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Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
Successful endeavors and_outcomes_final
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Successful endeavors and_outcomes_final

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Clinical Track …

Clinical Track
National Rx Drug Abuse Summit
Dr. Robert DuPont and Dr. William Johnson

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  1. Successful  Endeavors  and  Outcomes   Robert  DuPont,  M.D.   President,  Ins<tu<on  of  Behavior  and  Health  Inc.     Ibhinc.org   William  Johnson,  M.D.   Chief  Medical  Officer,  Pikeville  Medical  Center   April  2  –  4,  2013   Omni  Orlando  Resort     at  Champions  Gate  
  2. Learning  Objec<ves  •   Analyze  the  latest  data  about  the  cost  of   prescripAon  drug  abuse  to  hospitals.  •   Explain  the  Physician  Health  Program  model’s   relevance  to  the  treatment  of  prescripAon   drug  abuse.  •   Prepare  strategies  that  you  can  implement  in   your  own  pracAce  to  reduce  costs.  
  3. Disclosure  Statement  •  Robert  DuPont  has  no  financial  relaAonships  with   proprietary  enAAes  that  produce  health  care  goods   and  services  •  William  Johnson  has  no  financial  relaAonships  with   proprietary  enAAes  that  produce  health  care  goods   and  services.    
  4. Robert  L.  DuPont,  M.D.  •  Professor  of  Clinical  Psychiatry,  Georgetown  University   School  of  Medicine  •  President,  InsAtute  for  Behavior  and  Health   –  Non-­‐profit  organizaAon;  one  if  its  main  prioriAes  is  to  reduce   prescripAon  drug  abuse  •  Vice  President,  Bensinger,  DuPont  &  Associates   –  NaAonal  consulAng  firm  dealing  with  substance  abuse  •  Chairman,  PrescripAon  Drug  Research  Center   –  ConsulAng  firm  that  develops  risk  minimizaAon  acAon  plans  and   product  surveillance  programs,  conducts  special  populaAon              surveys   and  forensic  drug  extracAon  studies,  and  consults                                with   pharmaceuAcal  companies  reviewing  abuse-­‐resistant  formulaAons  to   assess  or  reassess  scheduling  
  5. Treatment  of  PrescripAon  Drug   Abuse  Today  •  Few  prescripAon  drug  abusers  want  treatment  •  Dropping  out  of  treatment  and  relapse  are  the  norm  •  The  treatment  challenge:  promote  lifeAme  recovery  •  Physician  Health  Programs  (PHPs)  set  the  standard   with  the  New  Paradigm  
  6. PrescripAon  Drug  Abuse  –  Opioids    •  Opioids  dominate  the  prescripAon  drug  abuse   problem    •  Virtually  all  opioid  use  among  PHP  parAcipants  is   from  prescripAon  opioids  
  7. Elements  of  the  PHP     System  of  Care  Management    •  Comprehensive  evaluaAon    •  Signed  contract  for  monitoring  and  consequences  •  IniAal  intensive,  high  quality  treatment  for   substance  use  disorders  and  comorbid  disorders  •  Random  tesAng  for  5+  years  for  alcohol  and  other   drugs  of  abuse  with  zero  tolerance  for  ANY  use  
  8. Elements  of  the  PHP     System  of  Care  Management    •  Leaving  the  PHP  or  relapse  to  substance  use   means  risk  of  losing  the  license  to  pracAce   medicine  •  Immersion  in  recovery  fellowships,  mostly     Alcoholics  Anonymous  (AA)  and  NarcoAcs   Anonymous  (NA)  
