SAFE OPIOID PRESCRIBING C.U.R.E.S. PROGRAM

Transcription

1 Sorin Buga, MD Associate Clinical Professor Department of Supportive Care City of Hope National Medical Center SAFE OPIOID PRESCRIBING C.U.R.E.S. PROGRAM Click to edit Master Presentation Date

2 Disclosure Statement I do not have anything to disclose

3 Objectives Opioid abuse epidemics Overprescribing part of the problem PDMP Programs PDMP - Pros and Cons CURES Program

4 Opioid Abuse - Facts Rates of opioid overdose deaths, opioid sales and opioid substance abuse treatment admissions, Addressing Prescription Drug Abuse in the United States Current Activities and Future Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities - Developed by the Behavioral Health Coordinating Committee Prescription Drug Abuse Subcommittee U.S. Department of Health and Human Services

5 Opioid Abuse - Facts Prescription opioid overdoses increased 300% in the past 20 years Deaths from overdose of prescription painkillers 46 / day Drug overdose: #1 cause of injury-related death 43,982 deaths in 2013

6 Opioid Abuse - Facts Overdose deaths rural areas vs. big cities: 2:1 Race: Whites, American Indian or Alaska Natives Men - more likely to die of prescription painkiller overdoses (> 10,000 deaths in 2010) Women - overdose deaths among women up by > > 400% from 1999 to 2010

7 Opioid Abuse - Facts National Institute on Drug Abuse Overdose Death Rates Revised December 2015

8 Opioid Abuse - Facts Drug overdose death rates by state per 100,000 people CA: increase by 16.5% of deaths from pain meds since 2006 National Center for Injury Prevention and Control / Division of Unintentional Injury Prevention Prescription Painkiller Overdoses 11, 2011

9 Opioid Abuse - Facts

10 Opioid Abuse - Facts Rates of motor vehicle traffic and drug overdose deaths, United States, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities - Developed by the Behavioral Health Coordinating Committee Prescription Drug Abuse Subcommittee U.S. Department of Health and Human Services

11 Opioid Abuse - Facts Drug overdose deaths by major drug types in U.S., Most common: Methadone, Oxycodone, Hydrocodone Source: National Vital Statistics System 2012

12 Opioid Abuse - Facts - L.A. County 6 th cause of premature death with > 400 lives/year leading cause of death for yo white women -2 nd leading cause of death in and yo white males Highest drug overdose death rate: white men

13 Opioid Abuse - Facts - Tip of the iceberg National Center for Injury Prevention and Control / Division of Unintentional Injury Prevention Prescription Painkiller Overdoses November 2011

14 Overprescribing Overprescribing cause for the increase in prescription overdoses Enough prescription painkillers were prescribed in 2010 g p p p p to medicate every American adult around-the-clock for a month!

15 Overprescribing

16 Overprescribing

17 Why should WE Care? Main sources of prescription drugs on the streets: elderly patients with pain doctor shoppers Most prescription drugs associated with overdose deaths - prescribed by physicians 27.3% who misused drugs for days/year got them from a prescriber

18 Why should WE Care? N ti l C t f I j P ti d C t l / Di i i f U i t ti l National Center for Injury Prevention and Control / Division of Unintentional Injury Prevention Prescription Painkiller Overdoses November 2011

19 What can We do? Safe Opioid Prescribing Education Opioid agreement - Pain Screening patients Contract Educating patients on opioid Urine Drug Screening use / dispense Prescribing Naloxone REMS Programs Documentation State PDMP

20 State PDMP - History early 1930 s - state regulatory and law enforcement agencies - need to track and monitor prescribing and dispensing of particular prescription drugs states had operational PDMPs states + District of Columbia + Guam: legislation authorizing creation / operation of PDMP 48 states and one U.S. territory (Guam) currently have PDMP that is operational

21 State PDMP - Cost July Congressional Research Service: PDMP startup costs $450,000 to more than $1.5 million annual operating costs $125,000 to nearly $1.0 million Cost = main barrier to expansion / implementation

