Oregon s PDMP: An epidemiological assist tool

Oregon s PDMP: An epidemiological assist tool Todd Beran Center for Prevention and Health Promotion Oregon Health Authority PDMP TTAC Webinar February 13, 2013 1

Acknowledgements Lisa Millet, MSH, Section Manager, Injury & Violence Prevention Prevention Dagan Wright, PhD, MSPH, Lead Research Analyst, Public Health Division Heidi Murphy, MPH, Research Analyst, Public Health Division Bruce Gutelius, MD, MPH, Administrator Center for Prevention & Health Promotion Katrina Hedberg, MD, MPH, Chief Science Officer, Public Health Division Data workgroup for the PDMP Gary Schnabel, RN, RPh, Executive Director, Board of Pharmacy Brad Anderson, MD, Kaiser Permanente, Chief Department of Addiction Medicine Wayne Wakeland, PhD, Associate Professor, Systems Science Program, Portland State University Ted Williams, Clinical Pharmacist, Oregon State University/Oregon Health Sciences University College of Pharmacy Drug Use Research & Management Group Rick Deyo, MD, Professor, Department of Family Medicine, Oregon Health Sciences University Sally Logan, RPh, Kaiser Permanente, Outpatient Pharmacy Quality Coordinator 2

Objectives Recognize the complex issue of overdose Explain the purpose of Oregon s PDMP data reports Identify how PDMPs can be helpful in addressing overdose from a public health framework Describe PDMP next steps and ongoing work 3

Think about how many Oregonians have medically necessary treatment with controlled substances 760,000 live with chronic pain (20%) 100,000+ are treated for injury in ED annually 213,000 have surgical visits each year (5.5%) 8,000 die of cancer 20,000 new cases of cancer each year Uncounted dental encounters to reduce pain 500,000 have an anxiety disorder (18%) Source: Statewide PDMP Data Report, Oct. 1 2011 to Mar. 31, 2012 4

450 Unintentional drug poisoning deaths by year and drug type, Oregon, 2000 to 2011 deaths Death rate per 100,000 population 12 400 350 10 300 8 250 200 150 6 4 Cocaine Heroin Prescription opioids Rate of drug poisoning 100 50 2 0 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Source: Oregon Center for Health Statistics Vital Records 5

Percentage of prescription opioid-related deaths by age group, Oregon, 2007-2011 Percentage of total deaths 35 31.99 30 25 22.9 20 18.87 15 14.73 10 9.67 5 0 0.23 1.27 0.35 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 Age Group Source: Oregon Center for Health Statistics Vital Records 6

Overdose death rate by drug type per 100,000 OR, 2000-2011 Note: a person can have more than 1 contributing drug related to their death 6.0 5.0 Heroin Prescrip. Opioid Drugs 4.0 Methadone 3.0 Benzodiazepines 2.0 Antiepileptic, sedative-hypnotic, antidepressant 1.0 Cocaine 0.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Methamphetamines and other psycholstim Source: Oregon Center for Health Statistics Vital Records

Overdose hospitalization rate by primary underlying drug per 100,000, OR, 2000-2011 14.0 Psychostimulants with abuse potential 12.0 Other,unspecified drugs 10.0 8.0 Heroin 6.0 Prescrip opioids 4.0 Benzodiazepines 2.0 Methadone 0.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Antidepressants,etc,psychotropic drugs NEC Source: Oregon Hospital Discharge Index

Frequency and percent of unintentional drug overdose deaths from more than one drug, OR, 2007-2011 188, 9% 83, 4% 24, 1% 3, 0% 4 out of 10 deaths have more than 1 drug listed as an underlying cause 1 476, 24% 2 3 1266, 62% 4 5 6 Source: Oregon Center for Health Statistics Vital Records

12 Overdose death rate by drug type per 100,000 among females by age group, OR, 2007-2011 Note: a person can have more than 1 contributing drug related to their death 10 8 6 4 2 0 15-24 25-34 35-44 45-54 55-64 65-74 Heroin Methadone Antiepileptic, sedative-hypnotic, antidepressant, other psychotropic Methamphetamines and other psychostimulants Prescrip opioids Other and unspecified narcotics Benzodiazepines Only unspecified drug mentioned Source: Oregon Center for Health Statistics Vital Records

10 Overdose death rate by drug type per 100,000 among males by age group, OR, 2007-2011 Note: a person can have more than 1 contributing drug related to their death 9 8 7 6 5 4 3 2 1 0 15-24 25-34 35-44 45-54 55-64 65-74 Heroin Methadone Antiepileptic, sedative-hypnotic, antidepressant, other psychotropic Methamphetamines and other psychostimulants Prescrip opioids Other and unspecified narcotics Benzodiazepines Only unspecified drug mentioned Source: Oregon Center for Health Statistics Vital Records