  9. PHP  Long-­‐Term  Drug  Test  Results  •  Over  the  course  of  5  years:     –  78%  of  all  physicians  had   zero  posiAve  drug  tests   –  14%  had  only  1  posiAve   drug  test   –  3%  had  only  2  posiAve  drug   tests   –  5%  had  3  or  more  
  10. Opioid  Users  /  IV  Status  •  N  =  694  parAcipants   Opioids/No  IV  Use   25%  (n=176)   Opioids/IV  Use   10%  (n=70)   Other  Drugs/No  IV  Use   15%  (n=106)   Alcohol   48%  (n=342)   Excluded:  28  physicians  treated  for  primary  alcohol  or  non-­‐opioid  drugs   with  histories  of  IV  use;  72  physicians  who  moved  out  of  their  state   program’s  jurisdicAon  with  unknown  results  
  11. The  Same  Outstanding  Results    •  No  significant  differences  were  found  among   groups  related  to:   –  PosiAve  drug  tests  over  5-­‐year  period   –  Contract  status  at  follow-­‐up   –  OccupaAonal  status  at  follow-­‐up  
  12. MedicaAon  Assisted  Treatment  •  46  physicians  were  treated  with  Naltrexone  and  1   was  treated  briefly  with  methadone  •  Demographics  similar  to  other  physicians   –  12  in  Opioids/No  IV  group   –  22  in  Opioids/IV  group   –  2  in  Other  Drug/No  IV  group   –  9  in  Alcohol  group  •  67%  of  these  46  physicians  had  no  posiAve  tests,   including    for  opioids  (no  difference)  
  13. Lessons  from  the  PHPS  for  PrescripAon   Opioid  Abusers  1)  Zero  tolerance  for  any  use  of  alcohol  and  other  drugs  2)  Thorough  evaluaAon  and  paAent-­‐focused  long-­‐term  care  3)  Frequent  random  tesAng  for  both  alcohol  and  other  drugs  4)  Defining  and  managing  relapses:  swio,  certain  and   meaningful  consequences  for  any  substance  use  or  other   noncompliance  5)  Immersion  throughout  care  in  community  fellowships    6)  Goal:  lifelong  recovery    
  14. ImplicaAons  for  Treatment  of   PrescripAon  Drug  Abuse  •  Outcomes  reflect  the  sepngs  in  which  the   decision  to  use  or  not  use  drugs  is  made   –  When  the  environment  permits  or  encourages  drug   use,  it  usually  conAnues   –  When  the  environment  quickly  and  effecAvely   idenAfies  any  drug  use  and  intervenes  swioly  with   serious  consequences,  it  usually  stops   –  ParAcipaAon  in  recovery  fellowships  extends  the   benefits  of  treatment  for  a  lifeAme  
  15. Applying  the  PHP  Model  to     Clinical  PracAce  •  Addressing  the  problems  of  translaAng  the   PHP  model  to  everyday  clinical  pracAce:   1)  The  populaAon  of  physicians  is  unique   2)  Most  clinical  populaAons  lack  the  leverage  of   PHPs   3)  Most  clinical  sepngs  lack  the  care  management   capabiliAes  of  the  PHPs  
  16. 1)  PaAent  PopulaAon  •  The  New  Paradigm  has  been  successfully  used  in   the  criminal  jusAce  system  –  a  populaAon  enArely   different  than  physicians  •  Example  of  Hawaii’s  Opportunity  ProbaAon  with   Enforcement  (HOPE)  –  populaAon  of  mostly   poorly  educated,  high-­‐risk  offenders  with   histories  of  drug  use  problems  
  17. HOPE  ProbaAon  •  Uses  intensive  random  drug  tesAng  for  up  to  6  years  •  Has  zero  tolerance  for  any  violaAon  of  probaAon   including  drug  use,  missed  tests,  missed  probaAon   appointments,  etc.  •  All  violaAons  lead  to  brief  incarceraAons    •  Treatment  is  available  but  only  required  when   monitoring  fails  –  “Behavioral  Triage”    •  12-­‐Step  parAcipaAon  is  encouraged  but  not  required  
