5/4/2015 PROTECTING PATIENTS AND COMMUNITIES THROUGH THE RI PRESCRIPTION MONITORING PROGRAM (PMP) KIMBERLY MCDONOUGH RIPF SPRING SEMINAR 6 MAY 2015

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1 PROTECTING PATIENTS AND COMMUNITIES THROUGH THE RI PRESCRIPTION MONITORING PROGRAM (PMP) KIMBERLY MCDONOUGH RIPF SPRING SEMINAR 6 MAY 2015 Jef frey Bratberg, PharmD, BCPS Clinical Professor of Pharmacy Practice, URI College of Pharmacy Panel: Ryan Baker, PharmD Junior Par tner/pharmaci st, Baker s Pharmacy Scott Campbell, Rph Chief Compliance Of ficer, RI Board of Pharmacy Peter Ragosta, Rph Chief Admin Of ficer, RI Board of Pharmacy OBJECTIVES Discuss the role of the PMP as part of a comprehensive patient and community safety strategy to reduce misuse, abuse, diversion, and overdose from Rx opioids Compare and contrast ideal PMP characteristics and outcomes with the RI PMP Discuss and apply successful examples of RI PMP utilization to pharmacy practice ADDICTION: WHO IS AT RISK? 10% of the population are genetically or psychologically susceptible to addiction. 2-3 % are addicted at any one time (about 20,000 Rhode Islanders) Addiction is a chronic relapsing disease which requires multiple rounds of treatment, significant effort at chronic disease management, which we also call recovery. 1

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3 [Accessed on 5 April 2015] SOURCE OF MOST RECENT RX OPIOIDS AMONG PAST-YEAR USERS AGE % 1.9% 3.9% 5% 18.1% 0.3% 54.2% Free: friend/relative 1 doctor Bought/took: friend/relative Other Drug dealer > 1 doctor Bought on Internet SAMHSA. (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) Rockville, MD. PAST MONTH NONMEDICAL USE AND OVERDOSE DEATHS BY AGE Kolodny A, et al. Annu. Rev. Public Health 2015; 36:

4 DEATHS FROM PRESCRIPTION OPIOID OVERDOSE Every day in the United States, 44 people die as a result of prescription opioid overdose. Men were more likely to die from prescription opioid overdose Deaths from prescription opioid overdoses among women increased more than 400% during , compared to 237% among men. People who died of drug overdoses often had a combination of benzodiazepines and opioid pain medications in their bodies. 1 [Accessed on 5 April 2015] ACCIDENTAL DRUG DEATHS IN RHODE ISLAND 2014 BY AGE total in 2014 apparent illicit fentanyl opioid (pharmaceutical and/or illicit) illicit drug part of COD 's 30's 40's 50's 60's & 70's THE RHODE ISLAND DRUG OVERDOSE EPIDEMIC OF deaths Deaths mid-april 2015 (90% involve an opioid/prescription drug) ( deaths, ) 2014* least 83 associated with illicit form of fentanyl (37%) Residents from 31 cities and towns Diverse group regarding demographics and SES Ages

5 N a t i o n w i d e, t h e y e a r l y c o s t o f o p i o i d a b u s e a n d a d d i c t i o n i s o v e r $ 5 6 b i l l i o n. 4 6 % ( $ 2 6 b i l l i o n ) i s d u e t o l o s t p r o d u c t i v i t y 4 5 % ( $ 2 5 b i l l i o n ) g o e s t o h e a l t h c a r e c o s t s It costs $14,000 MORE per year to take care of someone who abuses opioids than the average patient 9 % ( $ 5 b i l l i o n ) i s s p e n t o n c r i m i n a l j u s t i c e 5/4/2015 Accidental prescription drug overdose fatalities (includes prescription drugs combined with illicit drugs and with and without alcohol) OSME RI DOH WHY WORRY ABOUT ADDICTION AND OVERDOSE? CDC CDC - Prescription Painkiller Overdoses Policy Impact Brief - Home and Recreational Safety - Injury Center. Graphic: NOPE-RI THE PMP Housed at the Dept. of Health Operated by the Board of Pharmacy Perpetual database Updated q72 hours Data transmitted by pharmacies The PMP is tool for: Overprescribing Diversion Fraud All Schedule II-IV Rx Patient Specific Independent of payer ALL Pharmacies that dispense WITHIN OR INTO the State Available to Multiple Stakeholders Prescribers Pharmacists Law enforcement by search warrant Selected administrators (Scott, James, Jackie) Delegation Prescribers Pharmacists Slide modified, original courtesy RI Department of Health, Patrick Kelley, PharmD. Used with permission. 5

