Prescription Drug Monitoring Program

Transcription

1 Prescription Drug Monitoring Program Useful Tool or Government Control? Dr. John D. Lilly

2 Disclaimers Any opinions expressed in this presentation are solely mine and do not necessarily reflect the positions of any business or organization with which I am affiliated. It is a sad commentary on our society that I have to make this disclaimer.

3 The Solution Every state plus DC, except Missouri, now has a state run Prescription Drug Monitoring Program (PDMP). All of them now have a database of patients who have filled covered prescriptions at any pharmacy in the state. Proponents claim that doctor shopping is the biggest problem and the PDMP is the only solution.

4 Controlled Drugs Schedule I V Schedule I heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), peyote, methaqualone, and 3,4-methylenedioxymethamphetamine ( Ecstasy ). Research only Schedule II V Drugs prescribed by physicians Here is some basic information about controlled drugs.

5 Scheduled Drugs Schedule II hydrocodone (Lortab, Vicodin ), oxycodone (OxyContin, Percocet ), morphine (Roxanol, MS Contin ), fentanyl (Duragesic ), hydromorphone (Dilaudid ), methadone (Dolophine ), and meperidine (Demerol ) dextroamphetamine/amphetamine (Adderall ), methylphenidate (Ritalin, Concerta ), and lisdexamfetamine (Vyvance ) Schedule II drugs are the most addictive medication that can be prescribed. These medications have a very high abuse potential because they are addictive. These drugs can create a physical dependency. The second bullet point lists medication that treats attention deficit hyperactivity disorder (ADHD).

6 Scheduled Drugs Schedule III Products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with Codeine ), and buprenorphine (Suboxone ) Non-narcotics like ketamine (Ketalar ), and anabolic steroids such as testosterone (Depo-Testosterone ) This schedule mainly contains medication with codeine which is converted to morphine in the body which provides its pain relief.

7 Scheduled Drugs Schedule IV alprazolam (Xanax ), diazepam (Valium ), lorazepam (Ativan ), clonazepam (Klonopin ), temazepam (Restoril ), triazolam (Halcion ), zolpidem (Ambien ), carisoprodol (Soma ), modafinil (Provigil ), and armodafinil (Nuvigil ) These are primarily tranquilizer medications or nerve pills. Ambien is used for insomnia. Provigil and Nuvigil are used for obstructive sleep apnea and shift work sleep disorder.

8 Scheduled Drugs Schedule V Cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC, Phenergan with Codeine ), diphenoxylate/atropine (Lomotil ), and pregabalin (Lyrica ). This schedule contains medication with lower amounts of codeine. Lomotil is used to control diarrhea, and Lyrica is used to control diabetic nerve pain in the legs.

9 Fentanyl Fentanyl has been the main problem since It is manufactured in China and Mexico, shipped to the drug cartels in Mexico, mixed with heroin, and smuggled across the border into the U.S. Heroin is now in pill form.

10 This is the CDC Wonder website from which the data was obtained.

11 Drug Category ICD-10 Code Drugs Natural and semi-synthetic opioid analgesics (aka other opioids ) T40.2 Morphine, Oxycodone, Hydrocodone, Hydromorphone Methadone T40.3 Methadone Synthetic opioid analgesics, excluding methadone (aka Other synthetic narcotics ) T40.4 Fentanyl, Meperidine Heroin T40.1 Heroin Cocaine T40.5 Cocaine Other or unspecified narcotic T40.6 These are the International Classification of Diseases, 10 th Revision (ICD-10) codes and the primary drugs that are included in each category.

12 Drug Category ICD-10 Code Drugs Natural and semi-synthetic opioid analgesics (aka other opioids ) T40.2 Morphine, Oxycodone, Hydrocodone, Hydromorphone Methadone T40.3 Methadone Synthetic opioid analgesics, excluding methadone (aka Other synthetic narcotics ) T40.4 Fentanyl, Meperidine Heroin T40.1 Heroin Cocaine T40.5 Cocaine Other or unspecified narcotic T40.6 These are manufactured from natural opiates.

13 Drug Category ICD-10 Code Drugs Natural and semi-synthetic opioid analgesics (aka other opioids ) T40.2 Morphine, Oxycodone, Hydrocodone, Hydromorphone Methadone T40.3 Methadone Synthetic opioid analgesics, excluding methadone (aka Other synthetic narcotics ) T40.4 Fentanyl, Meperidine Heroin T40.1 Heroin Cocaine T40.5 Cocaine Other or unspecified narcotic T40.6 These are not manufactured from natural opiates.