  18. HOPE  vs.  Standard  ProbaAon    •  Randomized  control  study  of  HOPE  showed  that  in  a   one-­‐year  period,  HOPE  probaAoners  were:   •  55%  less  likely  to  be  arrested  for  a  new  crime   •  72%  less  likely  to  use  drugs   •  61%  less  likely  to  skip  appointments  with  their   supervisory  officer   •  53%  less  likely  to  have  their  probaAon  revoked  •  HOPE  probaAoners  were  sentenced  to,  on  average,   48%  fewer  days  of  incarceraAon  than  the                 standard  probaAon  group  
  19. HOPE  Drug  Test  Results  •  Over  the  course  of  one  year:   –  61%  of  all  HOPE  parAcipants   never  had  a  single  posiAve   drug  test   –  20%  had  only  1  posiAve   –  9%  had  2  posiAves   –  10%  had  3+  posiAves  
  20. 2)  Finding  Leverage  •  Many  sources  of  leverage  can  be  used  including   conAnued  physician  prescribing  of  opioids      •  Enhanced  acAons  in  treatment  programs     –  IntervenAons  with  counselors,  groups,  all  staff   –  Loss  of  privileges  (e.g.  take-­‐home  privileges  in  opioid-­‐ subsAtuAon  therapy)   –  Increase  drug  tesAng  frequency   –  Required  frequent  parAcipaAon  in  specialized  group   sessions  
  21. 3)  Lack  of  Care  Management  •  Responsible  clinicians  can  organize  effecAve   care  management:   –  Random  drug  and  alcohol  tesAng   –  Writen  contracts  that  specify  swio,  certain,  serious   consequences  for  any  use   –  AcAve  parAcipaAon  in  the  12-­‐Step  fellowships   –  Monitor  workplace  and  family  for  evidence  of   problems  
  22. Summary  of  Findings  •  Zero  tolerance  with  swio,  certain,  and  meaningful   consequences  for  any  use  of  alcohol  and  other  drugs  –   contrary  to  reasonable  assumpAons  –  leads  to  lower  rates   of  substance  use,  higher  rates  of  long-­‐term  success,  and   lower  rates  of  failure  •  PHPs  produced  impressive  results  previously  unseen  across   the  spectrum  of  drug  use,  including  individuals  with  opioid-­‐ related  SUDs  •  Principles  of  the  PHP  model  are  validated  in  the  criminal   jusAce  system  and  are  applicable  to  prescripAon  drug  abuse   in  clinical  pracAce    
  23. The  Good  News  •  AdapAng  the  PHP  model  to  clinical  pracAce   can  be  done  •  Leading  clinicians  are  now  invenAng  future   pracAces  for  treatment  as  part  of  care   management  •  Care  management  in  which  treatment  occurs   is  crucial  for  long-­‐term  success  of  these  efforts    
  24. The  Botom  Line    •  The  New  Paradigm  for  managing  prescripAon   drug  abuse:    1)  Promotes  long-­‐term  recovery  2)  Reduces  dropping  out  of  treatment,  relapses  to   drug  and  alcohol  use,  and  paAent  “recycling”    
  25. www.IBHinc.org     •  For  more  informaAon   on  other  new  and   important  ideas  to   reduce  illegal  drug  use   visit  the  home  website   of  the  InsAtute  for   Behavior  and  Health    
  26. Thank  you!  
