Twillman preventing rx abuse


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Twillman preventing rx abuse

  1. 1. Preventing Pharmaceutical Abuse:Prescription Monitoring Programs Robert Twillman, PhD American Academy of Pain Management The University of Kansas Medical Center
  2. 2. Pain is a major public health issue 80% of patients present for health care because of pain Chronic pain affects an estimated 116 mission American adults Chronic pain costs up to $635 billion per year in medical treatment and lost productivity
  3. 3. How big is this issue? Problem Number Affected Annual Cost Chronic Pain 116 million $635 billion Diabetes 17.5 million $174 billion Cancer 11.7 million $264 billion Heart disease, 27.1 million $197 billion stroke, CHF TOTAL 56.3 million $635 billion
  4. 4. Prescription Opioid Abuse is aPublic Health Issue 2010 National Survey on Drug Use and Health (NSDUH):  34.8 million Americans (12.8%) had used a pain reliever non-medically at least once in their lifetimes (18% increase from 2002)  12.2 million Americans (4.1%) had used a pain reliever non-medically at least once in the past year (number stable since 2002)
  5. 5. Prescription Opioid Abuse is aPublic Health Issue Among those initiating substance use in the past year, pain relievers ranked behind only alcohol, cigars, cigarettes, and marijuana as the drug of choice 1.9 million (0.6% of US population) had DSM-IV diagnosable dependence or abuse of pain relievers in the past year Based on a Montana study, estimated cost of prescription drug abuse is $6.1 billion per year
  6. 6. NSDUH Data Are Unclear Definition of “nonmedical use” is problematic  12.2 million in the past year admit nonmedical use  1.9 million qualify for a diagnosis  This means 10.3 million are doing other things  Recreational use  Abuse without consequences  Misuse to treat pain Does not mean we don’t have a problem
  7. 7. Prescription Opioid Abuse isa Public Health Issue 2009 Drug Abuse Warning Network data (DAWN; ED visits) :  342,628 for opioid analgesics (137% increase from 2004) 2007 Treatment Episode Data Set (TEDS):  Non-heroin opioids were primary drug of abuse for 90,516 patients entering substance abuse treatment nationwide (456% increase from 1997)
  8. 8. Drug Treatment Admissions, Non-Heroin Opioids as Primary Drug
  9. 9. Most-Abused Prescription Opioids:2009 DAWN Data
  10. 10. Prescription Drug Misuse isDangerous More people now die from prescription drug misuse than from use of heroin and cocaine combined In 17 states, more people now die from prescription drug misuse than from automobile crashes
  11. 11. Recent Survey Teen-agers now say it is easier to get prescription drugs than it is to get beer National Center on Addiction and Substance Abuse, August 2008
  12. 12. Prescription Monitoring Programs Designed to track prescriptions for controlled substances as an means of identifying patterns indicative of abuse and diversion Initially set up in 1939 in California Prescription details are transmitted electronically Information can be obtained for patients by their treating prescribers and dispensers Law enforcement, licensing boards also can access information in most states
  13. 13. Prescription Monitoring Programs Many programs have been funded through start-up and into implementation phases by federal grants from the Bureau of Justice Assistance, Department of Justice Some have found sustainable sources of funding Others still need to address this issue
  14. 14. State PMP Status, 2003 Operating No PMP Programs
  15. 15. State PMP StatusNovember 5, 2011 No Statute PMP Pending PMP Operating
  16. 16. States with Recent Bills Missouri: Bill passed House in 2011; will need to be reintroduced in 2012 New Hampshire: Bill sent to House floor with recommendation for interim study Pennsylvania: Bill in House committee to expand coverage to all CS schedules and to allow access by providers
  17. 17. States Mandating Use of AdvisoryCommittees Advisory Committees
  18. 18. Housing Entities for PMPs 2 1 1 Board of Pharmacy/Health 1 Dept./Single State Authority Law Enforcement 6 Dept. of Public Safety Professional Licensing Dept. of Consumer Protection Office of Controlled 37 Substances
  19. 19. Assessing Outcomes of PMPs What are the expected outcomes from a PMP? What do we need to know? What do we already know? How can we go about verifying the outcomes?
  20. 20. PMP Outcome Domains The initial reason for PMPs was based in law enforcement; they may have other uses Outcomes can fall into three general domains  Improved pain management  Misuse/abuse/addiction detection  Diversion deterrence, detection, and prosecution We need to evaluate outcomes in each of these three domains
  21. 21. PMP Outcome Domains:Improved Pain Management Clinician review of PMP data may promote improved pain management  Increased prescriber comfort that patient is not abusing/diverting  Exposure of patterns of inadequate prescribing  More accurate review of data than relying on patient self-report
  22. 22. PMP Outcome Domains:Detection and Treatment of Addiction Clinician review of PMP data may lead to detection of drug abuse/addiction  Aberrant patterns of medication use may spur in-depth assessment  Such assessment may result in diagnosis of substance abuse/addiction  If so, referral to substance abuse treatment is indicated
  23. 23. PMP Outcome Domains:Preventing and Detecting Diversion Clinician review of PMP data may prevent or uncover diversion activities  Knowledge of data review may prevent diversion activities (and/or shift source?)  Aberrant patterns may spur in-depth assessment, leading to detection of diversion  Legal and ethical obligations of clinician?
  24. 24. So, What Do You Know? Not much. You?