14 Drug Category ICD-10 Code Drugs Natural and semi-synthetic opioid analgesics (aka other opioids ) T40.2 Morphine, Oxycodone, Hydrocodone, Hydromorphone Methadone T40.3 Methadone Synthetic opioid analgesics, excluding methadone (aka Other synthetic narcotics ) T40.4 Fentanyl, Meperidine Heroin T40.1 Heroin Cocaine T40.5 Cocaine Other or unspecified narcotic T40.6 These are prescription medications.

15 Drug Category ICD-10 Code Drugs Natural and semi-synthetic opioid analgesics (aka other opioids ) T40.2 Morphine, Oxycodone, Hydrocodone, Hydromorphone Methadone T40.3 Methadone Synthetic opioid analgesics, excluding methadone (aka Other synthetic narcotics ) T40.4 Fentanyl, Meperidine Heroin T40.1 Heroin Cocaine T40.5 Cocaine Other or unspecified narcotic T40.6 With these three ICD-10 codes

16 Drug Category ICD-10 Code Drugs Natural and semi-synthetic opioid analgesics (aka other opioids ) T40.2 Morphine, Oxycodone, Hydrocodone, Hydromorphone Methadone T40.3 Methadone Synthetic opioid analgesics, excluding methadone (aka Other synthetic narcotics ) T40.4 Fentanyl, Meperidine Heroin T40.1 Heroin Cocaine T40.5 Cocaine Other or unspecified narcotic T40.6 except fentanyl which, since 2013, is also manufactured illegally in other countries in addition to prescription fentanyl.

17 Drug Category ICD-10 Code Drugs Natural and semi-synthetic opioid analgesics (aka other opioids ) T40.2 Morphine, Oxycodone, Hydrocodone, Hydromorphone Methadone T40.3 Methadone Synthetic opioid analgesics, excluding methadone (aka Other synthetic narcotics ) T40.4 Fentanyl, Meperidine Heroin T40.1 Heroin Cocaine T40.5 Cocaine Other or unspecified narcotic T40.6 The National Institute on Drug Abuse (NIDA) now classifies the entire category as illicit fentanyl. In the past, this was classified as a prescription opioid pain reliever. Now they classify it as a synthetic opioid drug. In the past, all of the deaths in T40.4 were included as prescriptions. Now they just call it synthetic opioid and treat it as an illicit opioid drug.

18 Prescription Opioid Deaths in the U.S. 7.0 Number of Deaths per 100,000 (age adjusted) states had an operational PDMP in place by That number increased to 21 by And to 34 by states had an operational PDMP in place by 2014, all except Missouri. Does this look like the programs are working?

19 30 Deaths due to Prescription Pain Relievers 25 Deaths per 100,000 (age adjusted) West Virginia Maryland Utah Maine Tennessee Rhode Island Kentucky New Mexico Oklahoma Nevada South Carolina District of Columbia New Hampshire Ohio North Carolina Connecticut Michigan Wisconsin Alaska Pennsylvania Arizona Florida Massachusetts New York Missouri Georgia 2016 Washington Virginia Colorado Arkansas Indiana North Dakota New Jersey Wyoming Illinois Oregon Delaware Idaho Vermont Minnesota Iowa Mississippi Hawaii South Dakota Kansas Montana Alabama California Louisiana Texas Nebraska This shows the 2016 numbers for each state and DC. The red column is Missouri is the perfect experiment. All of the states have an operational PDMP except Missouri. If the PDMPs actually worked, then Missouri should be #1 in the nation. Instead, it is #25. West Virginia is #1. They have had a PDMP since Their death rate is triple the Missouri death rate.

20 Number of Opioid Prescriptions Dispensed per 100 persons Opioid Prescriptions U.S. This is the number of opioid prescriptions dispensed in the U.S. The highest level was in 2012 and it has been decreasing since then.

21 2016 Death Rate and Number of Prescriptions per Capita by State Opioid Prescriptions Ranking Opioid Death Rate Ranking This is a scatter diagram of the ranking of each states prescription dispensing versus the ranking of each states death rate. If prescription writing and the death rate were correlated, then the rankings would form a straight line along the red line.

22 National Survey on Drug Use and Health 2016 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality This survey is the primary source of information on the use of illicit drugs, alcohol, and tobacco in the civilian, non-institutionalized population of the United States aged 12 years old or older. The report is 2,889 pages. A printed report would be 13 inches thick. In all of the recent published research on this subject, I have never seen this survey referenced, yet this is the definitive report on what the PDMP proponents claim is the underlying problem.

