New pdmp developments_final

New PDMP Developments

LCDR Chris Jones, PharmD, MPH Prescrip3on Drug Overdose Team, Division of Uninten3onal Injury Preven3on, Centers

for Disease Control and Preven3on

Josh Bolin Government Affairs Director, Na3onal Associa3on of Boards of Pharmacy

Marty Allain Director, INSPECT

Learning Objec3ves

1.  Explain a Prescrip3on Drug Monitoring Program (PDMP)

2.  Inves3gate the efficiency and effec3veness of state-‐level programs to make improvements.

3.  Outline strategies to enhance collabora3ons with law enforcement, prosecutors, treatment professionals, the medical community, pharmacies, and regulatory boards to establish a comprehensive PDMP strategy.

Prescrip;on Drug Monitoring Programs The Na;onal Perspec;ve

Christopher M. Jones, PharmD, MPH LCDR, US Public Health Service

Centers for Disease Control and Preven3on April 2 – 4, 2013

Omni Orlando Resort at ChampionsGate

Learning Objec;ves

•  Describe the current PDMP landscape in the US

•  Discuss the role of PDMPs in reducing prescrip3on drug abuse and overdose

•  Describe the evidence-‐base suppor3ng PDMPs

•  Describe PDMP best prac3ces

•  Discuss new opportuni3es for PDMPs

5

Overview of Presenta;on

•  PDMP background and role

•  PDMP best prac;ces •  PDMP effec;veness

•  Current ini;a;ves

Presenta;on overview

Prescrip;on Drug Abuse Preven;on Plan

•  Blueprint for Federal Agency efforts on prescrip3on drug abuse

•  4 focus areas –  Educa3on –  Prescrip3on Drug Monitoring Programs

–  Proper Medica3on Disposal

–  Enforcement

What are PDMPs? •  State databases that collect informa3on on controlled

prescrip3ons drugs dispensed by pharmacies (and dispensing physicians in some states)

•  Data Collected –  CII-‐CIV drugs (some CV)

–  Prescriber

–  Dispenser

–  Pa3ent

–  Date dispensed

–  Drug

–  Strength

–  Quan3ty

–  Refills

–  Method of payment

•  Varia3on in state programs

8

How can PDMPs be Used?

•  Clinical

•  Regulatory Oversight •  Surveillance and Evalua;on Tool

•  Law Enforcement •  Passive vs Proac;ve

9

Current Status of PDMPs   49 States have legisla;on authorizing a PDMP

  Opera;onal in 43 states

10



•  PDMP goals and best prac;ces •  PDMP effec;veness


Presenta;on Overview

PDMP Goals

•  All states have PDMPs

•  Mechanisms in place for communica3on between states (interoperability)

•  Incorporated in to normal workflow by leveraging HIT (EHRs/HIEs)

•  High u3liza3on among healthcare providers

•  Improved clinical care and reduced misuse, abuse, and overdose from controlled substances

12

PDMP Best Prac;ces •  Outlines a set of best prac;ces

•  Research agenda

•  PDMP Funding

•  A few best prac;ces •  Allow access to prescribers and dispensers

•  Allow access to regulatory boards, state Medicaid and public health agencies, Medical Examiners, and law enforcement (under appropriate circumstances)

•  Provide real-‐3me data

•  Share data with other states (interoperability)

•  Integrate with other health informa3on technologies to improve use among health care providers

•  Have ability to send unsolicited reports

•  Use PDMP data to iden3fy high-‐risk pa3ents

•  Use PDMP data to iden3fy outlier prescribers

13






14

PDMP Effec;veness peer-‐reviewed literature

•  Research consistently suggests PDMPs reduce prescribing of schedule II opioid analgesics. •  One study found compensatory increases in

schedule III opioids.

•  2009 study found states with PDMPs had lower opioid substance abuse treatment rates compared to states without PDMPs.

