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
Presenta;on overview • PDMP background and role • PDMP best prac;ces Overview of Presenta;on • PDMP eﬀec;veness • Current ini;a;ves 5
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
How can PDMPs be Used? • Clinical • Regulatory Oversight • Surveillance and Evalua;on Tool • Law Enforcement • Passive vs Proac;ve 8
Current Status of PDMPs 49 States have legisla;on authorizing a PDMP Opera;onal in 43 states 9
Presenta;on Overview • PDMP background and role • PDMP goals and best prac;ces Overview of Presenta;on • PDMP eﬀec;veness • Current ini;a;ves 10
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
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 12
Presenta;on Overview • PDMP background and role • PDMP goals and best prac;ces Overview of Presenta;on • PDMP eﬀec;veness • Current ini;a;ves 13
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. 14
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. 15
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. 16
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 17
Presenta;on Overview • PDMP background and role • PDMP goals and best prac;ces • PDMP eﬀec;veness • Current ini;a;ves 18
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 19
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 20
Thank You Christopher M. Jones, PharmD, MPH email@example.comThe 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.
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
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.
Pilot I Survey Results • 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