23 Survey The survey was started in Main sample size: 67,942 Historically the sample size is always at least 67, million people age 12 and older misused prescription pain medicine in % of the U.S. population age 12 and older

24 Table 6.53A Source Where Pain Relievers Were Obtained for Most Recent Misuse among Past Year Misusers Aged 12 or Older, by Age Group: Numbers in Thousands, 2015 and 2016 Source for Most Recent Misuse among Past Year Misusers of Pain Reliever Aged 12+ (2015) Aged 12+ (2016) Aged Aged Aged 18+ (2015) (2016) (2015) Aged 18+ (2016) Aged Aged Aged 26+ (2015) (2016) (2015) Aged 26+ (2016) GOT THROUGH PRESCRIPTION(S) OR STOLE FROM A HEALTH CARE PROVIDER 4,354 4, ,126 3, ,361 3,254 Prescription from One Doctor 4,066 3, ,874 3, ,155 3,124 Prescriptions from More Than One Doctor Stole from Doctor's Office, Clinic, Hospital, or Pharmacy GIVEN BY, BOUGHT FROM, OR TOOK FROM A FRIEND OR RELATIVE 6,422 a 5, ,953 a 5,382 1,717 b 1,432 4,236 3,951 From Friend or Relative for Free 4,843 4, ,531 4,143 1,225 a 1,009 3,307 3,133 Bought from Friend or Relative 1, , a Took from Friend or Relative without Asking BOUGHT FROM DRUG DEALER OR OTHER STRANGER SOME OTHER WAY b a a b * = low precision; -- = not available; da = does not apply; nc = not comparable due to methodological changes; nr = not reported due to measurement issues. Page Source where pain relievers were obtained for most recent misuse among past year misusers aged 12 and older, Number in Thousands.

25 Table 6.53B Source Where Pain Relievers Were Obtained for Most Recent Misuse among Past Year Misusers Aged 12 or Older, by Age Group: Percentages, 2015 and 2016 Source for Most Recent Misuse among Past Year Misusers of Pain Reliever Aged 12+ (2015) Aged 12+ (2016) Aged Aged Aged 18+ (2015) (2016) (2015) Aged 18+ (2016) Aged Aged Aged 26+ (2015) (2016) (2015) Aged 26+ (2016) GOT THROUGH PRESCRIPTION(S) OR STOLE FROM A HEALTH CARE PROVIDER Prescription from One Doctor Prescriptions from More Than One Doctor Stole from Doctor's Office, Clinic, Hospital, or Pharmacy GIVEN BY, BOUGHT FROM, OR TOOK FROM A FRIEND OR RELATIVE From Friend or Relative for Free Bought from Friend or Relative Took from Friend or Relative without Asking a BOUGHT FROM DRUG DEALER OR OTHER STRANGER a a 5.4 SOME OTHER WAY a a a * = low precision; -- = not available; da = does not apply; nc = not comparable due to methodological changes; nr = not reported due to measurement issues. This is the same information in percentages. 1.4% got them from one doctor. The survey also asked if you got them from a friend or relative for free, and that was 40.4%. The survey then asks where the friend or relative got the medicine as shown in the next slide.

26 Table 6.54B Source Where Friend or Relative Obtained Pain Relievers among Past Year Misusers Aged 12 or Older Who Obtained Most Recently Misused Pain Relievers from a Friend or Relative for Free in Past Year, by Age Group: Percentages, 2015 and 2016 Source Where Friend or Relative Obtained Pain Relievers Aged 12+ (2015) Aged 12+ (2016) Aged Aged Aged 18+ (2015) (2016) (2015) Aged 18+ (2016) Aged Aged Aged 26+ (2015) (2016) (2015) Aged 26+ (2016) GOT THROUGH PRESCRIPTION(S) OR STOLE FROM A HEALTH CARE PROVIDER Prescription from One Doctor Prescriptions from More Than One Doctor Stole from Doctor's Office, Clinic, Hospital, or Pharmacy 0.2 a GIVEN BY, BOUGHT FROM, OR TOOK FROM A FRIEND OR RELATIVE From Friend or Relative for Free Bought from Friend or Relative Took from Friend or Relative without Asking BOUGHT FROM DRUG DEALER OR OTHER STRANGER SOME OTHER WAY * = low precision; -- = not available; da = does not apply; nc = not comparable due to methodological changes; nr = not reported due to measurement issues. This shows the source where a friend or relative obtained pain relievers among past year misusers aged 12 or older who obtained most recently used pain relievers from a friend or relative for free in the past year. 0.8% got them from more than one doctor. So the total is 0.8% of 40.4% = 0.3% + 1.4% = 1.7%

27 Doctor Shopping 1.7% Only 1.7% of misusers of prescription pain medicine got the pills from doctor shopping. So where did 98.3% get their pills?