  27. References  •  Buhl,  A.,  Oreskovich,  M.  R.,  Meredith,  C.  W.,  Campbell,  M.  D.,  &  DuPont,  R.  L.  (2011).  Prognosis  for  the  recovery  of  surgeons  from   chemical  dependency.  Archives  of  Surgery,  146(11),  1286-­‐1291.  •  Caulkins,  J.  P.  &  DuPont,  R.  L.  (2010).  Is  24/7  Sobriety  a  good  goal  for  repeat  driving  under  the  influence  (DUI)  offenders?   [Editorial].  Addic5on,  105,  575-­‐577.    •  DuPont,  R.  L.  (1999).  Biology  and  the  environment:  Rethinking  demand  reducAon.  Journal  of  Addic5ve  Diseases,  18(4),  121-­‐138.  •  DuPont,  R.L.  (2009).  Blueprint  for  las5ng  recovery:  Physician  health  programs  drug  test  results.  Unpublished  manuscript.  •  Skipper,  G.  S.,  DuPont,  R.  L.,  Campbell,  M.  D.,  &  Shea,  C.  L.  (2012).  Recovery  from  opioid  dependence:  Lessons  from  the  treatment   of  opioid-­‐dependent  physicians.  Unpublished  manuscript.    •  DuPont,  R.  L.,  &  Humphreys,  K.  (2011).  A  new  paradigm  for  long-­‐term  recovery.  Substance  Abuse,  32(1),  1-­‐6.  •  DuPont,  R.  L.,  McLellan,  A.  T.,  Carr,  G.,  Gendel,  M.,  &  Skipper,  G.  E.  (2009).  How  are  addicted  physicians  treated?  A  naAonal  survey   of  physician  health  programs.  Journal  of  Substance  Abuse  Treatment,  37,  1-­‐7.    •  DuPont  R.  L.,  McLellan  A.  T.,  White  W.  L.,  Merlo  L.,  and  Gold  M.  S.  (2009).  Sepng  the  standard  for  recovery:  Physicians  Health   Programs  evaluaAon  review.  Journal  for  Substance  Abuse  Treatment,  36(2),  159-­‐171.    •  DuPont,  R.  L.,  Shea,  C.  L.,  Talpins,  S.  K.,  &  Voas,  R.  (2010).  Leveraging  the  criminal  jusAce  system  to  reduce  alcohol-­‐  and  drug-­‐ related  crime.  The  Prosecutor,  44(1),  38-­‐42.  •  DuPont,  R.  L.,  &  Skipper,  G.  E.  (2012).  Six  lessons  from  physician  health  programs  to  promote  long-­‐term  recovery.  Journal  of   Psychoac5ve  Drugs,  44(1),  72-­‐78.    •  Gold,  M.  S.,  &  Aronson,  M.  (2004).  Physician  health  and  impairment.  Psychiatric  Annals,  34(10),  739-­‐741.  •  Hawken,  A.  (2010).  Behavioral  Triage:  A  new  model  for  idenAfying  and  treaAng  substance-­‐abusing  offenders.  Journal  of  Drug  Policy   Analysis,  3(1),  1-­‐5.  •  Hawken,  A.,  &  Kleiman,  M.  (2009,  December).  Managing  drug  involved  probaAoners  with  swio  and  certain  sancAons:  EvaluaAng   Hawaii’s  HOPE.  NaAonal  InsAtute  of  JusAce,  Office  of  JusAce  Programs,  U.S.  Department  of  JusAce.  Award  number  2007-­‐IJ-­‐ CX-­‐0033.  •  Kleiman,  M.  (2009).  When  brute  force  fails:  How  to  have  less  crime  and  less  punishment.  Princeton,  NJ:  Princeton  University  Press.  •  McLellan,  A.  T.,  Skipper,  G.  E.,  Campbell,  M.  G.  &  DuPont,  R.  L.  (2008).  Five  year  outcomes  in  a  cohort  study  of  physicians  treated   for  substance  use  disorders  in  the  United  States.  Bri5sh  Medical  Journal,  337:a2038  •  Merlo,  L.  J.,  &  Greene,  W.  M.  (2010).  Physician  views  regarding  substance  use-­‐related  parAcipaAon  in  a  state  physician  health   program.  American  Journal  on  Addic5ons,  19,  529-­‐533.  
  28. William  Johnson,  M.D.    • Chief  Medical  Officer,  Pikeville  Medical  Center,  Pikeville,  KY  • Fellow,  American  College  of  Physicians  • Member,  Volunteer  Teaching  FaculAes,  University  of  Kentucky  and  University  of  Louisville  Medical  Schools  • Adjunct  Clinical  Professor,  Internal  Medicine,  Kentucky  College  of  Osteopathic  Medicine  
  29. • Bipar<san  Congressional  Caucus  was  established  in  2010  to  seek  effec<ve  policy  solu<ons  for  prescrip<on  drug  abuse.  • Opera<on  UNITE’s  (Unlawful  Narco<cs  Inves<ga<ons,  Treatment,  and  Educa<on)  goal  is  to  rid  communi<es  of  illegal  drug  use.  • Healthcare  costs  exceed  $70  billion  annually  for  non-­‐medical  use  of  prescrip<on  drugs.  
