High-Decile Prescribers: All Gain, No Pain? Len Paulozzi, MD, MPH National Center for Injury Prevention and Control Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Unintentional Injury Prevention 1
Outline of Presentation Background on the problem Examples of high-decile prescribers Addressing the problem through prescribers 2
Deaths Drug-induced vs types of injury deaths United States, 1999 2007 50,000 40,000 30,000 Druginduced deaths 20,000 10,000 0 Motor vehicle crash Suicide Injury by firearm Homicide 99 00 01 02 03 04 05 06 07 Year 3
Death rate per 100,000 10 9 8 7 6 5 4 3 2 1 0 Unintentional drug overdose deaths United States, 1970 2007 27,658 unintentional drug overdose deaths in 2007 '70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 National Vital Statistics System, http://wonder.cdc.gov 4
Number of deaths Unintentional overdose deaths by major drug type, U.S., 1999-2007 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Opioid analgesic Cocaine Heroin '99 '00 '01 '02 '03 '04 '05 '06 07 Source: National Vital Statistics system, multiple cause of death dataset 5
Unintentional opioid overdose deaths and per capita sales of opioid analgesics by year, U.S., 1997-2007 14000 12000 10000 8000 6000 4000 2000 0 Number of Deaths '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 * Opioid sales (mg/person) 800 700 600 500 400 300 200 100 0 Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS * 2007 opioid sales figure is preliminary. 6
Public Health Impact of Opioid Analgesic Use For every 1 overdose death there are Abuse treatment admissions 9 ED visits for misuse or abuse 35 People with abuse/dependence 161 Nonmedical users 461 Treatment admissions are for primary use of opioids from Treatment Exposure Data set Emergency department (ED) visits are from DAWN,Drug Abuse Warning Network, https://dawninfo.samhsa.gov/default.asp Abuse/dependence and nonmedical use in the past month are from the National Survey on Drug Use and Health 7
Far-reaching Public Health Impact of Widespread Opioid Analgesic Use Mental impairment leads to other types of unintentional injuries Falls and fractures among elderly Motor vehicle crashes involving drugged driving Substance abuse leads to intentional injuries Drug-related suicides and drug-crime-related interpersonal violence Intravenous use of drugs leads to infections HIV or hepatitis transmission related to injection of dissolved tablets Use during pregnancy can lead to reproductive health effects Congenital defects Newborn withdrawal syndrome 8
Meet Dr. Michael Brown of Cape Cod, MA Dr. Brown wrote for a third of all OxyContin pills dispensed in Massachusetts in 2004. http://www.boston.com/news/local/massachusetts/articles/2005/08/26/state_pulls_cape_cod_doctors_license/ 9
Meet Dr. Felix Lanting of Staten Island, NY Dr. Lanting wrote oxycodone prescriptions for 10-15 patients an hour for over two years. http://www.silive.com/eastshore/index.ssf/2010/11/staten_island_doctor_felix_lan_2.html 10
Percentage Leading types of prescribers of opioid analgesics, U.S., 2009 35 30 28.8 25 20 15 14.6 10 8.0 7.7 5 0 Primary care Internists Dentists Orthopedic surgeons Volkow ND, et al. Characteristics of opioid prescriptions in 2009. JAMA 2011;305:1299-1300. 11
Percentage of total prescriptions written Percentage of total CSII opioid prescriptions written by prescribers ranked by volume, CA Workers Compensation, 2005-2009 90 80 70 60 50 40 30 20 10 0 76.4 12 0.4 0.4 0.4 0.6 0.9 1.4 2.4 4.9 1 2 3 4 5 6 7 8 9 10 Deciles of prescribers from lowest to highest volume Swedlow et al. Prescribing patterns of schedule II opioids in California Workers Compensation, CWCI Institute, 2011 12
Prescriptions per patient Average number of rx per patient by prescribers ranked by volume, CA Workers Compensation, 2005-2009 12 10 8 9.6 6 5.5 4 2 1 1 1 1.1 1.4 1.8 2.3 3.6 0 1 2 3 4 5 6 7 8 9 10 Deciles of prescribers from lowest to highest volume Swedlow et al. Prescribing patterns of schedule II opioids in California Workers Compensation, CWCI Institute, 2011 13
