Harold Rogers Prescription Drug Monitoring Program Regional Meeting-Charleston, SC April 29, 2014 Andrew Holt, PharmD

Harold Rogers Prescription Drug Monitoring Program Regional Meeting-Charleston, SC April 29, 2014 Andrew Holt, PharmD

National Epidemic Highlighted numerous studies/media reports State Epidemic Highlighted several state-level studies/statistics Governor forms Public Safety Subcabinet Addresses many areas of public safety, including prescription drug abuse Overdose Deaths Overdoses NAS

Source: Tennessee Department of Health internal files, Baumblatt, et al

Source: Tennessee Department of Health internal files, Baumblatt, et al

Source: Tennessee Department of Health internal files, Baumblatt et al

Source: Department of Health internal files, Baumblatt et al

Source: Tennessee Department of Health internal files, Baumblatt et al

Number of Overdose Deaths Overdose Deaths 1200 1000 800 600 400 342 391 422 484 660 753 868 963 972 924 929 1059 1062 1094 200 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year International Classification of Diseases (ICD) version 10 cause of death codes X40-X44, X60-X64, X85, and Y10-Y14. Source: Tennessee Department of Health, Division of Policy, Planning and Assessment, Office of Health Statistics.

Administration bill introduced as a work product of the Governor s Public Safety Subcabinet Amended during the legislative process Passed by unanimous vote of both chambers on May 1, 2012 Signed by Governor Haslam on May 10, 2012.

Required registration as of January 1, 2013 Required checking of PMP as of April 1, 2013 in most cases involving the prescribing of an opioid or benzodiazepine Enabled interstate data sharing Established delegate accounts- extenders Increased administrative staffing

Automated Registration Web service established between vendor and: State professional licensing database State driver s license database Check against DEA database at vendor level Any non-matches are sent to PMP administrator for manual approval Established delegate accounts-extenders

Added capacity at vendor Hardware: Increased number of CPUs, Virtual Servers, Ram to handle 30 million transactions per year with a response time of 10.4 seconds or less in peak time; or 1,000 concurrent transactions per second with maximum query response time of 10.4 seconds per transaction during peak hours Personnel PMIX Interface Training database Use for demonstration purposes

Automated username retrieval Multiple practice locations per user Enhanced linking of extenders to supervisors Extender runs report on supervisor behalf Supervisor can run report on extenders Prescribing history and request history

Sent via email to all prescribers registered in the PDMP Over 900 responses Purpose was to seek feedback about the PDMP and the Prescription Safety Act

71% changed a treatment plan after viewing a PDMP report 73% are more likely to discuss substance abuse issues or concerns with a patient 57% are more likely to refer a patient for substance abuse treatment 79% feel that the PDMP is useful for decreasing doctor shopping

Jan 2012 Feb 2012 Mar 2012 Apr 2012 May 2012 Jun 2012 Jul 2012 Aug 2012 Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Mar 2013 Apr 2013 May 2013 Jun 2013 Jul 2013 Aug 2013 Sep 2013 Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Mar 2014 Requests per Month Number of Registrants Number of Requests/Month Number of Registrants at Month End 600000 40000 500000 35000 30000 400000 25000 300000 20000 200000 15000 10000 100000 5000 0 0 Source: Tennessee Department of Health internal files

1,200,000 1,000,000 800,000 600,000 400,000 CSMD Searches by Delegates CSMD Searches by Prescibers 200,000 0 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 2013 Source: Tennessee Department of Health internal files

Table 6. Number of Patient Requests from CSMD, 2010-2013 Year Healthcare Providers Law Enforcement 2010 1,200,435 N/A 2011 1,486,932 551 2012 1,861,485 2,565 2013 4,497,866 1,938 Source: CSMD Annual Report to the 108th General Assembly, 2014

Table 2. Number of Controlled Substances Prescriptions (by class) Reported to CSMD, 2010-2013* Year Opioids % Change Benzodiazepines % Change Other % Change 2010 8,150,946-3,951,144-4,423,662-2011 9,018,139 10.6 4,152,587 5.1 5,001,445 13.1 2012 9,265,450 2.7 4,061,418-2.2 5,125,142 2.5 2013 9,227,456-0.4 3,913,356-3.6 5,433,347 6 * Classes of controlled substances were defined based on CDC guidance document. Source: CSMD Annual Report to the 108th General Assembly, 2014

Table 3. Comparison of the 10 most frequently prescribed products in 2012 and 2013 in CSMD Rank 2013 2012 1 Hydrocodone products Hydrocodone products 2 Alprazolam Alprazolam 3 Oxycodone products Oxycodone products 4 Zolpidem Zolpidem 5 Tramadol Tramadol 6 Clonazepam Clonazepam 7 Lorazepam Lorazepam 8 Diazepam Diazepam 9 Morphine products Buprenorphine products 10 Buprenorphine products Morphine products Source: CSMD Annual Report to the 108th General Assembly, 2014

Source: CSMD Annual Report to the 108th General Assembly, 2014

C-II Controlled Substances Year Rx s Per Capita (TN Rank lower is better) 2008 TN: 0.53/person (4) US: 0.39/person 2012 TN: 0.64/person (2) US: 0.41/person 2013 TN: 0.68/person (2) US: 0.42/person Percent Change in Filled Rx s from Previous Year (TN Rank lower is better) N/A TN: 7.4% (23) US: 7.0% TN: 0.3% (31) US: 0.7% 24 Source: IMS Health, Inc.

MME in Billions 10.0 9.8 9.6 9.4 9.2 9.0 8.8 8.6 8.4 8.2 2010 2011 2012 2013 MME Reported by Newly Reporting Dispensers MME Reported by All Other Sources 25 Source: Tennessee Department of Health Internal Files, February 2014

Source: CSMD Annual Report to the 108th General Assembly, 2014

Patient Requests (in Millions) High Utilization Patients 5.0 10000 4.5 4.0 3.5 9000 8000 7000 Number of Searches Made by Prescibers, Dispensers, and Delegates 3.0 6000 2.5 2.0 1.5 1.0 0.5 5000 4000 3000 2000 1000 High Utilization Patients: Patients filled 5 or more prescriptions with different DEA Prescribers at 5 or more different DEA dispensers within 90 days. 0.0 2010 2011 2012 2013 0 27 Source: Tennessee Department of Health Internal Files, February 2014

Dr. David Udoko Keshia Evans James Graddey David Jones Debora Sanford (Project Manager) Dr. Zhi Chen (Epidemiologist)

Andrew Holt, PharmD Director Tennessee Controlled Substance Monitoring Database 665 Mainstream Dr. Nashville, TN 37243 615-253-1300 Andrew.holt@tn.gov