28 Table 6.53B Source Where Pain Relievers Were Obtained for Most Recent Misuse among Past Year Misusers Aged 12 or Older, by Age Group: Percentages, 2015 and 2016 Source for Most Recent Misuse among Past Year Misusers of Pain Reliever Aged 12+ (2015) Aged 12+ (2016) Aged Aged Aged 18+ (2015) (2016) (2015) Aged 18+ (2016) Aged Aged Aged 26+ (2015) (2016) (2015) Aged 26+ (2016) GOT THROUGH PRESCRIPTION(S) OR STOLE FROM A HEALTH CARE PROVIDER Prescription from One Doctor Prescriptions from More Than One Doctor Stole from Doctor's Office, Clinic, Hospital, or Pharmacy GIVEN BY, BOUGHT FROM, OR TOOK FROM A FRIEND OR RELATIVE From Friend or Relative for Free Bought from Friend or Relative Took from Friend or Relative without Asking a BOUGHT FROM DRUG DEALER OR OTHER STRANGER a a 5.4 SOME OTHER WAY a a a * = low precision; -- = not available; da = does not apply; nc = not comparable due to methodological changes; nr = not reported due to measurement issues. 35.4% got them from one doctor. 8.9% bought them from a friend or relative. 3.7% stole them from a friend or relative. 40.4% got them from a friend or relative for free. The breakdown of the 40.4% is on the next slide.

29 Table 6.54B Source Where Friend or Relative Obtained Pain Relievers among Past Year Misusers Aged 12 or Older Who Obtained Most Recently Misused Pain Relievers from a Friend or Relative for Free in Past Year, by Age Group: Percentages, 2015 and 2016 Source Where Friend or Relative Obtained Pain Relievers Aged 12+ (2015) Aged 12+ (2016) Aged Aged Aged 18+ (2015) (2016) (2015) Aged 18+ (2016) Aged Aged Aged 26+ (2015) (2016) (2015) Aged 26+ (2016) GOT THROUGH PRESCRIPTION(S) OR STOLE FROM A HEALTH CARE PROVIDER Prescription from One Doctor Prescriptions from More Than One Doctor Stole from Doctor's Office, Clinic, Hospital, or Pharmacy 0.2 a GIVEN BY, BOUGHT FROM, OR TOOK FROM A FRIEND OR RELATIVE From Friend or Relative for Free Bought from Friend or Relative Took from Friend or Relative without Asking BOUGHT FROM DRUG DEALER OR OTHER STRANGER SOME OTHER WAY * = low precision; -- = not available; da = does not apply; nc = not comparable due to methodological changes; nr = not reported due to measurement issues. The percentages from one doctor on this page is 38.5%. If you put all of these numbers from both pages in a pie chart, you get 86.5%.

30 Sources of Diverted Pain Medicine in % 11.8% 86.5% More than One Doctor Doctor Shopping One Doctor Personally or from Friend or Relative (Free, Bought, Took) Other than Doctor Stole from Doctor, Clinic, Hospital, or Pharmacy; Bought from Drug Dealer or Stranger; Some Other Way 1.7% got it from Doctor Shopping. 86.5% got it from one doctor either personally or from a friend or relative who got it from one doctor. 11.8% obtained it illegally.

31 Sources of Diverted Pain Medicine in % 98.3% Doctor Shopping Other Than Doctor Shopping This is the real problem. The PDMPs will never catch 98.3% of the problem.

32 PDMPs Failure There is one specific scenario that will not be flagged by a PDMP. When one patient consistently gets the same pain medicine from one physician every month. That is not doctor shopping. The burden of catching this type of diversion falls to the physician.

33 Editorial in the Western Journal of Emergency Medicine 2015 Our profession must come to consensus on the indications for opioid pain medications and their appropriate use in managing acute and chronic pain. Training clinicians in chronic pain management and responsible opioid prescribing may do more to reduce opioid prescribing than access to PDMPs. Improved patient education for those receiving opioids is also needed so our patients fully understand the risks and benefits of opioid therapy.