6 CONTROLLED SUBSTANCES SCHEDULES CONTROLLED SUBSTANCE PRESCRIPTIONS WRITTEN BY PHYSICIANS Controlled Substance Prescriptions Written By Physicians November 2014 December 2014 January 2015 Schedule II prescriptions 37,237 39,693 33,433 Schedule III prescriptions 5,442 5,874 4,783 Schedule IV prescriptions 44,634 47,481 40,056 Total prescriptions written by 87,313 93,048 78,272 physicians Of prescriptions written by all providers, percentage written by physicians 78.7% 75.5% 68.7% Data Source: Rhode Island Prescription Monitoring Program 6

7 ** **All prescribers Hydrocodone Rescheduled From III -> II Oct [Accessed on: 20 April 2015.] RED FLAGS Presentation of Prescription Patient Behavior Medication Taking/Supply Illicit/Illegal Stakeholders Challenges and Red Flag Warning Signs Related to Prescribing and Dispensing Controlled Substances {Accesssed on 5 April 2015] 7

8 RED FLAGS: PRESENTATION OF PRESCRIPTION Patients travel in groups to dispensing location Unknown relationships Same controlled substance from same prescriber Prescriptions for CS written in names of other people (NOT designated caregivers) Handwritten prescription Flawless OR Altered Prescription thought to be refused to be filled elsewhere Prescriber s DEA, suspended, revoked, or pending actions Stakeholders Challenges and Red Flag Warning Signs Related to Prescribing and Dispensing Controlled Substances {Accesssed on 5 April 2015] RED FLAGS: PATIENT BEHAVIOR Pharmacist threatened Patient shows physical signs of substance use Patient presents with either signs of intoxication or withdrawal Multiple prescribers and/or pharmacies used Prescriptions for highly abused CS medications Controlled and non-controlled Rx filled, patient only wants CS History of untruthfulness regarding CS Rx s Stakeholders Challenges and Red Flag Warning Signs Related to Prescribing and Dispensing Controlled Substances {Accesssed on 5 April 2015] RED FLAGS: MEDICATION SUPPLY AND/OR ILLEGAL BEHAVIORS Rx for large quantities and/or large number of CS Rx s Therapeutic duplication of two or more long-acting and/or two or more short-acting opioids Rx cocktails: Opioid + benzodiazepine + muscle relaxant Patient indicates drugs will be shared or sold Prescriber is prescribing outside their scope of practice Prescriber state license expired/suspended/revoked Patient alters, forges, sells, or re-writes Rx s for CS Patient is diverting/selling CS medications Stakeholders Challenges and Red Flag Warning Signs Related to Prescribing and Dispensing Controlled Substances {Accesssed on 5 April 2015] 8

9 RISK FACTORS RX DRUG ABUSE/OVERDOSE Obtaining overlapping prescriptions from multiple providers and pharmacies Taking high daily dosages of prescription pain medications Having mental illness or a history of alcohol or other substance abuse Living in rural areas, having low income White AG et al. Am J of Managed Care 2009;15(12): Hall AJ et al. JAMA 2008;300(22): Peirce GL et al. Med Care 2012 Jun;50(6): Yang Z et al. J Pain 2015; doi: /j.jpain [Epub ahead of print] Green TC et al. Drug and Alcohol Dependence 2011;115: Paulozzi LJ et al. Addiction 2009;104(9): Dunn KM et al Ann Intern Med. 2010;152(2): pidemic/riskfactors.html. [Accessed Bohnert AS et al JAMA 2011;305(13): Mack KA et al. J Health Care Poor Underserved 2015;26(1): on 5 April 2015.] RISK FACTORS RX DRUG ABUSE/OVERDOSE Observed patterns in Medicaid % of Medicaid enrollees with painkiller prescriptions had at least one indicator of potentially inappropriate use or prescribing: overlapping opioid analgesic prescriptions overlapping opioid analgesic and benzodiazepine prescriptions long-acting or extended release prescription pain medications for acute pain, any methadone, and high daily doses [Accessed on 5 April 2015.] RISK FACTORS FOR OPIOID OVERDOSE: INDICATIONS FOR NALOXONE Opioid prescription and: history of smoking COPD Respiratory illness or obstruction renal dysfunction or hepatic disease Known or suspected concurrent alcohol abuse Concurrent benzodiazepine prescription Concurrent SSRI or TCA anti-depressant prescription Pharmacist interactions Syringe purchase, medication lock box purchase, medication disposal Pharmacy Records show: Nicotine replacement therapy Varenicline, buproprion Inhalers, corticosteroids Respiratory antibiotics Dialysis medications Cirrhosis medications Naltrexone, disulfiram Concurrent benzodiazepine prescription Concurrent SSRI or TCA antidepressant prescription 9