Opioid overdose: factors among decedents Washington: Medicaid population at high risk - 5.7 times higher risk of death 1 Utah: 40% of decedents had history of substance abuse; 49% diagnosed with mental illness 2 1 Centers for Disease Control and Prevention (CDC). Overdose deaths involving prescription opioids among Medicaid enrollees - Washington, 2004-2007. MMWR Morb Mortal Wkly Rep. 2009 Oct 30;58(42):1171-5 2 Utah Drug Overdose Mortality Project: http://www.health.utah.gov/prescription/ 12

Who is most at risk? A CDC policy impact report cites the following indicators for people at highest risk for prescription painkiller overdose: Take high doses of prescription painkillers Have low incomes Live in rural areas Have a history of mental illness Have a history of substance misuse are at highest risk for overdosing Source: Policy Impact: Prescription Painkiller Overdoses: http://www.cdc.gov/homeandrecreationalsafety/rxbrief/ 13

Overdose data recap Many medically necessities for use of controlled substances 53% of drug overdoses in Oregon associated with prescription opioids Over 40% of deceased have multiple drugs on board Patients with history of substance abuse and/or mental illness have greatly increased risk for overdose Medicaid population over represented in overdose data About 30% of all drug-related deaths associated with methadone Misuse, abuse, and potentiating effects contribute to deaths 14

PDMP data reports Developed by a data work group consisting clinicians, research analysts, systems analysts, and pain and addiction specialists Consist of a statewide report and county-level reports for all 36 Oregon counties Distributed to local health officials and other key stakeholder groups Examine the most often prescribed controlled substances 15

Unique recipient count for opioids by age group, statewide, OR, 10/01/11 to 03/31/12 Age (in years) Prescription Recipient Count in 6 months dispensed in 6 months dispensed per prescription recipient in 6 months people receiving prescription, per 1,000 residents dispensed per 1,000 residents 1-14 9,952 12,968 1.3 13.9 18.1 15-24 62,147 109,811 1.8 122.5 216.5 25-34 93,963 239,079 2.5 177.9 452.5 35-44 94,613 291,795 3.1 187.0 576.7 45-54 115,510 425,036 3.7 216.1 795.0 55-64 115,134 419,282 3.6 224.5 817.6 65-74 68,201 218,115 3.2 223.7 715.3 75-84 35,583 107,866 3.0 210.1 637.0 85+ 16,882 48,582 2.9 216.6 623.3 TOTAL 611,985 1,872,534 3.1 158.6 485.4 Opioids include: Hydrocodone, Oxycodone, Morphine, Methadone, Fentanyl, and Hydromorphone.

HYDROCODONE by age group, statewide, OR, 10/01/11 to 03/31/12 Age (in years) Prescription Recipient Count in 6 months dispensed in 6 months dispensed per prescription recipient in 6 months people receiving, per 1,000 residents dispensed per 1,000 residents 1-14 8,442 10,490 1.2 11.8 14.6 15-24 47,183 72,590 1.5 93.0 143.1 25-34 68,100 138,192 2.0 128.9 261.6 35-44 67,805 159,488 2.4 134.0 315.2 45-54 81,033 220,199 2.7 151.6 411.9 55-64 80,197 216,647 2.7 156.4 422.5 65-74 48,505 122,290 2.5 159.1 401.0 75-84 25,679 63,739 2.5 151.7 376.4 85+ 11,331 27,231 2.4 145.4 349.4 TOTAL 438,275 1,030,866 2.4 113.6 267.2

OXYCODONE by age group, statewide, OR, 10/01/11 to 03/31/12 Age (in years) Prescription Recipient Count in 6 months dispensed in 6 months dispensed per prescription recipient in 6 months people receiving, per 1,000 residents dispensed per 1,000 residents 1-14 1,656 2,113 1.3 2.3 2.9 15-24 20,491 34,323 1.7 40.4 67.7 25-34 35,791 83,440 2.3 67.7 157.9 35-44 35,349 96,074 2.7 69.9 189.9 45-54 42,693 135,457 3.2 79.9 253.4 55-64 40,757 127,373 3.1 79.5 248.4 65-74 22,603 61,982 2.7 74.1 203.3 75-84 10,109 26,316 2.6 59.7 155.4 85+ 4,051 10,611 2.6 52.0 136.1 TOTAL 213,500 577,689 2.7 55.3 149.8

METHADONE* by age group, statewide, OR, 10/01/11 to 03/31/12 Age (in years) Prescription Recipient Count in 6 months dispensed in 6 months dispensed per prescription recipient in 6 months people receiving, per 1,000 residents dispensed per 1,000 residents 1-14 21 66 3.1 0.0 0.1 15-24 153 519 3.4 0.3 1.0 25-34 1,298 5,626 4.3 2.5 10.6 35-44 2,333 10,855 4.7 4.6 21.5 45-54 4,086 19,238 4.7 7.6 36.0 55-64 4,083 19,200 4.7 8.0 37.4 65-74 1,437 6,135 4.3 4.7 20.1 75-84 565 2,052 3.6 3.3 12.1 85+ 292 983 3.4 3.7 12.6 TOTAL 14,268 64,674 4.5 3.7 16.8 *Does not include methadone used to treat addiction.