34 PDMPs Failure There is one specific scenario that will not be flagged by a PDMP. When one patient consistently gets the same pain medicine from one physician every month. That is not doctor shopping. The burden of catching this type of diversion falls to the physician. So how do doctors catch the diversion of prescription drugs? There are specific scenarios that will not be flagged by a PDMP. When one patient consistently gets the same pain medicine from one physician every month. That is not doctor shopping. In these instances, there is no PDMP that will catch this type of diversion. That is how the 86.5% get their medicine.

35 Catching Diversion or Overuse Two primary methods Random urine drug screens Pill count visits The solution to the problem of prescription drug overdose deaths will not be found in one program or project. This is a multifaceted problem. PDMPs have been touted as the solution to prescription drug deaths. The proponents of PDMPs state that only a database will eliminate doctor shopping. As described above, the data shows that doctor shopping is a tiny percentage of the prescription drugs that are diverted. This paper has shown analytical evidence that PDMPs do not work. The solution to this problem includes not starting a program in Missouri. In other states, the solution includes dismantling the existing program and destroying any existing prescription databases. The only purpose of the databases is to expand control of the people by centralized government by having a national prescription database.

36 Catching Diversion or Overuse Two primary methods Random urine drug screens Pill count visits Physicians have a major role in controlling this problem. Physicians typically have patients that are on chronic pain medication sign a prescription drug agreement in order for that patient to receive pain medication. These agreements contain numerous stipulations including: no diverting or misusing the medication, no early refills, refills only during regular business hours, medications are to be kept in a safe place, using only one designated pharmacy, agreeing to random urine toxicology screening, and random office visit requests.

37 Catching Diversion or Overuse Two primary methods Random urine drug screens Pill count visits The two primary methods to catch diversion are random urine drug screens and pill count visits. There are several sophisticated urine drug tests that will tell the physician if the patient is taking the medication properly by checking for the actual drug and its metabolites in the urine. Some will even quantify the amount of the drug in the urine compared with the prescription amount. Doing these tests at random times helps ensure that patients are taking the medication consistently.

38 Catching Diversion or Overuse Two primary methods Random urine drug screens Pill count visits The second method is a pill count visit. Someone who sells or misuses their medication after getting the prescription filled at a pharmacy generally will do so within the first two weeks of obtaining the medication. In a pill count visit, the physician contacts the patient three to four weeks after writing the prescription telling them to come in for an office visit and to bring their prescription medication in the bottle dispensed by the pharmacy. If they refuse to make an appointment, do not show up for the appointment, or have the incorrect number of pills or the actual pills are not the pills that were prescribed, then that is an indicator that they did not have any pills left because they had already sold or used their monthly amount.

39 What is Driving the Expansion of Prescription Drug Monitoring Programs?

40 Government.

41 THE WHITE HOUSE PRESIDENT S COMMISSION ON MODEL STATE DRUG LAWS Executive Summary December 1993 The President s Commission on Model State Drug Laws was formed in A bipartisan commission went on a fact-finding mission to obtain information at the local level about drug and alcohol abuse problems. The commission then created a nonprofit organization, the National Alliance for Model State Drug Laws (NAMSDL), to help disseminate information and be a resource for state legislatures. Initially, NAMSDL worked to curb illegal drug and alcohol abuse. Later it took on the task of curbing prescription drug abuse. Its solution was to push to enact PDMPs in every state.

42 MISSION TheNationalAliance formodelstatedruglaws(namsdl)is aresourceforgovernors,state legislators,atorneysgeneral, local prosecutors,drugandalcoholprofessionals,healthprofessionals,communityleaders, therecoveringcommunityandothersstriving for comprehensiveandefective statedrugandalcoholaws, policies,regulationsandprograms. Fundedbycongressionalappropriations,NAMSDLis the non-profitsuccessortothepresident'scommissiononmodelstatedruglaws.in coordinationwith the OficeofNationalDrugControlPolicy,wedraftmodeldrugandalcoholaws, policiesandregulations.weresearch, analyzeandcomparerelated state statutes, policiesandregulations.welinkpeopletoournationwidenetworkofdrugandalcoholexperts.we helpstateandlocal oficials: Determinewhat'sworkingwith statutes, policiesandregulations. Eliminate duplicative eforts. Spotneededimprovements. Establishaccountabilitymethodsforassuringcompliance. Helpensuretheoptimalfiscaluseofpublicdolars. Create cost-efectivedrugandalcoholstrategies,lawsandservices. This is NAMSDL s Mission Statement. Notice the second paragraph. Funded by congressional appropriations. The taxpayers are paying for this.