10 OFFER NALOXONE TO EVERYONE Any opioid prescription Has prescription for IR & ER opioid Any opioid/benzo rx combination Any methadone Any buprenorphine Syringe purchase Methods Standing order/cpa Prescriber request EMR Transitions of care REGISTRATION: PHARMACIST + STORE DEA 10

11 NPI + REASON FOR REGISTRATION NEW REQUEST. 11

12 WHAT DATA TO ENTER Last name First name DOB Date range Need to check this box Click this pdf PRACTICAL TOOLS TO PREVENT DIVERSION: PATIENT LOOK UP ON THE PMP Here is what 1 patient did in a 10 month period Deliberate Is this the extreme? How many prescribers were registered for the PMP who saw this patient? 12

13 *Note all the different prescribers *Note all New RX s SUMMARY OF A 10 MONTH PERIOD 49 Prescribers 27 Dentists 16 MD/DO 3 Physician Assistants 3 Podiatrists 1 Nurse practitioner 32 pharmacies 84 prescriptions filled (25 private pay) Received 500 Days of drugs in 322 Days WHAT IS THE PROBLEM? Date Date Rx Days filled Written Supply Product Name Patient Address Patient Metric Patient Patient Last Prescriber First Rx Number Quanti DOB Name FullName Name ty Pharmacy Name 1/1/12 1/1/12 30 OXYCODONE-APAP MG TAB 123 MAIN ST 1/1/1946 GINNY PIPPILLINNI PEPPER, DR FLAVORS PHARMACY 1/5/12 1/5/ /9/12 1/8/12 30 OXYCODONE-APAP MG TAB OXYCODONE-APAP 5-325MG TAB 123 MAIN FEELGOOD, DR. ST 1/1/1946 GINNY PIPPILLINNI CRÜE PHARMACY 123 MAIN ST 1/1/1946 GINNY PIPPILLINNI PAIN, DR HURTZ PHARMACY 1/12/12 1/12/12 30 OXYCODONE-APAP MAIN 325MG TAB ST 1/1/1946 GINNY PIPPILLINNI SMITH, DR XYZ PHARMACY 1/15/12 1/15/12 30 OXYCODONE-APAP MG TAB 123 MAIN ST 1/1/1946 GINNY PIPPILLINNI QUINN, DR GREAT PLAINS PHARMACY 1/20/12 1/20/12 30 OXYCODONE-APAP 5-325MG TAB 123 MAIN ST 1/1/1946 GINNY PIPPILLINNI PHIL, DR HARMONY PHARMACY 1/21/12 1/21/12 30 OXYCODONE-APAP MG TAB 123 MAIN ST 1/1/1946 GINNY PIPPILLINNI DRE, DR SOUTH SIDE PHARMACY 1/25/12 1/24/12 30 OXYCODONE-APAP MG TAB 123 MAIN ST 1/1/1946 GINNY PIPPILLINNI SEUSS, DR ABC PHARMACY 1/28/12 1/28/12 30 OXYCODONE-APAP 5-325MG TAB 123 MAIN ST 1/1/1946 GINNY PIPPILLINNI WHO, DR TIMEWARP PHARMACY OXYCODONE-APAP MAIN 1/31/12 1/31/ MG TAB ST 1/1/1946 GINNY PIPPILLINNI EVIL, DR Slide courtesy RI Department of Health, Patrick Kelley, PharmD. YEAH BABY PHARMACY 13