•  A recent randomized trial of use of proac;ve repor;ng by an insurer rather than a PMDP suggests such repor;ng reduces the number of prescribers and prescrip;ons.

1. Simeone R, Holland L. Washington, D.C.: U.S. Dept. of Jus3ce, Office of Jus3ce Programs2006 2006. hgp://www.simeoneassociates.com/simeone3.pdf 2. Cur3s LH, Stoddard J, Radeva JI, Hutchison S, Dans PE, Wright A, et al. Geographic varia3on in the prescrip3on of schedule II opioid analgesics among outpa3ents in the United States. Health Serv Res. 2006 2006;41:837-‐55. 3. Paulozzi L, Kilbourne E, Desai H. Prescrip3on drug monitoring programs and death rates from drug overdose. Pain Medicine. 2011;12:747-‐54. 4. Reisman RM, Shenoy PJ, Atherly AJ, Flowers CR. Prescrip3on opioid usage and abuse rela3onships: an evalua3on of state prescrip3on drug monitoring program efficacy. Substance Abuse: Research and Treatment. 2009;3(SART-‐3-‐Shenoy-‐et-‐al):41. 5. Gonzalez A, Kolbasovsky A. Impact of a managed controlled-‐opioid prescrip3on monitoring program on care coordina3on. Am J Manag Care. 2012;18(9):516-‐24.

15

PDMP Effec;veness peer-‐reviewed literature

•  2012 analysis of Poison Control Center data concluded states with PDMPs had lower annual increases in opioid misuse or abuse from 2003-‐2009

•  Use of PDMP data in an ED suggests it can change prescribing. PDMP data review changed prescribing in 41% of cases •  61% received fewer or no opioids •  39% received more opioid medica3on than previously planned

•  Impact on overdose mortality has not been found, at least based on data through 2005.

1. Reifler L, Droz D, Bailey J, Schnoll S, Fant R, Dart R, et al. Do prescrip3on monitoring programs impact state trends in opioid abuse/misuse? Pain Medicine. 2012;3(3):434-‐42. 2. Baehren DF, Marco CA, Droz DE, Sinha S, Callan EM, Akpunonu P. A statewide prescrip3on monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2009 2009;doi:10.1016/j.annemergmed.2009.12.011. 3. Paulozzi L, Kilbourne E, Desai H. Prescrip3on drug monitoring programs and death rates from drug overdose. Pain Medicine. 2011;12:747-‐754.

16

PDMP Effec;veness grey literature

•  Surveys indicate prescribers find PDMPs to be a useful clinical tool.

•  Surveys find clinicians in many cases report altering their prescribing a]er reviewing a PDMP report.

•  Proac;ve repor;ng reduces doctor shopping by increasing awareness among providers about at-‐risk pa;ents leading to changes in prescribing behaviors.

1. PMP Center of Excellence, “Trends in Wyoming PMP prescrip3on history repor3ng: evidence for a decrease in doctor shopping?” 2010, hgp://www.pmpexcellence.org/sites/all/pdfs/NFF_wyoming_rev_11_16_10.pdf 2. PMP Center of Excellence, “Nevada’s Proac3ve PMP: The Impact of Unsolicited Reports” October, 2011. hgp://www.pmpexcellence.org/sites/all/pdfs/nevada_nff_10_26_11.pdf 4. Alliance of States with Prescrip3on Monitoring Programs, “An Assessment of State Prescrip3on Monitoring Program Effec3veness and Results” Version 1, 11.30.07, hgp://pmpexcellence.org/pdfs/alliance_pmp_rpt2_1107.pdf 5. Kentucky Cabinet for Health and Family Services and Kentucky Injury Preven3on and Research Center, 2010 KASPER Sa3sfac3on Survey. 6. Lambert D. Impact evalua3on of Maine’s prescrip3on drug monitoring program. Muskie School of Public Service, University of Southern Maine: Portland, Maine, March, 2007. 7. Communica3on from LA PMP to PMP Center of Excellence.