Milligrams per Prescription Average prescription size by prescribers ranked by volume, CA Workers Compensation, 2005-2009 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 3764 2539 1884 2170 1232 1217 1236 1381 1517 1022 1 2 3 4 5 6 7 8 9 10 Deciles of prescribers from lowest to highest volume Swedlow et al. Prescribing patterns of schedule II opioids in California Workers Compensation, CWCI Institute, 2011 14
CSII opioid prescriptions written by prescribers by rank, CA Workers Compensation, 2005-2009 Characteristic First Percentile (Top 1 Percent) 41 st -50 th Percentile Avg. number patients (claims) 53 1.4 Avg. number prescriptions per patient (claim) Avg. morphine equivalent milligrams (mg) per prescription Avg. daily dose (assuming 30 days per prescription) Percent of total morphine mg. accounted for by this group Percent of prescriptions accounted for by this group 15.5 1.8 4,287 mg. 1,517 mg. 143 mg. 51 mg. 41% 1% 33% 1% Swedlow et al. Prescribing patterns of schedule II opioids in California Workers Compensation, CWCI Institute, 2011 15
Risk (Odds Ratio) High opioid dosage is associated with overdose 10 9 8 7 6 5 4 3 2 1 0 8.87 3.73 1 1.44 1-19 20-49 50-99 100+ Opioid dosage (mg/d) Dunn et al, Opioid prescriptions for chronic pain and overdose. Ann Int Med 2010;152:85-92. 16
Percent of opioid prescriptions Rx per 1,000 people Prescription rate and percent of opioid prescriptions by prescriber volume, Public Drug Program, Ontario, Canada, 2006 100 90 80 70 60 50 40 30 20 10 0 71.7 1.1 3.4 7.4 16.3 1 2 3 4 5 Quintiles of prescribers from lowest to highest prescribing rate 1000 900 800 700 600 500 400 300 200 100 0 Dhalla, IA et al. Clustering of opioid prescribing and opioid-related mortality among family physicians in Ontario. Can Fam Physician 2011;57:e92-6 17
Number of prescriptions Range of number of CS II-V prescriptions for each prescriber decile ranked by volume, KY 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 26,072 41,191 2005 2006 2007 2008 2009 Top decile 9th 8th 7th 6th 5th 4th 3rd 2nd Lowest decile Blumenschein, K, et al. Independent Evaluation of the Impact and Effectiveness of the Kentucky All Schedule Prescription Electronic Reporting Program (KASPER) Institute for Pharmaceutical Outcomes and Policy, Univ of Kentucky, 2010 18
Percent of prescriptions Percent of CS II-V prescriptions prescribed by prescriber decile by year, KY, 2009 100 90 80 70 60 50 40 64.3 Top decile 9th 8th 7th 6th 5th 4th 30 20 10 17.9 8.4 3rd 2nd Lowest decile 0 2009 Blumenschein, K, et al. Independent Evaluation of the Impact and Effectiveness of the Kentucky All Schedule Prescription Electronic Reporting Program (KASPER) Institute for Pharmaceutical Outcomes and Policy, Univ of Kentucky, 2010 19
Percent of prescriptions Percent of CS II-V prescriptions by prescriber decile by year, KY, 2009 100 90 80 70 60 50 40 30 20 10 0 64.3 17.9 8.4 2009 Top 20% of prescribers accounted for 82.2% of all prescriptions. Blumenschein, K, et al. Independent Evaluation of the Impact and Effectiveness of the Kentucky All Schedule Prescription Electronic Reporting Program (KASPER) Institute for Pharmaceutical Outcomes and Policy, Univ of Kentucky, 2010 20
CS II-V controlled substance prescriptions per hour by prescriber rank by year, KY Year Median 80th %ile 90th %ile Highest Prescriber 2005 0.07 0.43 0.94 13.04 2006 0.07 0.43 0.96 14.85 2007 0.07 0.44 1.01 15.30 2008 0.06 0.40 0.95 17.32 2009 0.07 0.43 1.03 20.60 Calculated from Blumenschein et al. Independent Evaluation of the Impact and Effectiveness of the Kentucky All Schedule Prescription Electronic Reporting Program. Institute for Pharmaceutical Outcomes and Policy, Univ of Kentucky, 2010 21
Top prescribers in Medicaid program, Texas, 2009 Top 72 prescribers wrote 25 rx/week to Medicaid clients for antipsychotics and sedatives Top prescriber wrote 260/week, 6-7 per hour ~40% of the top 72 had been disciplined by the Texas Medical Board By comparison, the Board disciplines fewer than 1% of state physicians each year. Suggests that top prescribers are more likely to be engaged in inappropriate prescribing. Barbee, D. Some doctors handing out prescriptions to kids for potent medications. Fort Worth Star-Telegram, Dec. 11, 2010 22