43 Prescription Drug Monitoring Programs (PDMPs): Critical Decision Support Tools to Respond to the Opioid Crisis September 8, 2017 NAMSDL gave a Congressional briefing in September The National Survey on Drug Use and Health data did not appear in their presentation.

44 What are the Features of PDMPs in the Other States?

45 Established and Operational PMPs - 51 Jurisdictions (49 States, D.C. and St. Louis County) WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK TX LA FL HI St. Louis County has a network of 21 MO counties and six (6) MO cities participating in the PMP as of the 7/1/17 implementation date. Five (5) more MO counties are scheduled to participate as of the 8/1/17 implementation date, and two (2) more MO counties and one (1) more MO city are scheduled to participate as of the 9/1/17 implementation date The National Alliance for Model State Drug Laws (NAMSDL). Operational PDMPs. The national network is almost complete. Notice the name change from PDMP to PMP Prescription Monitoring Program.

46 States that Require Prescribers and/or Dispensers to Notify Consumers that Their PMP Information May Be Accessed or Reported WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK HI TX LA FL States that require prescribers and/or dispensers to notify consumers that their PMP information may be accessed or reported 2016 The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa Only 11 states require customer notification that they have information in a database that can be accessed. They don t want citizens to know about the database.

47 Evaluation of PMP Report to Legislature WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK HI TX LA FL States that require a report to the legislature regarding the PMP 2016 The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa Only 26 states require an annual evaluation of the program be given to the state legislature. They don t want legislators to know that the program is not working.

48 Substances Monitored by PMP 1 WA NH OR CA NV ID UT AZ MT WY CO NM ND SD 3 NE 4 KS OK MN WI IA IL MO AR MI OH IN KY TN 2 VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA States that monitor Schedules II - IV AK 5 TX LA FL States that monitor Schedules II - V States that monitor Schedules II IV and certain non-controlled substances HI States that monitor Schedules II V and certain non-controlled substances 1 This map reflects those states with statutory authority to collect dispensing data on certain non-controlled substances and does not necessarily reflect those states with such authority who are actively collecting such data. 2 Tennessee s law authorizes the monitoring of Schedule V substances that have been identified as demonstrating a potential for abuse. 3 In South Dakota, all federal Schedule V substances are listed in Schedule IV, so they do monitor Schedule V controlled substances. 4 The Nebraska provision becomes effective January 1, On July 17, 2017, Alaska will begin collecting data on Schedule II IV substances only The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states monitor some non-controlled drugs. Blue-green and Brown. The proponents tell us that only doctors and pharmacists can access the database and there are only 30,000 of them in the state.

49 Types of Authorized Recipients Prescribers and Dispensers WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK TX LA HI FL Prescribers and dispensers 2016 The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa Physicians and pharmacists can access the database in every state, BUT.

50 States that Allow Prescribers and/or Dispensers to Appoint a Delegate to Access the PMP WA NH MT ND VT ME OR MN CA NV ID AZ UT WY CO NM SD NE KS OK WI 2 IA IL MO AR MI OH IN KY TN NY PA WV VA NC SC DE MD DC RI CT NJ MA MS AL GA TX 1 AK 3 LA FL Delegates allowed HI 1 The Texas provision goes into effect on September 1, The Wisconsin provision goes into effect on April 1, The Alaska provision goes into effect on July 17, The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states allow prescribers to designate a delegate or delegates that can access the database. In 2015 it was 38 states.

51 Types of Authorized Recipients Physician Assistants, Medical Residents, Nurse Practitioners, and Other Authorized Prescribers 1 WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK HI TX LA FL States that provide data to physician assistants, nurse practitioners, and medical residents States that provide data to physician assistants States that provide data to nurse practitioners 1 The term nurse practitioners may include advanced registered nurse practitioners, certified nurse practitioners, certified nurse midwives, certified nurse anesthetists, or clinical nurse specialists The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states allow nurse practitioners to access the database. 48 states allow physician assistants to access the database. 47 states allow medical residents to access the database.

52 Types of Authorized Users Professional Licensing or Regulatory Boards WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK TX LA Licensing or regulatory boards FL HI 2016 The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states allow professional licensing or regulatory boards to access the database.

