor Shopping

Projected Enhancement

1. Increase emergency department ease to access

2. Automate law enforcement request

PDMP Track: Prescriber Viewpoint: How Mandating Compliance Is Working: New York State

Kelly S. Ramsey, MD, MPH, MA, FACP, Clinical Director of Special Programs, Hudson River Health Care, Inc.

Disclosures:

• Kelly S. Ramsey, MD, MPH, MA, FACP, has

disclosed no relevant, real or apparent personal

or professional financial relationships with

proprietary entities that produce health care

goods and services.

Learning Objectives:

1. Evaluate the impact on opioid prescribing by

state mandates that prescribers use the PDMP

prior to issuing opioid prescriptions to a new

patient and periodically thereafter.

2. Compare prescriber attitudes towards such

mandates before and after implementation.

3. Advocate that states adopt mandates that

prescribers use the PDMP prior to issuing opioid

prescriptions to a new patient and periodically

thereafter.

Age-adjusted drug poisoning death rates: United States, 1999-2012

NOTE: Drug-poisoning deaths may involve both opioid analgesics and heroin.SOURCE: CDC/NCHS, National Vital Statistics Systems, Mortality File

Scope of the Problem: New York City

• Drug overdose is a leading cause of accidental death in

New York City, with a majority involving either heroin or

prescription painkillers. Overdose deaths related to

prescription painkillers increased 233% between 2000

and 2012. Heroin-related overdose deaths increased

84% between 2010 and 2012 in New York City, after four

years on the decline.

• Source: http://www.nyc.gov/html/doh/html/pr2014/pr003-14.shtml

Scope of the Problem: New York State

• Deaths and Death Rates: 2012, New York State, exclusive of New York City:

• Total Deaths due to Accidental Poisonings: 1,036

• Crude Death Rate (per 100,000) due to Accidental Poisonings: 9.2

• Adjusted Death Rate (adjusted for age and sex) due to Accidental Poisonings: 9.3

• Source: https://www.health.ny.gov/statistics/vital_statistics/2012/table33b.htm

• New York State:

• I-STOP/PMP - Internet System for Tracking Over-Prescribing -Prescription Monitoring Program

• Prescription Monitoring Program Registry

• Effective August 27, 2013, most prescribers are required to consult the Prescription Monitoring Program (PMP) Registry when writing prescriptions for Schedule II, III, and IV controlled substances. The PMP Registry provides practitioners with direct, secure access to view dispensed controlled substance prescription histories for their patients. The PMP is available 24 hours a day/7 days a week via an application on the Health Commerce System (HCS) at https://commerce.health.state.ny.us. Patient reports will include all controlled substances that were dispensed in New York State and reported by the pharmacy/dispenser for the past six months. This information will allow practitioners to better evaluate their patients' treatment with controlled substances and determine whether there may be abuse or non-medical use. The same law allows pharmacists to consult the PMP registry before dispensing a controlled substance. Pharmacists are not required to consult the registry.

• Source: https://www.health.ny.gov/professionals/narcotic/prescription_monitoring/

Unfortunately, I-STOP Lacks Teeth: From I-STOP's FAQ:

• Q: What are the penalties if I willfully do not consult the PMP Registry when I prescribe a Schedule II,III, or IV?

• A: There are no specific penalties attached to failing to comply with

• I-STOP. However, a violation of the provisions of this law is the same penalty as for any violation of the Public Health Law.

• Source: https://www.health.ny.gov/professionals/narcotic/prescription_monitoring/docs/pmp_registry_faq.pdf

Provider Response to New York's I-STOP

• The Benefits of the Enhanced Prescription Monitoring Program (PMP)

• The Prescription Monitoring Program (PMP) registry will provide practitioners with confidential reports from data provided by pharmacies across the state. Accessed through the secure, online New York Health Commerce System, results will be available in real-time. The registry is a tool to help enhance understanding of a patient’s controlled substance utilization, guide management, and improve quality of care. For questions related to the Prescription Monitoring Program, the NYS Department of Health Bureau of Narcotic Enforcement has a toll-free number that you can call: 1-866-811-7957.

• Source: http://www.nyacp.org/i4a/pages/index.cfm?pageid=3700

One Organization's Response to the Problems with Prescription Opioid Abuse: HRHC, Inc.

• HRHC, Inc., a network of FQHC community health centers,

primarily in NYS's Hudson Valley

• Pre-2011:• Provider awareness was low regarding the risks of opioid prescribing

and the possibility of diversion/misuse/abuse.

• Oversight of patients with contracts and monitoring was inconsistent.

Interpretation of urine drug screenings (UDS) was often inaccurate.

• 2011-2013:• Focused pain management education and training, including

interpretation of UDS, done with more problematic prescribing sites.

• Collaboration with Mount Sinai Hospital Pain Management Department

via teleconferencing for pain management educational purposes.

• Creation of a pain management packet, including an opioid consent, an

enforceable contract, and use of an opioid risk tool (ORT). Routinization

of UDS. Peer pain management chart reviews instituted.

Encouragement of use of (then) NYS PMP (pre-I-STOP).

One Organization's Response to the Problems with Prescription Opioid Abuse: HRHC, Inc. (continued)

• 2013-2014:• Buprenorphine program started with mandatory behavioral health component.

Mandatory use of NYS PMP (I-STOP) for all controlled substance prescriptions written: with, ultimately (!), positive provider response. Acceptance by NYS DOH as an opioid overdose prevention site.

• Agency wide decreased opioid prescribing and increased referrals for interventional pain management and substance abuse treatment.

• 2015 (thus far):• Adoption of new pain management policies by HRHC, including an opioid ceiling

dose (120 MEQ) and mandatory yearly behavioral health assessment.

• The Future...• Consider expansion of buprenorphine program.

• Dissemination of opioid overdose prevention (distribution of naloxone kits) program to additional sites.

• Ongoing education of providers and clinical support staff (social workers, case managers, nurses, administrators) regarding prescription opioid abuse, substance abuse, drug history screening, and handling difficult situations and challenging patients.

Conclusions:• Increasing rates of prescription opioid abuse and heroin abuse are national

problems.

• Strategies to address these problems and prevent opioid abuse need to be multi-pronged efforts, including: PDMPs, prescription drug “take back” events, safe opioid prescribing education, expansion of opioid agonist treatment (buprenorphine), expanding access to naloxone (opioid overdose prevention programs), supervised injection facilities, and expanded syringe access programs (ESAP).*

• Mandatory PDMPs, such as in NYS, which requires checking the PDMP BEFORE ALL controlled substance prescriptions are written (with rare exception), help decrease prescription opioid misuse, abuse, diversion, and “doctor shopping”. An inappropriate finding on a PDMP printout offers a unique opportunity to have a conversation with a patient about their risk for opioid dependence, overdose, and death.

• A consideration to make implementation of the PDMP more efficacious would be implementing repercussions if it is not utilized as mandated.

• Source: Harm Reduction Coalition, NY

Thanks!

Contact Info: kramsey@hrhcare.org

PDMP Track

Prescriber Viewpoint: How Mandating Compliance is Working

Presenters:

• Ryan A. Stanton, MD, FACEP, Emergency Room Physician, Baptist Health Lexington

• John “Rett” Blake, III, MD, Medical Director, Specialists in Pain Management

• Kelly S. Ramsey, MD, MPH, MA, FACP, Clinical Director of Special Programs, Hudson River Health Care, Inc.

Moderator: John L. Eadie, Director, Prescription Drug Monitoring Program (PDMP) Center of Excellence, and Member, Rx Summit National Advisory Board