Unique recipient count for benzodiazepines by age group, statewide, OR, 10/01/11 to 03/31/12 Age (in years) Prescription Recipient Count in 6 months dispensed in 6 months dispensed per prescription recipient in 6 months people receiving prescription, per 1,000 residents dispensed per 1,000 residents 1-14 3,042 5,576 1.8 4.2 7.8 15-24 14,747 34,050 2.3 29.1 67.1 25-34 36,491 104,792 2.9 69.1 198.4 35-44 49,029 154,875 3.2 96.9 306.1 45-54 66,365 228,140 3.4 124.1 426.7 55-64 71,431 239,665 3.4 139.3 467.4 65-74 41,518 125,315 3.0 136.2 411.0 75-84 22,173 64,585 2.9 130.9 381.4 85+ 10,758 28,823 2.7 138.0 369.8 TOTAL 315,554 985,821 3.1 81.8 255.6 Benzodiazepines include: Alprazolam, Clonazepam, Diazepam, Lorazepam, Temazepam, and Zolpidem. *Cell sizes less than 10 for prescription recipient count have been suppressed.

Age (in years) OPIOID and BENZODIAZEPINE Combination by Age Group, Statewide, OR, 10/01/11 to 03/31/12 Prescription Recipient Count in 6 months dispensed in 6 months dispensed per prescription recipient in 6 months people receiving combination, per 1,000 residents dispensed per 1,000 residents 1-14 343 649 1.9 0.5 0.9 15-24 4,642 13,203 2.8 9.2 26.0 25-34 13,336 54,887 4.1 25.2 103.9 35-44 17,700 79,554 4.5 35.0 157.2 45-54 24,664 123,700 5.0 46.1 231.4 55-64 24,216 114,705 4.7 47.2 223.7 65-74 13,148 53,528 4.1 43.1 175.5 75-84 6,862 24,250 3.5 40.5 143.2 85+ 3,855 11,270 2.9 49.5 144.6 TOTALS 108,766 475,746 4.4 28.2 123.3 Opioids include: Hydrocodone, Oxycodone, and Morphine. Benzodiazepines include: Alprazolam, Clonazepam, Diazepam, and Lorazepam. Excludes Zolpidem that represents a chemically different class of benzodiazepine, and in which the risk of combination with opioids is thought to be somewhat lower.

How are these data reports helpful? Inform local health officials regarding prescribing practices in their areas Develop and implement population-based prevention approaches to reduce prescription drug overdose, such as public information campaigns and clinical guidance Target outreach Analyze the effects of overdose prevention efforts 22

Percentage of total CS II-IV written by prescriber cohort, OR, 1/1/12 to 9/30/12, N=49,330 21% of are written by the remaining 45,330 prescribers 19% of are written by a second cohort of 2,000 prescribers 60% of are written by a cohort of 2,000 prescribers* * Fifty-nine percent of these prescribers were authenticated system users as of 12/31/12

Sample: Methadone 10 mg tablet prescribing for XXXX County, Oregon, 2012 900 800 700 600 500 400 300 200 100 0 Jan 2012 Feb 2012 Mar 2012 Apr 2012 May 2012 Jun 2012 Jul 2012 Aug 2012 Sept 2012 Oct 2012 Nov 2012 Dec 2012 Recipient Count Rx Count 24

Additional use of PDMP data Better approximate exposure Greater potential to: Target risks Focus intervention efforts Tailor prevention programs Maximize therapeutic benefit to the population exposed 25

Selected drugs dispensed, statewide, OR, 10/1/2011 to 3/31/2012 Drug or drug type Prescription recipient count in 6 months dispensed to recipient in 6 months dispensed per prescription recipient in 6 months people receiving per 1,000 residents dispensed per 1,000 residents Methadone 14,268 64,674 4.5 3.7 16.8 Oxycodone 213,500 577,689 2.7 55.3 149.8 Hydrocodone 438,275 1,030,866 2.4 113.6 267.2 All opiods 611,985 1,872,534 3.1 158.6 485.4

