OBJECTIVES. ! Understand the rising epidemic of prescription drug abuse in Wyoming. ! Know how to access and use reports from the WORx program

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1 Full source: Wyoming Survey & Analysis Center (2013). Wyoming Prevention Needs Assessment: Interactive Graphing. Laramie, WY: University of Wyoming. ( Full Source: Wyoming Department of Education (2014). Youth Risk Behavior Survey. Cheyenne, WY: Wyoming Department of Education. ( ' PRESCRIPTION DRUG ABUSE IN WYOMING! David Wills, WORx Manager! Travis Beck, PharmD Candidate! Mary Walker, Executive Director! WY State Board of Pharmacy OBJECTIVES! Understand the rising epidemic of prescription drug abuse in Wyoming! Know how to access and use reports from the WORx program! Understand regulations and tips regarding prescribing controlled substances WYOMING! Population is roughly 582,000 residents! 3,476 Active Controlled Substance Registrants! 182 Active pharmacies, resident retail and Institutional TRENDS! In 2010, there were approximately 2.4 million opioid abusers in the United States.! Between 1992 and 2000, a 225% increase is seen in the number of new opioid abusers.! 60% of the opioids obtained are through physician s prescriptions! In the past year, physicians at Wyoming Medical Center treated 112 cases of poisoning related to opiate medications, up from 95 the previous year and 82 the year before that " Source: Department of Psychiatry, Stanford University, Stanford, CA and the Wyoming Health Department 50.0% 50.0%! According to Wyoming s vital statistics, the average age of those who died from a prescription overdose was 43 years old. Prescription drug related deaths affects all ages, both males and females and is not occupational centered. 40.0% 30.0% 20.0% 10.0% 0.0% Lifetime 14.3% 14.5% 11.7% 30-Day 5.9% 6.0% 4.4% Lifetime 30-Day Source: Wyoming Prevention Needs Assessment, Students were asked two questions related to prescription drug abuse: On how many occasions (if any) have you used a prescription medication to get high in your lifetime? On how many occasions (if any) have you used a prescription medication in the past 30 days to get high? 40.0% 30.0% 20.0% 10.0% 0.0% Lifetime 19.5% 19.1% Source: Youth Risk Behavior Survey, Students were asked a single question related to prescription drug abuse: During your life, how many times have you taken a prescription drug (such as OxyContin, Percocet, Vicodin, codeine, Adderall, Ritalin, or Xanax) without a doctor's prescription? 1'

