2017 NASCSA Conference

Transcription

1 2017 NASCSA Conference Drug Trends & Investigations Eric Griffin Director of Compliance & Enforcement

2 Ohio Quick Facts 2006 Ohio established the OARRS PMP program 2011 In the midst of the Opiate epidemic Ohio passed legislation to license and regulate pain management clinics and prescribers who personally furnish controlled substances 2011 OARRS starts sharing data with neighboring state 2012 Approximately 793 million Opiates were dispensed in the State of Ohio The Board adopts rule to require daily reporting of dispensing data to OARRS 2015 Mandatory checks of OARRS are required before prescribing opiates and benzodiazepines 2015 The Board launches integration projects with pharmacies and healthcare systems to improve access.

3 State Of Ohio Board of Pharmacy In Ohio the Board of Pharmacy is the Controlled Substance authority and houses the OARRS PMP program. Additionally the Board is a regulatory and enforcement agency. Four Main Functions Licensing Legislation OARRS Compliance & Enforcement

4 Enforcement Main Sources of Diversion Aberrant Prescribers (Drug Trafficking) Doctors, Nurse Practitioners, Vets, Dentists, Physician Asst. Aberrant Pharmacies Healthcare Facility Drug Theft Retail Drug Theft Robberies Illegal Drug Sales Prescription Forgeries Doctor Shoppers

5 Current Drug Trends in Ohio 1. Drug Trafficking Prescribers 2. Retail Drug Theft 3. Healthcare Facility Theft 4. Prescription Forgery 5. Robberies Drugs of Choice Opioids Hydrocodone, Oxycodone, Morphine, Codeine Benzodiazepine Alprazolam, Diazepam, Midazolam Promethazine, Promethazine with codeine Buprenorphine - Suboxone Phentermine - Adipex Gabapentin

6 Prescriber Investigation Developed through analysis of OARRS data Average MED/Script Total opioid doses Number of opioid patients Total MME Average Days/Script Number of days of opioids overlapping with benzos

7 Law Enforcement Agencies State of Ohio Board of Pharmacy Medicaid Fraud Control Unit (MFCU) Health & Human Services-Office of Inspector General (HHS OIG) Bureau of Workers Compensation State Highway Patrol

8 Prescriber Ranking Average MED daily dose per Rx (97 th Percentile) Total MME prescribed (Ranked #1) Number of days prescribing opioids overlapping with benzos (Ranked #1) Number of solid dosage units prescribed (Ranked #2) Number opioid patients (99 th Percentile) Number opioid day supply (Ranked #2) Prescribed to more than 640 patients in 30 days

9 Patient analysis Intelligence -Travelers, Address similarities, History Employee & former employees Address search FINCEN- Financial Crimes Enforcement Network

10 Additional Resources Undercover office visits USPS mail cover Medical Board history Toll records Subpoena of additional records Pole camera

11 Death Cases Identified 17 patients through OARRS who were prescribed drugs from the Prescriber in question and died of a drug overdose. Identified which patients had coroner s reports, autopsies and whose deaths were attributed to drug toxicity and whose controlled substances were prescribed by the Prescriber.

12 Specialist Review Patient X (DOB 1/25/1956) A review of the coroner's report indicates that Patient X died on 3/17/15 at 8:10 AM and the cause of death was multiple drug toxicity including morphine and amitriptyline. A review of the toxicology report indicates a positive result in the blood for diazepam (191 ng/ml), nordiazepam (277 ng/ml), morphine (292 ng/ml), naloxone, pregabalin (1.8 mcg/ml), amitriptyline (463 ng/ml), nortriptyline (312 ng/ml), caffeine, selenium and phosphorous. It should be noted that the results for morphine, amitriptyline and nortriptyline were above the therapeutic range. *Note: Nordiazepam is a metabolite of diazepam (Drug Facts and Comparisons 2017). *Note: Over-dosages of amitriptyline and nortriptyline have been known to show critical manifestations including cardiac arrhythmias, severe hypotension (low blood pressure), convulsions, and central nervous system depression including coma. Deaths have occurred from over-dosage with this class of drugs (Drug Facts and Comparisons 2017). A review of Patient X OARRS report, dated 3/22/17 provides the following information Prescriber prescribed a combination of morphine extended release tablets, morphine immediate release tablets, diazepam, Lyrica and zolpidem since at least April Both the morphine extended release tablet and the immediate release tablet was dispensed to Patient X on 3/14/15. A review of the patient chart and medical records associated with Patient X would be warranted to determine the appropriateness of the morphine/diazepam therapy and the legitimacy of the prescriptions.

13 Search Warrants Prescribers Office GPS on Prescribers vehicle Electronic Health Records

14 Expert Review In summary, after thorough review of the office charts and other information provided to me about the above twenty-nine patients, it is my medical opinion, with a high degree of medical certainty, regarding the prescribing of Controlled Substances by Prescriber that over the chronological course of treatment of these patients, Prescriber did not meet the requirements of the Medical Board of Ohio, the Ohio Administrative Code and the Ohio Revised Code in the management of chronic pain. This appears to violate Chapter 4731 of the Ohio Revised Code, specifically Section Also, in all these patient s charts, I do not believe the he/she met the usual standards of care required for the medications he prescribed. The information in total, in all of these charts, indicates the greatest majority of Controlled Substances prescribed by the Prescriber were for other than legitimate medical purposes.

15 Interviews Current and former patients Current and former employees Coroners Family and friends of deceased Family practitioners

16 Interview Quotes The medication killed my mother. Dr. XXXX murdered her (Patient X) She was always (opiate) drunk.

17 What Works Traditional law enforcement techniques *Interviews, Research, Undercover Operations & Surveillance Utilization of Healthcare Experts *Doctors, Pharmacists, Nurses and Dentists Multi-Agency Coordination *Regulatory & Law Enforcement Local, State and Federal

18 Healthcare Facility Diversion & Tampering Issues: Under Reported Media Concerns HR protection/union interference Legal concerns General lack of cooperation with law enforcement Suspect fired or allowed to quit Drug diversion is a crime! Facilities must be educated!

19 Healthcare Facility Diversion & Tampering

20 Types of Health Facility Diversion Operating Room Many different opportunities, not well monitored Waste Common, under reported Falsification PRN orders Omission Tampering

21 Drug Diversion and Patient Safety Diversion of any drug can result in patient harm Denial of pain medication or therapy Sub-standard delivery of care by impaired provider Diverting/tampering with injectable drugs = potential bacterial or viral infection

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23 On the road with David Kwiatkowski

24 On the road with David Kwiatkowski 9 years, 17 facilities, 8 states 7 staffing agencies Numerous license falsifications Co-workers report: Erratic behavior Signs of intoxication/withdraw Attendance issues NO FORMAL ACTION TAKEN!

25 On the road with David Kwiatkowski 45 patients infected with Hepatitis C Arrested by the FBI, convicted in New Hampshire and sentenced to 39 years in prison. Acknowledgments John Burke, President IHFDA Katrina Hansen, Chief of Bureau of Infections Disease Control - New Hampshire Department of Public Health