Unintentional methadone and opioid overdose rate per 10,000 by exposure and population, OR, 2011 Count Crude rate/10,000 state population Crude rate/10,000 prescription recipients Methadone Hospitalizations Prescrip. Opioid Hospitalizations Methadone Deaths Prescrip. Opioid Deaths 94 0.2 52.3 386 1.0 4.0 81 0.2 45.1 179 0.5 1.9 Sources: Oregon Vital Statistics and Hospital Discharge Index

Factors among decedents in methadone overdose, OR, N=56 41% had - 30% did not Misuse or abuse contributed to death in 77% History of substance abuse in 75% History of substance abuse treatment in 21% History of mental illness in 52% Source: Injury and Violence Prevention Program, Unpublished review of Oregon Medical Examiner data, 2010 28

Why is methadone especially dangerous? For the same reason it is useful for treating pain: Long half-life Delayed onset Narrow therapeutic window Respiratory depression Cardiac arrest Interactions with other commonly used drugs Benzodiazepines Alcohol 29

Next steps Continue to look at exposure rates Support the PDMP data work group activities Examine acute versus chronic pain prescribing Analyze prescribing by discipline Explore how to measure system use Develop and support a local health department work group Analyze and revise data reports Explore practice guidelines Continue evaluation, quality assurance, and quality improvement activities 30

PDMP system accounts by discipline, OR, Sept 2011 to Dec 2012, N=5,270 PA 7% (353) ND 1% (31) RPh 17% (915) NP/CNS-PP 13% (682) DDS/DMD 6% (324) DO 5% (277) MD 51% (2,679)

Count PDMP queries by discipline, OR, Feb 2012 to Dec 2012, N=262,837 25000 20000 15000 10000 5000 0 Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec ND 102 104 150 117 68 79 76 84 99 149 156 DDS/DMD 163 384 294 420 338 400 333 457 421 389 368 RPh 1,484 1,094 1,300 1,443 1,675 1,605 1,537 2,169 2,407 2,969 3,056 NP/CNS-PP 3,416 4,126 4,278 3,829 3,367 4,033 3,804 4,443 4,417 4,467 4,079 MD, PA, and DO) 15,484 14,638 15,861 17,149 17,456 18,804 17,838 19,558 19,286 18,693 17,921

Count Average monthly number of PDMP queries per querying user by discipline, OR, May 2012 to Dec 2012 18 15 12 9 6 3 0 May Jun Jul Aug Sept Oct Nov Dec ND 9 7 5 3 7 8 12 10 DDS/DMD 10 7 4 4 7 7 7 6 RPh 8 4 4 5 7 9 10 11 NP/CNS-PP 14 11 7 6 14 14 14 13 MD, PA, and DO 15 11 16 15 15 15 14 13

0 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99 100+ providers Distribution of queries per provider, OR, Jan 2012 to Dec 2012 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 queries

Program evaluation 2012 survey results: Overall positive - program shows promise Providers who strongly agreed or agreed that it would. likely improve management of patient for controlled substances - 92% likely engender interest for most providers and pharmacists for registering as users - 92% likely increase communication between providers 80% likely have an impact 82% 35

Survey result: Most registered users indicated that the program had been very helpful in: helping to monitor patients controlled substances (65%) helping to control doctor shopping (64%) 36

Survey result: Top reasons for using the system 1. Assess controlled substance use for patients who might be over using (86% of providers and 71% of pharmacists) 2. Assess controlled substance use of new patients (72% of providers and 59% of pharmacists) 37

Survey result: Actions taken after using system Spoke with a patient about controlled substance use - 78% Confirmed patient not misusing 68% Confirmed patient was doctor shopping 59% Reduced or eliminated for a patient 59% Contacted other providers or pharmacies 49% 38

Survey result: Increased communication About 2 in 3 system users reported increased communication as a result of system use with... Patients (79%) Providers who write (67%) Clinicians and staff inside my practice (64%) Pharmacists (63%) 39

Ongoing overdose prevention work 1. Enroll top cohort of prescribers 2. Engage local public health officials in efforts to increase use of prescribing guidelines and practice improvement 3. Disseminate controlled substance toolkit resource information health care system and community level interventions 4. Develop and disseminate a tool on use of PDMP reports with patients 40

Ongoing overdose prevention work 5. Explore how to better incorporate the PDMP into the clinical workflow 6. Improve information access for behavioral health treatment providers 7. Engage county substance abuse prevention specialists to disseminate public information 8. Work with health care systems and CCOs to integrate PDMP use into health care practice 41

Oregon PDMP Website www.orpdmp.com Oregon PDMP reports can be found at http://www.orpdmp.com/reports.html 42

Questions? Todd Beran Oregon PDMP Coordinator Injury and Violence Prevention Program Public Health Division Oregon Health Authority todd.beran@state.or.us 971-673-1105 43