5/31/2016. Lobby Poll. Facilitator. Preventing the Non-Medical Use of Prescription Drugs: Using the PDMP and Other Strategies for Success CAPT WEBINAR

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1 Lobby Poll Which of the public health uses of PDMP Information are you most interested in learning more about today? 1 CAPT WEBINAR May 31, 2016 Preventing the Non-Medical Use of Prescription Drugs: Using the PDMP and Other Strategies for Success Thomas Clark, Manager, PDMP Center of Excellence Clearinghouse Joshua Esrick, Policy Analyst, Carnevale and Associates Meelee Kim, Project Consultant, PDMP Center of Excellence Facilitator Gisela Rots Coordinator CAPT Northeast Resource Team 3 1

2 Technical Information This webinar is being recorded and archived, and will be available to all webinar participants. Please contact the webinar facilitator if you have any concerns or questions. This training was developed under the Substance Abuse and Mental Health Services Administration s Center for the Application of Prevention Technologies task order. Reference #HHSS I/HHSS T. For training use only. 4 Objectives Identify categories of strategies for preventing the non-medical use of prescription drugs Describe how Prescription Drug Monitoring Program (PDMP) data can be leveraged to address the non-medical use of prescription drugs at multiple levels Describe limitations of PDMP data 5 Roadmap Key recommendations for PDMP use Strategies to address NMUPD Use of PDMP in substance abuse prevention 6 2

3 Presenters Thomas Clark Manager PDMP Center of Excellence Clearinghouse Joshua Esrick Policy Analyst Carnevale and Associates Meelee Kim Project Consultant PDMP Center of Excellence 7 Factors That May Influence Strategy Implementation Staff capabilities and capacity Cultural competence, lived experience, familiarity with strategy components Availability of training and technical assistance T/TA to the local entity from federal/state/non-profit organization T/TA to involved stakeholders from the local entity Stakeholder support Organizational leadership Evaluation feedback mechanisms 8 Taking Action: Implementing a Combination of Strategies 9 3

4 Categories of Strategies Education Enforcement Multi-Component Disposal Tracking and Monitoring 10 Education Strategies Patient education 1 Prescriber education 2,3 Social marketing campaigns 4,5 Information dissemination campaigns 6 Prescription Safe Campus Initiative 7 11 Enforcement Strategies Tip and reward programs 8 Law enforcement training on supply reduction 9,10 Law enforcement training on harm reduction 11 Enforcement against doctor shopping 12 Enforcement against pill mills

5 Multi- Component Strategies Local community coalitions 14 PROSPER/college and university partnerships 15 Harmful legal product prevention project 16,17,18 Project Lazarus/Overdose prevention programs 19,20 13 Multi-Component Strategies: Common Components Collecting relevant local assessment data Building capacity and determine feasibility Engaging with key stakeholders Developing relationships throughout the community Implementing strategies across socio-ecological domains school-based curricula + parent education + community intervention + patient education + prescriber education + law enforcement training 14 Disposal Strategies 21 Take-back programs and events Permanent drop-off sites 15 5

6 Tracking and Monitoring Strategies Physical exams prior to issuing prescriptions 24 Follow-ups prior to renewing prescriptions 25 Patient ID checks prior to dispensing prescriptions 26 Prescription Drug Monitoring Programs (PDMPs) 22 Mandatory use of 16 PDMPs 23 Poll What strategies are being implemented in your state, tribal community, or jurisdiction? 17 Prescription Drug Monitoring Programs May 31, 2016 Presented by: PDMP Center of Excellence, Brandeis University 6

7 Webinar overview Overview of PDMPs PDMP data for Epidemiological purposes Targeting interventions Evaluating interventions Other potential uses Key recommendations for PDMPs Resources Source: PDMP TTAC: Source: PDMP Training and Technical Assistance Center at Brandeis University 7

8 PDMP: What data are in the system? Patient identification Prescriber information Dispensing pharmacy information Drug information Source of payment (some states) Note: No patient diagnoses are collected. 8