Prescribers have not been the focus of the conversation about drug diversion Prescribers do not appear as statistics in medical examiner or emergency department files Prescribers are not the target of substance abuse surveys With the exception of pill mill bills in a few states, most of the recent legislative concern has been with doctor shopping, not patient recruitment. 23
Barriers to focusing on prescribers Numerous state laws now protect prescribers from prosecution, whereas only a few so-called Good Samaritan immunity laws protect the patients. Prescribers are often fiercely independent and have higher status, professional organizations, and more legal resources than patients. The chilling effect myth that good prescribers will be too frightened to prescribe if scrutinized. 24
Reasons to focus on prescribers Cost-effectiveness Many fewer prescribers than patients. ~700,000 prescribers ~9 million people taking prescribed opioids in a typical month Each proactive report on a prescriber goes to one or a few agencies, not every doctor that a patient may have seen, so workload is reduced. At least 80% of the proactive reports on patients are going to the doctors prescribing most. They may be less influenced than other prescribers. Social justice Why should dated or dishonest prescribers feel none of the pain? 25
Reasons to focus on prescribers High-decile prescribers are currently targeted by pharmaceutical industry for aggressive marketing and rewarded for high volume. Patients are physiologically dependent, so behavioral change may be more difficult for them than for high-decile providers, who are only financially dependent. Consistency with public health approach to other epidemics 26
Salmonellosis from eggs o Low risk when providers meet safety standards o Try to prevent by educating consumers re cooking and handling o Some people take risks o Some providers (farms) distribute dirty dozens Overdoses from opioids Low risk when prescribed cautiously, eg, low doses Try to prevent by educating patients re safe use of drugs Some people take risks Some prescribers write for dangerous amounts 27
Approach to Epidemic Salmonellosis o Bad eggs can sometimes be tracked back to farms. o We dispose of unused eggs from bad lots. o We mandate changes among egg providers. o We educate the egg users. Approach to Epidemic Opioid Overdoses Drugs can sometimes be tracked back to prescriber. We dispose of unused drugs. We recommend educating the prescribers. We prosecute the drug users. 28
Recommendations for PDMPs for addressing bad eggs Proactive reporting of high-decile prescribers who are using CS inappropriately Seek authority if PDMP does not have it Evaluate what happens after a report using PDMP data If reporting is not effective, make changes Sharing PDMP data with state Medicaid programs and peer review organizations Requiring dispensing physicians to report to PDMPs 29
Other recommendations for addressing bad eggs Changing institutional policies Hospital policies for EDs requiring prescriber adherence Medicaid /insurers denial of claims Enhance reach, authority, and effectiveness of state medical boards Tailoring the approach to the root cause Some prescribers require education, others prosecution or economic penalties, e.g., cancellation of state Medicaid contracts Do not delay initiating and escalating enforcement actions when necessary 30
Thank You The findings and conclusions in this report are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention. National Center for Injury Prevention and Control Division of Unintentional Injury Prevention
Extra slides National Center for Injury Prevention and Control Division of Unintentional Injury Prevention
Daily dosage in mg morphine Distribution of mean daily opioid dose, patients with chronic pain, private insurance, 2005 250 200 230 150 100 100 50 38 72 0 0 10 20 30 40 50 60 70 80 90 100 Percentile among patients Edlund et al. J Pain Symp Manage 2010;40:279289 33
Percentage of total opioids consumed Percentage of total opioids consumed by patient consumption level, patients with chronic pain, private insurance, 2005 90 80 70 60 50 40 30 20 10 0 0.2 0.3 0.5 0.7 0.8 1.5 1.9 3.7 8.4 81.8 Daily Dosage in Milligrams of Morphine Edlund et al. J Pain Symp Manage 2010;40:279289 34