Pharmacy	
  Track	
  
Panel	
  Discussion:	
  
Trends	
  in	
  Prescribing	
  Prac7ces	
  	
  
Presenters:	
  
Len	
  Paul...
Disclosures	
  
•  Len	
  Paulozzi	
  
•  Denise	
  Paone	
  has	
  no	
  financial	
  rela7onships	
  with	
  
proprietary...
Learning	
  Objec7ves	
  
1.  Describe	
  current	
  trends	
  in	
  effec7ve	
  
prescribing	
  habits.	
  	
  
2.  Outlin...
TM
Centers for Disease Control and Prevention
National Center for Injury Prevention and Control
Trends	
  in	
  Prescribin...
5	
  
Overview	
  
Trends	
  in	
  mortality	
  
Trends	
  in	
  prescribing	
  of	
  controlled	
  substances	
  
Conclus...
Motor	
  vehicle	
  traffic,	
  poisoning,	
  and	
  	
  
drug	
  poisoning	
  death	
  rates,	
  United	
  States,	
  	
  
...
Drug	
  overdose	
  deaths	
  by	
  major	
  drug	
  type,	
  
United	
  States,	
  1999-­‐2010	
  
CDC/NCHS	
  Na7onal	
 ...
8	
  
Rates	
  of	
  opioid	
  overdose	
  deaths,	
  sales	
  and	
  treatment	
  
admissions,	
  	
  U.S.,	
  1999-­‐201...
9	
  
Prescrip7on	
  Data	
  Source	
  
  Purchase	
  from	
  IMS	
  
•  Na7onal	
  Prescrip7on	
  Audit	
  (NPA)	
  2007...
10	
  
Total	
  prescrip7on	
  rate,	
  	
  
United	
  States,	
  2007-­‐2012	
  
128,000	
  
129,000	
  
130,000	
  
131,...
11	
  
Opioid	
  analgesic	
  prescrip7on	
  and	
  unit	
  rates,	
  	
  
United	
  States,	
  2007-­‐2012	
  
7,500	
  
...
12	
  
Percent	
  change	
  in	
  prescrip7on	
  rates,	
  all	
  drugs	
  versus	
  
opioid	
  analgesics,	
  U.S.,	
  20...
13	
  
Hydrocodone	
  and	
  oxycodone	
  prescrip7on	
  rate,	
  	
  
United	
  States,	
  2007-­‐2012	
  
0	
  
500	
  
...
14	
  
Other	
  major	
  opioids	
  prescrip7on	
  rate,	
  	
  
United	
  States,	
  2007-­‐2012	
  
0	
  
100	
  
200	
 ...
15	
  
Other	
  major	
  opioids	
  prescrip7on	
  rate,	
  	
  
United	
  States,	
  2007-­‐2012	
  
0	
  
100	
  
200	
 ...
16	
  
Oxymorphone	
  prescrip7on	
  rate,	
  	
  
United	
  States,	
  2007-­‐2012	
  
0	
  
10	
  
20	
  
30	
  
40	
  
...
17	
  
Opioid	
  analgesic	
  prescrip7on	
  rate	
  by	
  payment,	
  	
  
United	
  States,	
  2007-­‐2012	
  
0	
  
1,0...
18	
  
Hydrocodone	
  and	
  oxycodone	
  prescrip7on	
  rate	
  paid	
  
with	
  cash,	
  United	
  States,	
  2007-­‐201...
19	
  
Benzodiazepine	
  prescrip7on	
  and	
  unit	
  rates,	
  	
  
United	
  States,	
  2007-­‐2012	
  
200,000	
  
205...
20	
  
Major	
  benzodiazepine	
  prescrip7on	
  rate,	
  	
  
United	
  States,	
  2007-­‐2012	
  
0	
  
200	
  
400	
  
...
21	
  
Carisoprodol	
  prescrip7on	
  rate,	
  	
  
United	
  States,	
  2007-­‐2012	
  
290	
  
300	
  
310	
  
320	
  
3...
Conclusions	
  
 Drug	
  overdose	
  epidemic	
  driven	
  by	
  overdoses	
  of	
  prescrip?on	
  
opioids,	
  oPen	
  c...
Comments or questions:
Len Paulozzi, MD, MPH
lpaulozzi@cdc.gov
The	
  findings	
  and	
  conclusions	
  in	
  this	
  repor...
Prescrip?on	
  Monitoring	
  Program	
  