9 PDMPs: Who uses them? PDMP authorized users Number of states* Prescribers 49 Dispensers 49 Law enforcement 47 Regulatory licensing boards 45 Researchers 44 Patients 38 Medical examiners/coroners 36 Substance abuse treatment providers 12 Drug courts 12 *Missouri does not have legislation to enable a PDMP. Public health uses of PDMP information Epidemiological surveillance: Determining incidence and prevalence of certain medical and non-medical uses of controlled pharmaceuticals statewide, by county, region or city, and over time. Prevention: Enabling health care providers to avoid prescribing duplicate therapies and creating deterrents to drug diversion; providing needs assessment and evaluation data for community coalitions. Public health uses of PDMP information Early intervention: Detecting patients at risk of drug abuse at initial stages of drug-seeking behavior. Education: Providing information on prescribing trends and raising general awareness of the prescription drug abuse epidemic. 9

10 Strengths of PDMP data Timeliness vs. health outcome data Patient, prescriber, and pharmacy identifiers* Transactions located in time and space Detailed information on controlled substance dispensed name, dosage, days supply, refills Includes all methods of payment *Identifiers are anonymized for research and evaluation purposes but potentially linkable to other health data. PDMP Data for Epidemiological Purposes Prescription Behavior Surveillance System (PBSS) De-identified PDMP data from participating states 12 currently submitting data Prescribing rates by age/gender/drug/quarter/year, plus risk measures for patients, prescribers and dispensers Products: Updated tables of measures for each state by quarter and year Annual reports of major trends by state Data and issue briefs for individual states, multi-state comparisons Special analyses, e.g., validating prescriber risk measures MMWR papers on prescribing trends, mandates (forthcoming) 30 10

11 31 Source: Brandeis University, Prescription Behavior Surveillance System Multiple Provider Episodes (MPE) Defined in PBSS as the number of patients with CS prescriptions from 5 or more prescribers and 5 or more pharmacies in a 3-month period, per 100,000 state residents a measure of doctor/pharmacy shopping Differences in how states determine which prescription records belong to the same patient preclude comparisons between states in MPE levels We can, however, compare state MPE trends Simeone reported decreasing trends nationally Decline in MPEs in many PBSS states Source: Brandeis University, Prescription Behavior Surveillance System 11

12 Geographic variation State comparisons: trends in mean daily opioid dose Maine: County level percent change in opioid rate Kentucky: Regional level - NAS cases and opioid rates Massachusetts: Town level Opioid overdose rates Multiple provider episode rates California: Zip code level Multiple provider episode rates Data can inform allocation of prevention and treatment resources 36 12

13 Data source: Maine Prescription Drug Monitoring Program, Office of Substance Abuse & Mental Health Services 39 13

14 Opioid-related Health Problems Rate per 100,000 by Town Rate per 100,000 Quintiles Prescriptions Associated w ith Q uestionable Activity (R ates per 100,000 Prescriptions) by Pharm acy Tow n Questionable activity rates

15 California 2012: Multiple Provider Episode Rates by Zip Code MPE rates, Zip Code quintiles Multiple Provider Episode Rates, 2012: Enlargement of Greater Los Angeles MPE rates, Zip Code quintiles PDMP Data for Targeted Interventions 15

16 Project Lazarus prevention initiative (NC) Presentations to community groups included county- and state-level data on prescriber PDMP enrollment and utilization, prescribing rates, and doctor shopping. PDMP data were associated with health data related to Rx abuse: Outcomes partially a function of PDMP utilization. Data presentation motivated Wilkes County residents to take steps to increase PDMP enrollment and utilization. Outcomes: Increase in PDMP utilization, decline in doctor shopping, reduction in overdose deaths in Wilkes County. Arizona prescriber report cards Peer comparisons by prescriber specialty sent quarterly via ; pilot in four counties. Measures: Prescriptions for carisoprodol, benzodiazepines, hydrocodone, oxycodone, and other pain relievers Prescriber identified as an outlier if one, two or three standard deviations from mean on measures Outcomes: Increased PDMP enrollment and utilization, reductions in outlier status Now expanding report cards to entire state Need data on prescriber specialty for report cards Arizona s PDMP prescriber report cards 48 16