22 State PDMP - Design Provide information on prescribing trends Raise awareness of the Rx drug abuse epidemic Detect & prevent abuse, misuse, diversion of Rx drugs Determine incidence & prevalence of medical and nonmedical uses of controlled pharmaceuticals statewide and by county, region, or city Prescribers avoid prescribing duplicate therapies Reduce doctor shopping Detect patients at risk of drug abuse at initial stages of drug-seeking behavior

23 PDMP Pros 1. Reduce prescribing of Schedule II opioid analgesics Lower substance abuse treatment admission rates Lower annual increases in opioid misuse or abuse: 2012 database from RADARS (Researched, Abuse, Diversion and Addiction-Related Surveillance) poison center and opioid treatment found that states without a PDMP had significant increases in opioid-related incidents reported to poison control centers

24 PDMP Pros 2. Quality of care: Identify patients receiving multiple legitimate Rx but are at risk of complications from polypharmacy

25 PDMP Pros 3. Reduce over prescribing and doctor shopping: Identify doctor shoppers Development of specific doctor shopping laws

26 PDMP Pros 4. Reduce fraudulent prescribing by physicians: Florida: of the top 100 prescribers for oxycodone located in Florida number dropped d to 13

27 PDMP Pros 5. Help physicians detect a prescription drug seeking behavior: Survey in CA physicians - 74% of responders indicated they changed their prescribing practices by using PDMP Patient t Activity it Reports [PARs] - 91% of responders rated the effectiveness of the PAR in maintaining the care and health of your patient as good to excellent

28 PDMP Pros 6 Decrease the time and effort required by law 6. Decrease the time and effort required by law enforcement in researching drug diversion cases

29 PDMP Cons 1. Physician concerns: Increase scrutiny decrease in legitimate prescribing of controlled substances ( chilling effect ) patients suffer / increase pseudo-addiction Legal risk for prescribing too much pain medication less than for prescribing too little patients suffer / increase pseudo-addiction Negative impact on service rapport and trust

30 PDMP Cons 2. Patient concerns: Scrutiny from law-enforcement for using meds monitored by the PDMP More office visits increase costs Hx (past or present) of opioid dependency risk of not obtaining the treatment for valid conditions Unfettered law enforcement access to prescription information

31 PDMP Cons 3. Privacy concerns: Medical consultation is no longer a private affair? Unscrupulous use or data leaking from PDMP

32 PDMP Cons 4. Another mandatory requirement?: Additional time pressure on physicians Additional passwords PDMP not always easy to navigate

33 PDMP Cons 5. Does it really make a difference?: Canadian study: no differences in the opioid prescribing rate when comparing provinces with and without PDMPs

34 CA - PDMP 1939 creation of California Triplicate Prescription Program ( TPP ) for schedule II 1998 TPP replaced by CURES that t captures schedule II through IV CURES = Controlled Substance Utilization Review and Evaluation System 2016 CURES 2.0 launched

35 CURES 2.0 CURES 2.0 (Controlled Substance Utilization Review and Evaluation System) is a database of Schedule II, III and IV controlled substance prescriptions dispensed in California serving the public health, regulatory oversight agencies, and law enforcement. CURES 2.0 is committed to the reduction of prescription p drug abuse and diversion without affecting legitimate medical practice or patient care.

36 CURES 2.0 Effective January 1, 2016, all California-licensed licensed prescribers authorized to prescribe, order, administer, furnish or dispense Schedule II, III, or IV controlled substances must be registered to access CURES (as required by California Health and Safety Code Section ) or upon issuance of a Drug Enforcement Administration Controlled Substance Registration Certificate, whichever occurs later Extended to July 1, 2016

37 CURES 2.0 Prescribers must have CA license + DEA # : Dentist Medical Physician Naturopathic Physician Optometrist Ot Osteopathic thi Physician ii Physician Assistant Podiatrist Registered Certified Nurse Midwife Registered Nurse Practitioner Veterinarian

38 CURES Registration

39 CURES Registration

40 CURES Registration

41 CURES Registration

42 CURES Registration

43 CURES Registration

44 CURES 2.0 CURES must use Microsoft Internet Explorer CURES 2.0 must use Microsoft Internet Explorer version 11.0 or higher, Mozilla Firefox, Google Chrome or Safari!