53 Types of Authorized Recipients Judicial/Prosecutorial Officials WA NH OR CA AK NV 1 ID UT AZ HI MT WY CO NM ND SD NE KS OK TX VT MN WI NY MI IA PA OH IN IL WV 1 VA MO KY NC TN AR SC MS AL GA LA FL ME DE MD DC RI CT NJ MA Probable cause, search warrant, subpoena, or other judicial process Pursuant to an active investigation or as part of official duties Both judicial process and active investigation Upon request of the grand jury 1 Nevada and West Virginia also allow the release of information in civil cases with a court order. Upon request for records of Schedule II substances; court order for all other Schedules 2016 The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states allow judicial and prosecutorial officials some form of access to the database.

54 Types of Authorized Recipients Law Enforcement Officials WA NH OR CA AK NV ID UT AZ HI MT WY CO NM ND SD NE KS OK TX VT MN WI NY MI IA PA OH IN IL WV VA MO KY NC TN AR SC MS AL GA LA FL ME DE MD DC RI CT NJ MA Probable cause, search warrant, subpoena, or other judicial process Pursuant to an active investigation or as part of official duties Both judicial process and active investigation May only receive data from professional licensing boards Upon request for records of Schedule II substances; court order for all other Schedules 2016 The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states allow law enforcement officials some form of access to the database.

55 Types of Authorized Recipients Probation/Parole Officers or Department of Corrections WA NH OR CA NV ID UT 1 AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK HI TX LA FL Probation or parole officers Department of Corrections 1 The Utah provision goes into effect on October 31, The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states allow probation or parole officers or Department of Corrections officials some form of access to the database.

56 Types of Authorized Recipients County Coroners, Medical Examiners, and/or State Toxicologists WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK 2 TX 1 LA FL County coroners and/or medical examiners HI State toxicologists 1 The Texas provision goes into effect on September 1, The Alaska provision goes into effect on July 17, The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states allow county coroners, medical examiners, and/or state toxicologists access to the database.

57 Types of Authorized Recipients Medicare, Medicaid, State Health Insurance Programs, and/or Health Care Payment/Benefit Provider or Insurer WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK 1 HI TX LA FL Medicare, Medicaid, and/or State Health Insurance Programs Health care payment/benefit provider or insurer and Medicare, Medicaid, or state health insurance programs 1 The Alaska provision goes into effect on July 17, The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states allow Medicare, Medicaid, state health insurance programs, and/or health care payment/benefit providers or insurer to access the database.

58 Types of Authorized Recipients Mental Health/Substance Abuse Professionals, Peer Review Committee, or Quality Improvement Committee of Hospital WA NH MT ND VT OR MN ID SD WI 3 NY MI WY NE IA PA 2 NV OH UT IN IL CA CO 1 WV VA KS MO KY NC TN AZ OK NM AR SC MS AL GA TX LA AK FL HI 1 The Colorado PMP will release information to the medical director of a facility that treats addiction with controlled substances if the patient consents. 2 The release of information to the Department is limited to those individuals engaged in the administration of the Methadone Death and Incident Review Team. 3 The Wisconsin provision goes into effect on April 1, The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa ME DE MD DC RI CT NJ MA Mental health/substance abuse professionals Peer review committees or substance abuse professionals for services to licensed health care professionals Peer review committees or licensed addiction counselor State Dept. of Drug and Alcohol Programs or State Dept. of Mental Health and Substance Abuse Services. Dept. of Mental Health and Substance Abuse Services and quality improvement committee of hospital 16 states allow mental health and substance abuse professionals, peer review committees or quality improvement committees of hospitals to access the database.

59 Types of Authorized Recipients Patient, Parent or Guardian on Behalf of Minor Child, Health Care Agent, Attorney, or Third Party with Consent WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK HI TX LA FL Patient or parent/guardian of minor child Patient or parent/guardian of minor child and health care agent Patient or parent/guardian of minor child and attorney 2016 The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states allow patients, parents or guardians on behalf of minor children, health care attorney, or third party with consent to access the database.

60 Types of Authorized Users Department of Health or Commissioner of Public Safety WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK TX LA Department of Health FL Commissioner of Public Safety HI 2016 The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states allow the Department of Health or Commissioner of Public Safety to access the database.

61 Types of Authorized Recipients Worker s Compensation Specialists WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK TX LA FL Worker s compensation specialists HI 2016 The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 100 ½ E. Main Street, Suite C, Manchester, Iowa states allow worker s compensation specialists access to the database. Access always expands. It never contracts.