17

PDMP Effec;veness grey literature

•  Public safety officials have endorsed the u3lity of PDMPs.

•  A 2010 survey found 73% of KY law enforcement officers who used PDMP data strongly agreed that the PDMP was an excellent tool for obtaining evidence in the inves3ga3ve process.

•  2002 GAO report concluded that PDMPs are a useful tool to reduce drug diversion.

1. PMP Center of Excellence. Perspec3ve from Kentucky: using PMP data in drug diversion inves3ga3ons. May, 2011. hgp://www.pmpexcellence.org/sites/all/pdfs/NFF_kentucky_5_17_11_c.pdf 2. U.S. General Accoun3ng Office. Prescrip3on Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion. Washington, DC: U.S. General Accoun3ng Office; 2002. Report No. GAO-‐02-‐634

18





19

Current PDMP Ini;a;ves •  Interoperability

•  Health Informa;on Technology and PDMP Pilot programs •  PDMP Interoperability and Electronic Health Record

Integra;on Project

•  Interagency Working Group subcommi^ee on PDMP integra;on

•  Providing technical assistance to states and others to: •  Focus efforts on pa3ents at highest risk of abuse and overdose •  Focus on prescribers devia3ng from accepted medical prac3ce

•  Maximize surveillance and evalua3on capabili3es of PDMPs

•  PDMP evalua;ons

20

Conclusions

•  PDMPs can be very useful for clinical, surveillance, evalua;on, and regulatory purposes

•  Best prac;ces need to be implemented to maximize u;lity of PDMPs

•  Incorpora;on into clinical workflow can increase u;liza;on among health care providers

•  Public health and public safety must partner to make the most use of PDMP data

Christopher M. Jones, PharmD, MPH [email protected]

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.

Josh Bolin Government Affairs Director

PMIX Architecture

•  Harold Rogers Prescrip3on Drug Monitoring Program Grants

•  Sponsored by the Bureau of Jus3ce Assistance •  Prescrip3on Monitoring Program Informa3on Exchange (PMIX) Architecture is an interoperability infrastructure that seeks to facilitate interstate data sharing between PMPs or “Hubs”

Problems with PMPs: •  Persons engaging in doctor shopping don’t stay in one state,

par3cularly areas that border other states •  Querying the state PMP may not give a complete picture to a

physician or pharmacist of the controlled substances a person is obtaining

•  Low U3liza3on/Lack of Integra3on •  PMPs lack func3on and Analy3cal Tools

•  Creates interoperability for individual state PMPs via a hub system

•  Authorized users log into their own state PMP and check boxes for other par3cipa3ng states from which they want data

•  The hub routes the requests to the various states and the informa3on back to the authorized user in one collated report

•  All protected health informa3on is encrypted and not visible to the hub, secure, and HIPAA compliant –  No protected health informa3on stored by the hub, just a pass through

from one state to the authorized requestor in another state

•  Easy for states –  Only sign one memorandum of understanding (MOU)/contract with

NABP – do not have to sign one for every other state to exchange data

–  Each state’s rules about access are enforced automa3cally by the hub

•  Governed by states via PMP InterConnect Steering Commigee

•  July 2011 went live and today…since launch, PMP InterConnectTM has processed nearly 1.5 million requests in an average of 7.8 seconds to process a request.