45 CURES 2.0 Report available for 12 months from date of inquiry: i Patient name Date Rx was dispensed Patient DOB Rx # Patient Address Drug name Prescriber name and DEA # Drug quantity and strength Pharmacy name & license # # refills remaining i

46 CURES 2.0

47 CURES 2.0

48 CURES When to Access Data Periodically (every 3-6 months) New patients requiring medications with abuse potential Patients utilizing multiple physicians Patients with inconsistent urine drug test results Red flag cases Patients who exhibit signs of abuse or diversion LA L.A. County Department of Public Health - MDs and Pharmacists to routinely check Patient Activity Reports

49 CURES When to Access Data SB 482 Governor Brown signed SB 482 on 09 / 27 / 2016 Requires prescribers to : consult CURES prior to prescribing a Schedule II, III or IV drug to a patient for the first time at least once every 4 months thereafter if the substance remains part of the treatment of the patient a health care practitioner who fails to consult the CURES database is required to be referred to the appropriate state professional licensing board solely for administrative sanctions, as deemed appropriate by that board

50 Good News? Surratt HL, Cicero TJ, Parrino MW, Severtson SG, Bucher-Bartelson B, Green JL - Trends in opioid analgesic abuse and mortality in the United States. Dart RC, - N Engl J Med Jan;372(3):241-8

51 References County of Los Angeles Department of Public Health Fact Sheet : Drug Use and Misuse in Los Angeles County September 2010 Mortality in Los Angeles County Leading cause of death and premature death with trends for A publication of the Los Angeles County Department of Public Health Prescription Drug Monitoring Program Center of Excellence at Brandeis - Briefing on PDMP Effectiveness -Updated September 2014 Prescription Drug Monitoring Program Center of Excellence at Brandeis - COE Briefing PDMP Delegate Account Systems May 2015 National Center for Injury Prevention and Control / Division of Unintentional Injury Prevention Prescription Painkiller Overdoses November 2011 Center for Disease Control and Prevention Increase in Drug and Opioid Overdose Deaths United States January 1, 2016 Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities - Developed by the Behavioral Health Coordinating Committee Prescription Drug Abuse Subcommittee U.S. Department of Health and Human Services CDC VitalSigns Opioid painkiller prescribing Where you live makes a difference July Prescription Drug Monitoring Program Center of Excellence at Brandeis - Using PDMP Data to Guide Interventions with Possible At-Risk Prescribers - October Mary-Lynn Brecht, Ph.D.- Patterns and Trends in Drug Abuse in Los Angeles County, California: 2013 California Department of Justice CURES Prescription Drug Monitoring Program February 2013 H. Gugelmann, J. Perrone, L. Nelson -Windmills and Pill Mills: Can PDMPs Tilt the Prescription Drug Epidemic?- J. Med. Toxicology 2012 Dec; 8(4): ; Published online 2012 Nov 21. doi: /s M.M. Islam, I. McRae - An inevitable wave of prescription drug monitoring programs in the context of prescription opioids: pros, cons and tensions BMC Pharmacol. Toxicol.2014; 15: 46.;Published online 2014 Aug 16. doi: / Hedegaard H, Chen LH, Warner M - Drug-poisoning deaths involving heroin: United States, NCHS Data Brief March Surratt HL, Cicero TJ, Parrino MW, Severtson SG, Bucher-Bartelson B, Green JL - Trends in opioid analgesic abuse and mortality in the United States. Dart RC, - N Engl J Med Jan;372(3):241-8 Senate Bill No. 482 Chapter An act to amend Sections and of, and to add Section to, the Health and Safety Code, relating to controlled substances.

52 Thank you

53 QUESTIONS???