2 ' SCHEDULED DRUGS! Developed by The Controlled Substances Act of 1970! Currently there are 5 Schedules " Schedule I: no accepted medical use, high potential of abuse. # Example: heroin, ecstasy " Schedule II: accepted medical use with severe restrictions with high potential for abuse # Example: codeine, morphine " Schedule III: accepted medical use with moderate to low potential for abuse # Example: vicodin, suboxone " Schedule IV: accepted medical use with potential for abuse, but less than Schedule III # Example: valium, ambien " Schedule V: accepted medical use with low potential for abuse # promethazine with codeine! State and local laws may be more restrictive PDMP-WHAT IS IT?! The Wyoming State Board of Pharmacy established a Prescription Drug Monitoring Program in July, 2004, as authorized in W.S ! Doctor and pharmacist participation went from 1,500 a quarter at the beginning of the program to nearly 5,000 a quarter. (Source: Wyoming Online Prescription Database Coordinator, David Wills)! 1,171,179 prescriptions for controlled meds filled in 2010 " 2.2 prescriptions for every person in Wyoming per year. PURPOSE OF A PRESCRIPTION MONITORING PROGRAM PMPs provide:! A Tool for prescribers and dispensers to identify and prevent abuse, misuse, or addiction! A Tool for law enforcement to inhibit and prevent diversion HOW THE WYOMING PRESCRIPTION DRUG MONITORING PROGRAM WORKS! Solicited Profiles! As of July 17 th 2013! Patient activity reports can be accessed online at worxpdmp.com! Once a prescriber or pharmacist is registered access is 24/7! Requests still can be made by fax through the office during the week! Law enforcement & Regulatory agencies still have to send in a request Unsolicited Profiles! Second week of each month, a query is run using the Board of Pharmacy parameters! Each letter is prepared and sent to each physician and pharmacy listed for the previous month on each of the patient s report! Practitioners can also request the patient s report sent out Section 4. Unsolicited Patient Profiles The board may generate patient profiles based on information showing use of controlled substances, which is in excess of established parameters. Profiles generated will be mailed to each pharmacy and practitioner where the patient was seen. A letter of explanation will accompany each profile USE OF PARAMETERS! First part of each month a query is generated for the previous month! Wait until all the data is in from all pharmacies, we are at 100% reporting each month! Letters are sent to each practitioner and each pharmacy USE OF PARAMETERS, CONT! Wyoming Board of Pharmacy does have a set of parameters, but! That hasn t always been the case to send out unsolicited profiles! Before we were online I manually faxed the reports back to the practitioners, so I saw almost every patient s report! I also sent out unsolicited reports based on some numbers and types of drugs! Can send to Law Enforcement and Regulatory Agencies David'N.'Wills,'MBA,'PA7C,'MD Wills'Drive'Urgent'Care 5858'Kenosha'Street Cheyenne,'WY'82001' ' Dear'PracHHoner,' The' Board' of' Pharmacy s' WORx' Program' monitors' the' controlled' substance' prescriphons' dispensed'in'wyoming'for'potenhal'abuse'problems.'asached'you'will'find'a'pahent s'controlled' substance' drug' uhlizahon' profile' report' for' the' previous' month.' You' are' listed' as' one' of' the' prachhoners'who'prescribed'controlled'substances'for'this'pahent.'if'you'feel'you'need'addihonal' informahon,'please'fax'us'a'pahent'profile'request. We'are'providing'the'aSached'profile'to'you'confidenHally'for'informaHonal'and'assessment' purposes.' It' is' our' experience' that' prachhoners' oyen' are' unaware' that' a' pahent' is' receiving' controlled'substance'prescriphons'from'other'prachhoners. We'are'requesHng'that'you'review'your'records'to'determine'whether'this'person'is'your' pahent'and'whether'you'wrote'or'authorized'the'prescriphons'shown'on'the'asached'profile.'if' you'find'that'any'of'the'prescriphons'shown'on'the'profile'were'not,'in'fact,'authorized'by'you,' please'contact'our'office'immediately.'if,'on'the'other'hand,'you'find'that'the'prescriphons'were' authorized'by'you,'please'consider'whether'and'how'you'should'discuss'your'concerns'with'your' pahent,' as' you' deem' appropriate.' You' may' also' want' to' keep' this' profile' in' the' pahent' file' or' chart. We' are' aware' that' some' pahents' have' special' needs' and' condihons' such' as' severe' or' intractable'pain'that'require'large'quanhhes'of'controlled'substances.'on'the'other'hand,'many' Hmes'paHents'who'may'be'addicted'to'or'abusing'controlled'substances'use'various'mechanisms' that'involve'the'good'names'of'prachhoners'such'as'you'to'obtain'excess'drugs.'by'providing'the' asached'profile,'we'are'not'judging'the'propriety'of'the'pahent s'conduct.'rather'it'is'our'belief' that'well'informed'prachhoners'can'use'their'professional'experhse'to'assist'pahents'who'may'be' abusing' controlled' substances,' and' we' are' hopeful' that' providing' you' with' this' informahon' will' lead'to'ophmum'care'for'your'pahent. Thank'You,' 2'

3 ' Wyoming: Zip Codes with Population Greater than 1,000 and High Doctor Shopping Rates (Number of Prescriptions Associated with Doctor Shopping per 10,000 Prescriptions) Aug., July, Number of Unsolicited Profiles Since Number of Unsolicited Profiles Legend Pop < 1000 or doctor shopping rate < 20 Pop > 1000 and doctor shopping rate between 20 and 60 Pop > 1000 and doctor shopping rate > WORXPDMP.COM 3'