  30. Drug  overdose  deaths  increased  eighold  from   1991  to  2007.  According  to  the  CDC  
  31. Drug  diversion  costs  health  insurance  over  $72.5  billion  a  year  for  bogus  claims  including  opioids  alone.  According  to  the  Coali<on  Against  Insurance  Fraud  
  32. Admission  for  prescrip<on  related  opioid  treatment   increased  from  8%  in  1999  to  33%  in  2009.  According  to  reports  from  Substance  Abuse  and  Mental  Health  Services  Administra<on  
  33. • Criminal  jus<ce  officials  conserva<vely  es<mate  that  70-­‐80%  of  all  criminal  arrests  are  drug  related.  • Drug  increased  deaths  due  to  use  of  addic<ve  drugs  exceed  traffic  fatali<es  for  the  first  <me  in  30  years.  • Opioid  addic<on  is  a  chronic  lifelong  issue.  
  34. • The  drama<c  increase  in  physician  prescribing  of  narco<cs  for  chronic  pain  parallels  the  increase  of  deaths  from  overdose  of  narco<cs.    • This  increase  is  adributed  to:  a.  Manufacturing  companies  increase  spending  to  market  drugs  such  as   Oxycon<n  to  treat  chronic  pain.  b.  Pressure  on  the  Joint  Commission  to  make  pain  assessment  the  fifh   vital  sign  through  raising  awareness  to  control  pain.  c.  Educa<on  of  physicians  that  physical  dependence  and  addic<on  are  not   a  problem  to  worry  about  when  managing  chronic  pain  (erroneously).  d.  Manufacturers  get  state  medical  socie<es  to  tell  physicians  that  it  is  ok   to  prescribe  addic<ve  medicines  and  that  pain  must  be  controlled.  
  35. • In  2003  Eastern  Kentucky  was  iden<fied  as  the  highest  in  the  na<on  for  Oxycon<n  use  and  90%  of  people  wai<ng  in  Florida  pill  mills  were  from  Kentucky.  • Kentucky  alone  has  82  deaths  per  month  from  prescrip<on  drug  overdose.  • In  2010  The  Na<onal  Center  for  Health  Sta<s<cs  reported  38,329  drug  overdose  deaths  in  the  United  States.    Most  (22,134)  involved  pharmaceu<cals.    Opioids  accounted  for  75.2%.  
  36. Effec<ve  Implementa<on  of  Interven<ons   to  Prevent  Prescrip<on  Drug  Abuse  
  37. State  Level:  • HB1  Kentucky  2012.    Kentucky  HB1  passed  in  a  special  session  to  the  General  Assembly  and  was  signed  in  to  law  by  the  Governor  on  4/24/2012  and  became  effec<ve  7/12/12.    The  bill  placed  restric<ons  on  pain  management  clinics,  set  strict  new  limits  on  prescribing  controlled  substances,  and  increased  repor<ng  requirements  for  prescrip<ons  using  Kentucky’s  KASPER  (an  electronic  controlled  substances  monitoring  system).  
  38. Impacts  of  HB1  in  the  last  six  months  (as  of  March  5,  2013):  • Total  doses  of  all  controlled  substances  dropped  10.4%  from  the  same  <me  period  a  year  earlier  •   Hydrocodone  down  11.8%  • Oxycodone  down  11.8%  • Oxymorphone  (Opana)  down  45.5%  • Alprazolam  (Xanax)  down  14.5%   March  5,  2013  News  Release,  Kentucky  Governor  Steve  Beshear  
  39. Pain  Management  Clinics  in  Kentucky   • 2012  –  44   • March  5,  2013  –  25   • 19  closed  including  11  since  HB1  implementa<on   • Another  4  have  received  cease  and  desist  from  OIG  March  5,  2013  News  Release,  Kentucky  Governor  Steve  Beshear  
  40. Local  Level:  1.  Educa<on  of  physicians  to  comply  with  HB  1  (KASPER  CME).    David   Hoskins,  KASPER  Program  Manager,  Office  of  Inspector  General   presented  at  the  October  2,  2012  monthly  Medical  Staff  mee<ng  an   update  on  the  Kentucky  All  Schedule  Prescrip<on  Electronic  Repor<ng   (KASPER).       a.  The  KASPER  Program     b.  Provider  shopping     c.  Controlled  substances  prescribing  in  Kentucky  (HB1)   d.  Controlled  substances  trends  in  Kentucky.  2.  Expand  Pain  Management  services   a.  Hire  an  addi<onal  physician  provider   b.  Hire  two  addi<onal  mid-­‐level  providers   c.  Build  to  double  the  office  space   d.  Expand  the  hours  of  opera<on  to  7:00am-­‐7:30pm  M-­‐F  
  41. Local  Level  Con<nued:  3.  Assistance  of  Physicians   a.  Provide  physicians  with  delegates  to  run  KASPER  reports.       b.  Provide  physicians  with  check  lists  to  keep  on  track  with  the  new   <me  requirements  of  HB1  that  must  be  kept.  4.  Results  –  Outcome   a.  Pain  management  center  visits   b.  Pain  management  average  monthly  visits   c.  Narco<c  Rx  volumes  by  schedule   d.  Select  narco<c  trend   e.  Narco<c  Rx     f.  Narco<c  Rx  refills  
