Maximizing Use of Prescription Drug Monitoring Programs

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1 Maximizing Use of Prescription Drug Monitoring Programs Christopher M..Jones, PharmD, MPH Division of Unintentional Injury Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention 1 Overview of Presentation PDMP background Status of PDMPs PDMP effectiveness Current initiatives Other prescription drug monitoring options Conclusions 2 1

Prevention and Control Centers for Disease Control and Prevention 1 Overview of Presentation

2 CDC Goal Reduce abuse and overdose of opioids and other controlled prescription drugs while ensuring patients with pain are safely and effectively treated. 3 Motor vehicle traffic, poisoning, and drug poisoning (overdose) death rates United States, Motor Vehicle Traffic Poisoning Drug Poisoning (Overdose) 25 s per 100,000 population Deaths Year NCHS Data Brief, December, 2011, Updated with 2009 and 2010 mortality data 4 2

3 Motor vehicle traffic, poisoning, and drug poisoning (overdose) death rates United States, 1980-2010 Motor Vehicle Traffic

3 Drug overdose deaths by major drug type, US, Opioids Heroin Cocaine Benzodiazepines 18,000 16,000 14,000 Number of Deaths 12,000 10,000 8,000 6,000 4,000 2, Year CDC/NCHS National Vital Statistics System, CDC Wonder 5 Rates of Opioid Overdose Deaths, Sales, and Treatment Admissions, US, Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10, Rate Year CDC MMWR updated with 2009 mortality and 2010 treatment admission data 6 3

Admissions, US, 1999-2010 Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000 8 7 6 5 Rate 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007

4 CDC public health policy options Prescription Drug Monitoring Programs (PDMPs) Patient Review & Restriction Programs Laws/Regulations/Policies Insurers & Pharmacy Benefit Managers (PBM) mechanisms Clinical Guidelines Substance Abuse Treatment 7 What are PDMPs? State databases that collect information on dispensed controlled prescriptions drugs by pharmacies (and dispensing physicians in some states) Data Collected CII-CIV prescriptions (some CV) Prescriber Dispenser Patient Date Dispensed Drug Strength Quantity Refills Method of Payment Variation in state programs 8 4

State databases that collect information on dispensed controlled prescriptions drugs by pharmacies (and dispensing physicians in some states)

5 How can PDMPs be used? Clinical Regulatory Oversight Surveillance and Evaluation Tool Law Enforcement Passive vs Proactive 9 Overview of Presentation PDMP background Status of PDMPs PDMP effectiveness Current initiatives Other prescription drug monitoring options Conclusions 10 5

Enforcement Passive vs Proactive 9 Overview of Presentation PDMP

6 Current status of PDMPs 49 States have legislation authorizing a PDMP Operational in 42 states 11 Best practices Outlines a set of best practices Research agenda PDMP Funding A few best practices 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-time data and access Share data with other states (interoperability) Integrate with other health information technology to improve use among health care providers Have ability to send unsolicited reports 12 6

public health agencies, Medical Examiners, and law enforcement (under appropriate circumstances) Provide real-time data and access Share data with other

7 Overview of Presentation PDMP background Status of PDMPs PDMP effectiveness Current initiatives Other prescription drug monitoring options Conclusions 13 PDMP effectiveness- peer-reviewed literature Research consistently suggests PDMPs reduce prescribing of schedule II opioid analgesics. One study found compensatory increases in schedule III opioids study found states with PDMPs had lower opioid substance abuse treatment rates compared to states without PDMPs. 1. Simeone R, Holland L. Washington, D.C.: U.S. Dept. of Justice, Office of Justice Programs Curtis LH, Stoddard J, Radeva JI, Hutchison S, Dans PE, Wright A, et al. Geographic variation in the prescription of schedule II opioid analgesics among outpatients in the United States. Health Serv Res ;41: Paulozzi L, Kilbourne E, Desai H. Prescription drug monitoring programs and death rates from drug overdose. Pain Medicine. 2011;12: Reisman RM, Shenoy PJ, Atherly AJ, Flowers CR. Prescription opioid usage and abuse relationships: an evaluation of state prescription drug monitoring program efficacy. Substance Abuse: Research and Treatment. 2009;3(SART-3-Shenoy-et-al):

2009 study found states with PDMPs had lower opioid substance abuse treatment rates compared to states without PDMPs. 1. Simeone R, Holland L. Washington, D.C.: U.S. Dept.