4 - ' 2013 Filled Prescriptions by Category 300, , ,000 Number of C-II Filled Prescriptions 200, , , ,000 96, ,344 50,000 62, ,704 CARISOPRODOL 21,837 19,557 12,037 10,956 6,967 5, , CODEINE FENTANYL HYDROCODONE HYDROMORPHONE MEPERIDINE Methadone MORPHINE NUCYNTA Source: Wyoming Online Prescription Database (WORx) OXYCODONE OXYMORPHONE Soma TRAMADOL , Source: Wyoming Online Prescription Database (WORx) SUCCESS MAY INCREASE DIVERSION! Success in regulatory areas have reduced the access to prescriber outliers! Success in identifying doctor shoppers! Success in criminal prosecutions! Success in reducing the # of Rx for Schedule II controlled substances! Increased use of WORx by prescribers and pharmacists INCREASE IN DIVERSION! More robberies/burglaries of pharmacies! More desperation by addicts! Looking for easier ways to obtain drugs! Increase in use of heroin (cheaper, easier)! Institutions, nursing homes, pharmacies, medicine storage being targeted! Burglary! Robbery! Forgery METHODS OF DIVERSION " Complete Rx, Altered Rx(quantity, dose # of refills), Rinsing, Bogus Pads! Theft! Fraud DRUG DIVERTER S TARGETS! Medical Practitioners: MD, DO, DDS, DVM, Podiatrist, Nurse Practitioner, Physician Assistants! Medical Facilities/Services: Hospitals, Practitioners offices, Ambulance, Nursing Homes, Hospices, Home Health Services! Pharmacies! Drug Manufacturers! Patients 4'

5 ' PRESCRIPTIONS FOR CS! A prescription for a controlled substance to be effective must be issued for a legitimate medical purpose by a practitioner acting in the usual course of his professional practice. The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription. LIST OF SOME CHARGEABLE CRIMINAL ACTIVITIES! Wyoming Law " Delivery of a Controlled Substance " Possession of a Controlled Substance " Prescription Fraud " Conspiracy " Enhancements for Distribution to Persons under 18 years or School Zone or School Bus STREETRX.COM WYOMING STATUTES WY Stat Public Health and Safety; Food and Drugs; Unlawful acts; distribution; registration; possession; records; counterfeiting; punishment.! (a) It is unlawful for any person knowingly or intentionally: " (i) To distribute as a registrant a controlled substance classified in Schedule I or II, except pursuant to an order form as required by W.S ; " (ii) To use in the course of the manufacture or distribution of a controlled substance a registration number which is fictitious, revoked, suspended, or issued to another person; " (iii) To acquire or obtain possession of, to procure or attempt to procure the administration of, or to obtain a prescription for, any controlled substance by misrepresentation, fraud, forgery, deception or subterfuge. The conduct prohibited by this paragraph includes but is not limited to: # (A) Failing to disclose to a practitioner that the person has received the same or similar controlled substance or prescription for a controlled substance from another source within the prior thirty (30) days; # (B) Alteration or forgery of a prescription or written order for a controlled substance; and # (C) The use of a false name or address. MEDICAL PRACTICE ACT! (a) The board may take disciplinary action on one or more of the grounds under (a)(i)-(x)(xii),(xiv-xxxiv)! (xxiv) (xii) Repeatedly prescribing, selling, supplying or administering any drug legally classified as a narcotic, addicting or scheduled drug to a parent, spouse or child of the applicant or licensee, or to himself; SELF PRESCRIBING! The pharmacist must determine a valid Rx! Should a dentist prescribe birth control pills?! Patient-physician relationship means there is an assessment, record, care plan, monitoring! usual course of practice! Rural nature of WY! repeatedly and controlled substances MEDICAL PRACTICE ACT Prescription of drugs. (c) A physician assistant may prescribe medications only as an agent of the supervising physician. A physician assistant may not prescribe schedule I drugs as defined by W.S through The supervising physician may delegate authority to the physician assistant to dispense prepackaged medications in rural clinics when pharmacy services are not physically available. The board shall, after consultation with the state board of pharmacy, promulgate rules and regulations governing the prescription of medications by a physician assistant. BOARD OF MEDICINE! POLICY NUMBER: 40-01! Title: Pain Management! Date Issued: February 13, 2009! Date(s) Revised:! Reference:! Purpose: Establishing model protocols and a general standard of care for treatment of chronic pain by physicians and physician assistants WY CONTROLLED SUBSTANCES ACT! Rules Chapter 6 describe prescriptions! Recently revised! Security paper! Electronic prescriptions for CS! 90 day Schedule II! Use of stickers 5'