  42. Problems  with  controlled  substances   Misuse   Abuse   Diversion  
  43. Provider  shopping:  Controlled  substances  are  acquired  by  decep<on.  
  44. KASPER  Opera<on:  • KASPER  tracks  most  schedule  II-­‐V  substances  dispensed  in  Kentucky  (over  11  million  prescrip<ons  per  year).  • Reports  are  available  via  web  typically  within  15  seconds  for  90%  of  requests.  • eKASPER  registra<on  is  mandatory  for  Kentucky  physicians  and  pharmacists  authorized  to  prescribe  or  dispense  controlled  substances  to  humans.  • Controlled  substance  prescribing  2011  reports  available    per  zip  code  areas.  
  45. Impact  of  House  Bill  1  on  Narco<c  Rx  Paderns   Pain  Management  Center  Visits   5500 5000 4500 4000 3500 3000 2500 2000 1500 1127 1110 1206 1195 900 927 914 946 1000 500 0 July Aug Sept Oct Nov Dec Jan Feb # Visits 2012 July 12 - Feb 13 Visits July 12 - Feb 13 Trend
  46. Impact  of  House  Bill  1  on  Narco<c  Rx  Paderns   Narcotic Rx Trend 2,600 2,400 2,200 1,991 1,955 2,000 1,842 1,755 1,800 1,657 1,600 1,490 1,436 1,496 1,400 1,184 1,192 1,200 1,048 1,066 952 961 1,000 883 852 800 600 400 200 - July Aug Sept Oct Nov Dec Jan Feb All Narcotic Rx Select Narcotic Rx All Narcotic Rx Trend Select Narcotic Rx Trend NOTE: All graphs exclude Cancer Physician data
  47. Impact  of  House  Bill  1  on  Narco<c  Rx  Paderns   Select  Narco<c  Trend  900850 800 810800 741750 695700 628650 593600 545 529550500450 407 384 382400 353 368350 323 325300 255250 July Aug Sept Oct Nov Dec Jan Feb Oxycodone/Generics Hydrocodone/Generics Oxycodone/Generic Trend Hydrocodone/Generic Trend
  48. Impact  of  House  Bill  1  on  Narco<c  Rx  Paderns   Narco<c  Rx  Volume  by  Schedule   50% 45%   45%   45% 43%   41%   41%   38%   38%   40% 37%   35% 38%   30% 32%   33%   30%   28%   29%   29%   25% 28%   25%   24%   24%   20% 23%   22%   21%   21%   15% 18%   10% 5% 6%   6%   7%   6%   6%   6%   6%   5%   0% July Aug Sept Oct Nov Dec Jan Feb Sched 2 (High Abuse Potential) Sched 3 (Some Abuse Potential Relative to Sched 2) Sched 4 (Low Abuse Potential Relative to Sched 3) Sched 5 (Low Abuse Potential Relative to Sched 4) Sched 2 Trend Sched 3 Trend Sched 4 Trend Sched 5 Trend
  49. Impact  of  House  Bill  1  on  Narco<c  Rx  Paderns   Narco<c  Rx  Refills  600 569 564 542550 527 501500 477450 408 385400350300 271 237 226 234250 196 204 194 185200150100 66 61 63 61 54 42 50 54 50 0 July Aug Sept Oct Nov Dec Jan Feb Sched 3 Sched 4 Sched 5 Sched 3 Trend Sched 4 Trend Sched 5 Trend
  50. THANK  YOU!   Ques<ons?  

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