17 Interventions for at-risk prescribers Universal educational campaigns vs targeted educational efforts Prescribing volume by prescriber decile: Proportion of total prescriptions accounted for by prescriber 10% groupings Top prescribers responsible for disproportionate amount of opioid prescribing See Center of Excellence (COE) briefing on interventions with at-risk prescribers Tennessee letters to top 50 prescribers State law mandating annual letters to top 50 prescribers asking them to justify prescribing started 2012 Sent by TN Department of Health, reply requested in 15 days Outcomes: 18% reduction in opioid prescribing 36% (18) of recipients no longer among the top 50 Program expanded in 2015 to include letters to top 10 prescribers in combined county regions. Pros: Easy analysis, simple intervention Cons: Burden on legitimate prescribers to justify practice 17

18 North Carolina licensing board initiative Collaboration between NC medical board, NC mental health, NC public health and UNC injury prevention center Measures of at-risk prescribing were validated by examining PDMP data of practitioners who had prescribed to opioid overdose decedents within 30 days of death Predictive measures: > 100 daily MMEs; simultaneous opioid and benzo combinations; overlapping prescriptions Prescribers meeting these criteria are subject to investigation by licensing board Evaluation: What proportion of prescribers identified are engaged in legitimate practice (false positives)? Source: Asbun, Kirby, Ringwalt, Schiro (2016). PDMP TTAP Webinar Presentation PDMP Data for Needs Assessments and Evaluation Source: Brandeis University, Prescription Behavior Surveillance System 18

19 Example: Project Lazarus in Wilkes County, NC Source: Project Lazarus, Example: Florida s PDMP (E-FORCSE) Source: Kentucky s PMDP Prescriber Queries to KASPER & CS II-IV Prescriptions Dispensed by County, FY10 Prescriber Queries to KASPER & CS II-IV Prescriptions Dispensed by County, FY13 Source: Freeman PR, et al., Kentucky House Bill 1 Impact Evaluation, March

20 Poll How has your state used PDMP data to target or evaluate interventions? 58 Other Uses of PDMP Data Other uses of PDMP data Drug take-back days/drop boxes: Identifying hot spots of high rates of dispensed Rx by ZIP codes or towns/cities Public awareness campaigns of opioid/prescription drug abuse/misuse: Using PDMP data and other data sources (i.e., YRBS) to drive informed discussion (Norfolk County, MA) 20

21 Other uses of PDMP data Drug courts: Monitoring abstinence, proper Rx use (KY NFF) Medical examiners: Determining cause of death (VA NFF) CMS and workers compensation: Patient lock-ins (WA NFF) Opioid use disorder: Monitoring Rx use by OTP patients (COE Briefing on OTP use of PDMP data) Key Recommendations of PDMP Data Recommended PDMP Key Practices Data quality: Completeness, accuracy, timeliness Integration of PDMP with health information systems Patient data summaries, prescriber report cards Mandates to query database (COE briefing) Proactive alerts or reports (COE guidance document) Cross-border integration/cooperation Secure funding Use data for public health surveillance and policy evaluation, e.g., PBSS, HB1 evaluation 21

22 Limitations of PDMP data No unique identifier for patients: record linking procedures vary by PDMP Probabilistic vs. deterministic record linking PDMP relies on pharmacy submissions for data accuracy Practices to assess and ensure data quality vary by PDMP Recording of PRN prescriptions subject to pharmacist discretion (e.g., 30 pills may be recorded as 30 days supply) Resources State administrators contact information for each PDMP: Technical assistance, PDMP-related guides and publications: PDMP TTAP: State Epidemiological Workgroups Federal partners: Bureau of Justice Assistance (BJA) Centers for Disease Control and Prevention (CDC) Food and Drug Administration (FDA) Contact Information Meelee Kim Tom Clark