Cost for States to Par3cipate •  $0 par3cipa3on costs, although may incur

some costs by their own PMP sovware

companies

•  NABP paying from its own revenues (exams/

accredita3ons)

•  Harold Rogers Prescrip3on Monitoring

Program Grants

•  NABP Founda3on Grants

•  14 PMPs-‐-‐Arizona, Connec3cut, Illinois, Indiana, Kansas, Michigan, New Mexico, North Dakota, Ohio, South Carolina, South Dakota, and Virginia are ac3vely sharing data

•  Colorado, Delaware, Louisiana, Tennessee and West Virginia should all be connected and sharing data by the end of Q2

•  Arkansas, Idaho, Minnesota, Mississippi, Nevada and Utah have executed agreements to par3cipate

Integra3on Projects

•  Leveraging our growing “na3onal network” •  Guidance from PMP InterConnect Steering Commigee

•  ONC Pilots •  3rd Party Inquiries

– Networks – Electronic Medical Records – Pharmacy – Health Informa3on Exchanges

MAPS/Electronic Prescribing Sovware

MAPS/Electronic Prescribing Sovware

PDMP Workshop: Data Integra;on

April 2 – 4, 2013 Omni Orlando Resort

at ChampionsGate

Topics for Discussion

•  Status of Indiana PDMP pre-‐data integra3on and mo3va3on to increase use;

•  Challenges to using program via Web; •  Integra3on efforts and INPC partner; •  Pilot I results; •  Integra3on efforts + NarxCheck; and •  Pilot II results.

LICENSE TYPE UNREGISTERED REGISTERED TOTAL % REGISTERED CLINICAL NURSE SPECIALIST 61 73 134 54% CSR-‐CERTIFIED NURSE MIDWIFE 42 16 58 28% CSR-‐OSTEOPATHIC PHYSICIAN 680 524 1204 44% CSR-‐PHYSICIAN 10885 5256 16141 33% DENTIST 2030 1149 3179 36% NURSE PRACTITIONER 1599 1382 2981 46% PHARMACIST 7002 2903 9905 29% PHYSICIAN ASSISTANT 362 250 612 41% PODIATRIST 229 101 330 31% RESIDENT 1204 95 1299 7% VETERINARIAN 1360 34 1394 2% TOTALS 25454 11783 37237 32%

Username: Mallain Password: 27%9874M

Workflow Ready

•  There was a 58% reduc;on in either prescrip3ons wrigen or number of pills prescribed.

•  In 72% of cases there was more informa;on in the report than the physician was aware of.

•  100% reported that integrated report was easier to use.

•  2 out of 3 accessing report in INPC not registered w/ INSPECT •  Worst offenders are less ac3ve

•  Requests increased from 5,000 to 9,000 daily

•  “I have to say that this is probably one of the more genius moves of the 21st century. Having easy access to INSPECT without going to a totally different website and have it pop up instantly has taken a lot of Eme off of decision making for me. Thanks for spearheading it.” Wishard ER Physician

Pilot I Survey Results

START DATE

END DATE 8+ 9+ 10+

1 11/9/2011 1/8/2012 146 66 33

2 11/16/2011 1/15/2012 134 67 37

3 11/23/2011 1/22/2012 135 71 38

4 11/30/2011 1/29/2012 136 59 39

5 12/7/2011 2/5/2012 125 63 41

6 12/14/2011 2/12/2012 133 61 35

7 12/21/2011 2/19/2012 130 71 37

8 12/28/2011 2/26/2012 143 64 32

START DATE

END DATE 8+ 9+ 10+

2 11/14/2012 1/13/2013 116 51 25

3 11/21/2012 1/20/2013 109 52 22

4 11/28/2012 1/27/2013 107 30 29

5 12/5/2012 2/3/2013 107 47 26

6 12/12/2012 2/10/2013 105 39 19

7 12/19/2012 2/17/2013 101 38 14

8 12/26/2012 2/24/2013 102 43 13

WEEK 8+ 9+ 10+ 1 -23 -20 -12 2 -13 -24 -32 3 -19 -27 -42 4 -21 -49 -26 5 -14 -25 -37 6 -21 -36 -46 7 -22 -46 -62 8 -29 -33 -59

# Pts. w/ 8+ Rxs. in 60 days

Patient, Dummy, DOB: 25-Apr-1973 (39 yrs) Male





Pilot II Preliminary Findings

Documents

New pdmp developments_final