  25. 25. Normative Data: Katz et al. (2010) Analysis of 11 years’ data from Massachusetts PMP This PMP covered only Schedule II medications Did not allow access to data by healthcare providers Goal: Describe normative patterns of prescription use by Massachusetts residents during this time frame; define “questionable activity”
  26. 26. Normative Data: Katz et al. (2010)Trends in C-II Prescribing Number of prescriptions increased by 142% during this time frame Doses dispensed increased by 292%  Greatest increase was for short-acting oxycodone Number of estimated individual recipients increased by 71%  Approximately 11% of Massachusetts residents received C-II prescriptions in 2006
  27. 27. Normative Data:Prescribers & Dispensers (2006) Prescribers DispensersMean Number 1.36 + 0.93 1.13 + 0.52Median Number 1 1% Using 1 or 2 92.3% 97.5%% Using 10 or More 0.1% 0.02%
  28. 28. Normative Data: Katz et al. (2010)Early Refills Defined as two consecutive prescriptions for the same individual/same drug, with the number of days between prescriptions being > 10% lower than number of days’ supply in first prescription Mean was 0.12 (+ 0.67); median was 0 93.1% had NO early refills Fewer than 1% had more than three
  29. 29. Normative Data: Katz et al. (2010)“Questionable Activity” Defined as use of > 3 prescribers AND > 3 pharmacies in 2006:  1.6% of individuals (n = 8797)  7.7% of prescriptions (n = 112,381)  8.5% of dosage units (n = 7,622,840) Defined as use of > 4 prescribers AND > 4 pharmacies in 2006:  0.5% of individuals (n = 2748)  3.1% of prescriptions (n = 45,102)  3.1% of dosage units (n = 2,805,613) Defined as use of > 5 prescribers AND > 5 pharmacies in 2006:  0.2% of individuals (n = 1149)  1.5% of prescriptions (n = 22,075)  1.4% of dosage units (n = 1,247,666) For all criteria, numbers increased 1996 to 2002, then decreased to 2006
  30. 30. Examples from Early Queries(KS) Top 5 utilizers of pharmacies (9 months):  Wichita: 28 pharmacies/31 prescribers  Stilwell: 21 pharmacies/23 prescribers  Olathe: 20 pharmacies/26 prescribers  Paola: 20 pharmacies/28 prescribers  Olathe: 18 pharmacies/24 prescribers These 5 utilizers received 1842 days’ supply of controlled substances, totaling 5833 dosage units
  31. 31. Examples from Early Queries(KS) Top 5 utilizers of prescribers (9 months):  Topeka: 45 prescribers/11 pharmacies  After 12 months, 80 prescribers/61 pharmacies, 1788 days’ supply  Overland Park: 37 prescribers/13 pharmacies  Wichita: 31 prescribers/28 pharmacies  Wichita: 30 prescribers/15 pharmacies  Mission: 30 prescribers/16 pharmacies These 5 utilizers received 3197 days’ supply of controlled substances, totaling 14,282 dosage units
  32. 32. PMPs and Overdose Death Rates Study in Pain Medicine (Paulozzi, Kilbourne, & Desai, 2011) Examined opioid consumption in states from 1999-2005 Studied effects of PMPs on rates of drug overdose mortality, opioid overdose mortality, and opioid consumption Also examined effects of some PMP characteristics
  33. 33. PMPs and Overdose Death Rates:Key Findings (PMP vs. no PMP) No significant differences in rates of drug or opioid overdose mortality or opioid use No effect for proactive reporting More hydrocodone, less C-IIs consumed in PMP states Rates of increase in OD mortality and opioid consumption were lower in states requiring use of special prescription forms
  34. 34. PMPs and Overdose Death Rates:Explanations, Potential Confounds Increased C-III use may reflect substitution effect due to some states not monitoring C-IIs No control for availability of data to clinicians No control for utilization of PMP in each state Decreases in consumption due to elimination of “doctor shoppers” may be offset by increased prescribing due to reassurance provided by PMP report data Conclusion: “TBU”
  35. 35. What Should We Expect to Findin Reviewing Reports? For each 100 PMP reports reviewed, how many “cases” of SUD and “doctor shopping” should we expect to find? Relatively no data on this, but it will probably look like this:  85% of reports will be completely “clean”  14.5% of reports will cause concerns  0.5% of reports will show “doctor shopping”
  36. 36. Research Needs Normative data Effects of PMPs on the three outcome domains Specific qualities of PMPs that are most conducive to achieving desired effects Cost/benefit analysis
  37. 37. What’s Next for PMPs? Interstate data sharing  Hub run by National Association of Boards of Pharmacy, called PMP InterConnect  In first 60 days, processed 13,600 requests  Average response time: 15.07 seconds
  38. 38. PMP Interconnect Status November 5, 2011 PMPI PMPI Pending PMPI Operating Considered
  39. 39. What’s Next for PMPs? Efforts to make checking the PMP mandatory before controlled substances are prescribed Increased recognition of need for meaningful outcome data Shorter timelines for dispensers to report Inclusion of dispensing physicians
  40. 40. Future Efforts Increase evaluation of PMPs’ impacts Enhance awareness and utilization Improve resources for pain and substance abuse assessment and treatment Enhance real-time capability Assess utility of Advisory Committees Evaluate cost effectiveness
  41. 41. Thank You!