6 ' CHAPTER 6 SECTION 5(A) SECURITY PAPER! Any controlled substance prescription written by a Wyoming practitioner issued on nonsecurity paper may not be dispensed by a pharmacist! Security features: Void, erasure protection, green/blue, security warning list, quantity check-off boxes, numeric quantity values, refill indicator to circle CHAPTER 6 SECTION 5 (B)(V) STICKERS! Prescriptions may be prepared for dating and signature and the use of preprinted prescriptions is allows. Under no circumstances may stickers be utilized for information relating to patient name, drug, strength, quantity or directions. CHAPTER 6 SECTION 5(B)(IV) SIGNATURE! All controlled substance prescriptions written by a Wyoming practitioner shall be manually signed in the same manner as the practitioner would sign a check or legal document. The use of electronic or digital signatures or signature stamps are not allowed unless electronic prescriptions are used according to this chapter. CHAPTER 6 SECTION 5 (B)(VI) DATING! Prescriptions shall be dated as of, and signed on, the day when issued and shall bear the full name, address, telephone number and DEA registration number of the issuing practitioner. No post dating! written in ink, typed, or electronically generated! Prescriber and dispensing pharmacist share responsibility to assure compliance SCHEDULE II 90 DAY RX S! Separate Rx, dated as of day prescribed! Instructions as to when to dispense! Total of up to a 90 day supply in multiple prescriptions! Consider for ADHD meds! Conclude: does not create an undue risk of diversion or abuse CHAPTER 6 SECTION 12 PARTIAL FILL C-II! If unable to supply full quantity! Remaining portion must be with 72 hr! No further quantity may be supplied beyond 72 hr without a new prescription SCHEDULES III, IV, V! 5 refills in 6 months! Can be phoned or faxed! If not manually signed the pharmacist can turn it into a phone Rx! Electronic computer to computer ELECTRONIC RX FOR CS! Computer to computer! Legal in WY as of July 1, 2011! Prescriber software must be accredited! Dispensing software must be accredited! Eliminates handwriting, forgery, copying! Brings new issues in medication safety WYOMING PHARMACIES Systems Capable of Accepting Electronic Controlled Substance Orders! Coalition Family Pharmacy! Evanston Community Health Center! Osco! Safeway! Sav-On Pharmacy! Shopko! Vicklund Pharmacy! Walgreens 6'

7 ' HYDROCODONE! #1 prescribed in the world! US uses 99% of the hydrocodone! FDA and DEA propose to make it C-II due to the high diversion! Many instances of diversion in WY (over 8000 doses from a pharmacy, impaired professionals, street value $10/tablet)! Lower acetaminophen in combo products SUBOXONE! For detox/maintenance must have another DEA number and a program set up! PA cannot get the X in their DEA! If calling in Rx for the physician be sure to do it on their behalf DEA is watching! Use in pain management as off-label is legal, Rx must state for pain CONTACTS! David Wills, WORx coordinator at the WY State Board of Pharmacy " David.wills@wyo.gov " ! Mary Walker, Executive Director of the WY State Board of Pharmacy " Mary.walker@wyo.gov! Questions? 7'

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