23 Poll Which recommended key practices of the PDMP are you interested in learning more about? 67 Questions? Evaluation Please click on the link below to provide feedback on this event: Your feedback is very important to us! 69 23

24 References 70 References 1. American College of Preventive Medicine. (2011). Use, abuse, misuse and disposal of prescription pain medicine clinical reference U.S. Department of Health and Human Services (2013). Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities Cochella, S. & Bateman, K. (2012). Provider detailing: an intervention to decrease prescription opioid deaths in Utah. Pain Medicine, 12(Suppl 2) S73-S Grier, S. & Bryant, C. A. (2005). Social marketing in public health. Annual Review of Public Health, 26, SAMHSA (n/d). Understanding social marketing. Center for the Application of Prevention Technologies Ferri, M., Allara, E., Bo, A., Gasparrini, A., & Faggiano, F. (2013). Media campaigns for the prevention of illicit drug use in young people. The Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD Clinton Foundation. (2013). CHMI works with partners to address the prevalence of prescription drug misuse. Retrieved February 6, 2015, from 8. RxPatrol. (2012). What s RxPatrol? 9. U.S. Department of Justice (DOJ). (n/d). Domestic training - State and local training. Drug Enforcement Administration Brandeis University. (2013). Prescription drug monitoring program administrators guide for training law enforcement. Prescription Drug Monitoring Program Training and Technical Assistance Center New York State Division of Criminal Justice Services. (2014). Opioid overdose and intranasal naloxone training for law enforcement: Trainer s guide. %20Trainer%20Guide.pdf 12. CDC (n/d). Doctor shopping laws Betses, M. & Brennan, T. (2013). Abusive prescribing of controlled substances: A pharmacy view. New England Journal of Medicine, 369(11), Community Anti-Drug Coalitions of America (n/d). Handbook for Community Anti-Drug Coalitions PROSPER Partnerships. (n/d). How it works. E. R., Plested, B. A., Edwards, R. W., Thurman, P. J., Kelly, K. J., Beauvais, F., & Stanley, L. (2014). Community readiness for community change. Tri-Ethnic Center for Prevention Research. Retrieved February 26, 2015, from Oetting, E. R. et al. (2014). Community readiness for community change. Tri-Ethnic Center for Prevention Research. Retrieved February 26, 2015, from 71 References 17. Collins, D. A., Johnson, K. W., & Shamblen, S. R. (2012). Examining a home environmental strategy to reduce availability of legal products that can be misused by youth. Substance use & misuse 47(12): doi: / Johnson, K. W. et al. (2010). Studying implementation quality of a school-based prevention curriculum in frontier Alaska: Application of video-recorded observations and expert panel judgment. Prevention Science 11(3), Project Lazarus. (n/db). The Project Lazarus model Community Care of North Carolina (CCNC). (n/d). Project Lazarus: A community-wide response to managing pain Gray JA, Hagemeier NE. (2012). Prescription drug abuse and DEA-sanctioned drug take-back events: Characteristics and outcomes in rural Appalachia. Archives of Internal Medicine, 172(15), Clark, T., Eadie, J., Kreiner, P., & Strickler, G. (2012). Prescription drug monitoring programs: An assessment of the evidence for best practices. Pew Charitable Trusts Haffajee, R. L., Jena, A. B. & Weiner, S. G. (2015). Mandatory use of prescription drug monitoring programs. Journal of the American Medical Association. Published online January 26, U.S. Centers for Disease Control and Prevention. (2015). Prescription drug physical examination requirements

25 References 25. Oliver, R. L. & Taylor, A. (2003). Chronic opioid rules: Prescribing opioids for chronic pain requires set rules, a written plan, periodic re-evaluation, and vigilance to prevent illegal diversion of controlled substances. Practical Pain Management, 3(2), CDC. (n/d). Menu of state prescription drug identification laws