14 PHYSICIAN USE OF PMP Physician Use of Prescription Monitoring Program November 2014 December 2014 January 2015 Reports run by physicians 7,737 8,942 8,899 Total schedule II prescriptions written by 37,237 39,693 33,433 physicians Percentage of reports run by physicians for schedule II 20.8% 22.5% 26.6% prescriptions written Percentage of reports needed to minimize drug overdose deaths 100% 100% 100% Data Source: Rhode Island Prescription Monitoring Program Raksasil P. RI PMP FACTSHEET Raksasil P. 14

15 [Accessed on: 20 April 2015.] PHARMACISTS TRAINING, PERCEIVED ROLES, AND ACTIONS ASSOCIATED WITH DISPENSING CONTROLLED SUBSTANCE PRESCRIPTIONS Fleming M, et al. J Am Pharm Assoc. 2014; 54:

16 LEADING A HORSE TO WATER: FACILITATING REGISTRATION AND USE OF A PMP Deyo R, et al. Clin J Pain Ahead of print. LEADING A HORSE TO WATER: FACILITATING REGISTRATION AND USE OF A PMP Deyo R, et al. Clin J Pain Ahead of print. HOW DOES USE OF A PMP CHANGE PHARMACY PRACTICE? Pharmacists surveyed CT & RI ~84% opioid rx dispensed Several times/day Significant Results: PMP Users 52% LESS LIKELY to discuss concerns with patient Green TC, et al. J Am Pharm Assoc 2013;53:

17 AN INEVITABLE WAVE OF PMP S IN THE CONTEXT OF RX OPIOIDS: PROS, CONS AND TENSIONS PRO Informed and safe prescribing for patients Appropriately designed real-time PMP is likely to reduce diversion, MD shopping, and OD deaths CON Patient may not receive sufficient meds due to prescriber fear of legal retribution ( chilling effect ) Inappropriate or inadequate alternative medications prescribed (Substitution effect) Islam M, McRae I. BMC Pharm and Tox 2014: 15:46. AN INEVITABLE WAVE OF PMP S IN THE CONTEXT OF RX OPIOIDS: PROS, CONS AND TENSIONS PRO Reduction of overprescribing by prescribers Reduced risk of polypharmacy CON Legitimate prescribing deterred by confusion between concepts of addiction, pseudoaddiction Patients may fear law enforcement scrutiny and/or be deprived of necessary medications Islam M, McRae I. BMC Pharm and Tox 2014: 15:46. AN INEVITABLE WAVE OF PMP S IN THE CONTEXT OF RX OPIOIDS: PROS, CONS AND TENSIONS PRO Help monitor and deter forged/stolen controlled substance Rx Reduce fraudulent prescribing and inform licensing boards about inappropriate Rx/dispensing CON PMP-induced reduction of Rx opioids may increase crime/push pain patients into illicit market (heroin) Fear among prescribers of being categorized as fraudulent prescribers when only lack training Islam M, McRae I. BMC Pharm and Tox 2014: 15:46. 17

18 OBJECTIVES Discuss the role of the PMP as part of a comprehensive patient and community safety strategy to reduce misuse, abuse, diversion, and overdose from Rx opioids Compare and contrast ideal PMP characteristics and outcomes with the RI PMP Discuss and apply successful examples of RI PMP utilization to pharmacy practice PROTECTING PATIENTS AND COMMUNITIES THROUGH THE RI PRESCRIPTION MONITORING PROGRAM (PMP) KIMBERLY MCDONOUGH RIPF SPRING SEMINAR 6 MAY 2015 Jef frey Bratberg, PharmD, BCPS Clinical Professor of Pharmacy Practice, URI College of Pharmacy Panel: Ryan Baker, PharmD Junior Par tner/pharmaci st, Baker s Pharmacy Scott Campbell, Rph Chief Compliance Of ficer, RI Board of Pharmacy Peter Ragosta, Rph Chief Admin Of ficer, RI Board of Pharmacy 18