62 State/Local Jurisdictions Legally Authorized to Share Their PMP Data with Other State/Local Jurisdictions or Users Located in other State/Local Jurisdictions (47 States, D.C., and St. Louis County, Missouri) WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA MS AL GA AK TX LA FL HI. Oregon allows prescribers in Washington State, California, Idaho and Nevada to access Oregon PMP Data. St. Louis County, Missouri Narcotics Control Act allows the PMP network to share data with users in other jurisdictions. Florida is able to receive PMP data from other jurisdictions and provide that data to authorized users in Florida The National Alliance for Model State Drug Laws (NAMSDL). 47 states plus DC share data with other states PDMP and/or authorized users in other states. We are almost to a de facto national prescription database. This is the real goal of government bureaucrats.

63 Mandated Registration with PMPs* WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC DE MD DC ME RI CT NJ MA AK HI TX LA MS AL GA FL States that require prescribers in one or more professional categories to register with the PMP (34 states) States that require pharmacists or dispensers in general to register with the PMP (25 states) * Exceptions may apply and effective dates may vary. Preparation for implementation may result in a time difference between enactment and effective date(s) and date of implementation of the mandate National Alliance for Model State Drug Laws (NAMSDL) 34 states require physicians to register with the PDMP.

64 Mandated Use of PMPs 37 States with Specified Circumstances Requiring Prescriber Access* WA NH OR CA NV ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA WV VA NC SC ME DE MD RI CT NJ MA DC (no mandate) MS AL GA AK TX LA FL HI * Exceptions may apply and effective dates may vary. Preparation for implementation may result in a time difference between the enactment and effective date(s) and date of implementation of the mandate. For more information about mandated use of PMPs, please see Mandated Use of Prescription Drug Monitoring Programs (PMPs) Highlights of Key State Requirements, The National Alliance for Model State Drug Laws (NAMSDL). 37 states mandate physicians use of the PDMP in specific circumstances.

65 Missouri Constitution Article I, Section 15. Unreasonable search and seizure prohibited contents and basis of warrants. That the people shall be secure in their persons, papers, homes, effects, and electronic communications and data, from unreasonable searches and seizures; and no warrant to search any place, or seize any person or thing, or access electronic data or communication, shall issue without describing the place to be searched, or the person or thing to be seized, or the data or communication to be accessed, as nearly as may be; nor without probable cause, supported by written oath or affirmation. Article I, Section 15 of the Missouri Constitution protects us from what the PDMP does.

66 Unconstitutional Private insurance companies and government programs like Medicare, Medicaid and the Veterans Administration have prescription databases. When you sign up for the insurance policy or the government program, you agree to become part of that database. The PDMP is completely different. It is a mandatory, involuntary database which makes it unconstitutional. When you take a covered prescription to the pharmacy that is mandated to report that prescription, no one asked you if you want to be in a database that could be accessed. It s not voluntary. Only 11 states will tell you that your prescription is going into a database that can be accessed.

67 Conclusions The Prescription Drug Monitoring Programs are not working. Doctor shopping is not the problem. Databases are not secure. Citizens are loosing their liberty, because it s unconstitutional. So what s the bottom line?

68 The Real Goal is a National Prescription Database

69 Sources DEA (U.S. Drug Enforcement Administration). Drug Schedules. National Institute on Drug Abuse. Graphs on deaths due to prescription medication and illicit drugs.

70 Sources CDC Wonder website. Some of the charts in this white paper were created from data obtained on the CDC Wonder website. President s Commission on Model State Drug Laws The National Alliance for Model State Drug Laws (NAMSDL).

71 Sources Compilation of Prescription Monitoring Program Maps. The National Alliance for Model State Drug Laws. Center for Behavioral Health Statistics and Quality. (2017) National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD. (tables 6.53A, 6.53B, 6.54A, and 6.54B) NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf.

72 Sources Medicare Part D Opioid Drug Mapping Tool. Medicare Opioid Prescribing in uploads/medicare-opioid-prescribing-2014.pdf. Leonard J. Paulozzi, MD, MPH, Edwin M. Kilbourne, MD, and Hema A. Desai, M Med Sci. Prescription Drug Monitoring Programs and Death Rates from Drug Overdose. Pain Medicine 2011; 12:

73 Sources Stephen W. Patrick, Carrie E. Fry, Timothy F. Jones, and Melinda B. Buntin. Prescription Drug Monitoring Programs and Death Rates from Drug Overdose. Health Affairs, July 2016 vol. 35, no. 7, pg Fox News: DEA blasted for no-warrant searches of patient records, court battle heats up Scripps News investigation led by Mark Greenblatt, senior national investigative correspondent, and Angela M. Hill, national investigative producer.

74 Prescription Drug Monitoring Programs Questions An Analytical Evaluation Website drjohnlilly.com Author: Dr. John D. Lilly