8 PDMP effectiveness- peer-reviewed literature 2012 analysis of poison control center data concluded states with PDMPs had lower annual increases in opioid misuse or abuse from 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 medication than previously planned Impact on overdose mortality has not been found, at least based on data through Reifler L, Droz D, Bailey J, Schnoll S, Fant R, Dart R, et al. Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Medicine. 2012;3(3): Baehren DF, Marco CA, Droz DE, Sinha S, Callan EM, Akpunonu P. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med ;doi: /j.annemergmed Paulozzi L, Kilbourne E, Desai H. Prescription drug monitoring programs and death rates from drug overdose. Pain Medicine. 2011;12: PDMP Effectiveness Grey Literature Surveys indicate prescribers find PDMPs to be a useful clinical tool. Surveys find clinicians in many cases report altering their prescribing after reviewing a PDMP report. Proactive reporting reduces doctor shopping by increasing awareness among providers about at-risk patients leading to changes in prescribing behaviors. 1. PMP Center of Excellence, Trends in Wyoming PMP prescription history reporting: evidence for a decrease in doctor shopping? 2010, 2. PMP Center of Excellence, Nevada s Proactive PMP: The Impact of Unsolicited Reports October, Alliance of States with Prescription Monitoring Programs, An Assessment of State Prescription Monitoring Program Effectiveness and Results Version 1, , 5. Kentucky Cabinet for Health and Family Services and Kentucky Injury Prevention and Research Center, 2010 KASPER Satisfaction Survey. 6. Lambert D. Impact evaluation of Maine s prescription drug monitoring program. Muskie School of Public Service, University of Southern Maine: Portland, Maine, March, Communication from LA PMP to PMP Center of Excellence. 16 8

PDMP data review changed prescribing in 41% of cases 61% received fewer or no opioids 39% received more opioid medication than previously planned Impact on overdose mortality has not been found, at

9 PDMP Effectiveness Grey Literature Public safety officials have endorsed the utility 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 investigative process GAO report concluded that PDMPs are a useful tool to reduce drug diversion. 1. PMP Center of Excellence. Perspective from Kentucky: using PMP data in drug diversion investigations. May, U.S. General Accounting Office. Prescription Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion. Washington, DC: U.S. General Accounting Office; Report No. GAO Overview of Presentation PDMP background Status of PDMPs PDMP effectiveness Current initiatives Other prescription drug monitoring options Conclusions 18 9

2002 GAO report concluded that PDMPs are a useful tool to reduce drug diversion. 1. PMP Center of Excellence. Perspective from Kentucky: using PMP data in drug diversion investigations. May, 2011.

10 Current PDMP Initiatives ONC SAMHSA ONDCP CDC Health Information Technology and PDMP Pilot programs SAMHSA CDC PDMP Interoperability and Electronic Health Record Integration Project ONDCP Interagency Working Group subcommittee on PDMP integration Providing technical assistance to states and others to: Focus efforts on patients at highest risk of abuse and overdose Focus on prescribers deviating from accepted medical practice Maximize surveillance and evaluation capabilities of PDMPs Bureau of Justice Assistance CDC MOU Various PDMP evaluations 19 Interoperability RxCheck (formerly PMIX) AL, KY and FL are connected ME working on MOUs with AL, KY, MA, WA, VT MA working on MOU with KY and ME PMPi (NABP) AZ, CT, IN, KS, MI, NM, ND, OH, SC, VA are connected Several other states currently working on connecting or MOUs HID AL and ME are connected (data sharing unclear) 20 10

from accepted medical practice Maximize surveillance and evaluation capabilities of PDMPs Bureau of Justice Assistance CDC MOU Various PDMP evaluations 19 Interoperability RxCheck (formerly PMIX) AL,

11 Overview of Presentation PDMP background Status of PDMPs PDMP effectiveness Current initiatives Other prescription drug monitoring options Conclusions 21 What about other monitoring programs? Insurer and pharmacy benefit manager claims data Identify high-risk patients Identify inappropriate prescribing Identify geographic patterns Drug utilization review programs can alert to high-dose opioid prescribing and other potential risky medication combinations at the point of care and point of dispensing A recent randomized trial of use of proactive reporting by an insurer rather than a PMDP suggests such reporting reduces the number of prescribers and prescriptions. 1. Gonzalez A, Kolbasovsky A. Impact of a managed controlled-opioid prescription monitoring program on care coordination. Am J Manag Care. 2012;18(9):

opioid prescribing and other potential risky medication combinations at the point of care and point of dispensing A recent randomized trial of use of proactive reporting by an insurer rather than a

12 Conclusions PDMPs are a promising intervention to address prescription drug abuse, diversion, and overdose Serve multiple purposes clinical, surveillance, evaluation, regulatory and enforcement Multiple efforts at the Federal and state level to maximize utility of PDMPs Current research will further inform evidence-base State support to implement PDMP best practices and evaluate impact is critical 23 Additional information PolicyImpact-PrescriptionPainkillerOD.pdf 3a4.htm l/mm6126a5.htm?s_cid=mm6126a5_w 12

evidence-base State support to implement PDMP best practices and evaluate impact is critical 23 Additional information http://www.cdc.

13 Thank You Christopher M. Jones, PharmD, MPH 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. 13

Prescription Drug Monitoring Programs: A State Policy to Address Prescription Opioid Poisonings. Michael Kim, MPH April 30, 2012

Prescription Drug Monitoring Programs: A State Policy to Address Prescription Opioid Poisonings Michael Kim, MPH April 30, 2012 Overview 1. Prescription Opioid Abuse and Poisoning 2. Prescription Drug