(PMP)	
  in	
  New	
  York	
  City	
  
Denise	
  Paone,	
  EdD	
  
Director	
  of...
Disclosure	
  Statement	
  
Denise	
  Paone	
  has	
  no	
  financial	
  rela7onships	
  with	
  
proprietary	
  en77es	
  ...
PMP:	
  Background	
  	
  
•  Historically	
  ,	
  seen	
  as	
  a	
  law	
  enforcement	
  tool:	
  
–  To	
  iden7fy	
  ...
PMP:	
  public	
  health	
  surveillance	
  tool	
  
•  Number	
  of	
  prescrip7ons,	
  pa7ents,	
  prescriber,	
  
pharm...
PMP	
  surveillance	
  used	
  to	
  inform	
  public	
  
health	
  ini?a?ves	
  
•  Opioid	
  prescribing	
  guidelines	
...
Analy?c	
  methods	
  
•  Focus	
  on	
  schedule	
  II	
  prescrip7on	
  opioid	
  
analgesics	
  (excluding	
  codeine-­...
Descrip?ve	
  sta?s?cs	
  
•  Demographic	
  characteris7cs	
  of	
  pa7ent	
  (gender,	
  
age,	
  residence,	
  payment)...
Prescrip?on	
  variables	
  
•  Dura7on	
  of	
  ac7on	
  
–  Long-­‐ac7ng	
  or	
  short-­‐ac7ng	
  
•  Day	
  supply	
  ...
USING	
  PMP	
  TO	
  DESCRIBE	
  PATTERNS	
  OF	
  
OPIOID	
  ANALGESIC	
  PRESCRIPTION	
  USE	
  
IN	
  NEW	
  YORK	
  C...
Opioid	
  analgesic	
  (OA)	
  prescrip?ons	
  NYC,	
  
2008–2012	
  
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
20...
From	
  2008–2012	
  there	
  was	
  a	
  17%	
  increase	
  in	
  the	
  
number	
  of	
  pa?ents	
  filling	
  OA	
  pres...
15%	
  of	
  prescribers	
  wrote	
  83%	
  of	
  
opioid	
  analgesic	
  prescrip?ons	
  
48%
2%
37%
15%
14%
49%
1%
34%
0...
In	
  2012,	
  10%	
  of	
  prescribers	
  (n	
  =	
  5,384)	
  
wrote	
  75%	
  of	
  prescrip?ons	
  (n	
  =1,623,157)	
...
Two-­‐thirds	
  of	
  pa?ents	
  filled	
  only	
  one	
  prescrip?on;	
  
one-­‐third	
  filled	
  78%	
  of	
  all	
  opio...
Pa?ents	
  visi?ng	
  mul?ple	
  prescriber	
  and	
  
mul?ple	
  pharmacies	
  are	
  rare	
  
•  In	
  2012,	
  1.2%	
  ...
Two-­‐thirds	
  of	
  opioid	
  analgesic	
  prescrip?ons	
  
filled	
  were	
  paid	
  with	
  commercial	
  Insurance	
  ...
Staten	
  Islanders	
  filled	
  OA	
  prescrip?ons	
  at	
  
higher	
  rates	
  in	
  2012	
  
0
50
100
150
200
250
300
35...
OA	
  prescrip?ons	
  filled	
  by	
  Staten	
  Islanders	
  have	
  
longer	
  median	
  day	
  supply	
  
0
5
10
15
20
25...
OA	
  prescrip?ons	
  filled	
  by	
  Staten	
  Islanders	
  are	
  
more	
  frequently	
  high	
  dose	
  (>100	
  MED)	
 ...
PMP	
  PUBLIC	
  HEALTH	
  SURVEILLANCE	
  
AND	
  DATA	
  DRIVEN	
  INITIATIVES	
  
Neighborhoods	
  with	
  high	
  rates	
  of	
  OA	
  prescrip?ons	
  
have	
  high	
  rates	
  of	
  uninten?onal	
  (ove...
Opioid	
  prescribing	
  guidelines	
  
•  Less	
  oqen:	
  avoid	
  prescribing	
  opioids	
  for	
  
chronic	
  non-­‐ca...
New	
  York	
  City	
  Emergency	
  Department	
  Discharge	
  Opioid	
  Prescribing	
  Guidelines	
  Clinical	
  Advisory...
Staten	
  Island	
  public	
  health	
  
“detailing”	
  campaign	
  
•  1-­‐on-­‐1	
  “detailing”	
  visits	
  from	
  
He...
48	
  
Morphine	
  Milligram	
  Equivalent	
  (MME)	
  
calculator	
  
•  A	
  tool	
  to	
  calculate	
  total	
  MME	
  per	
  ...
50	
  
Media	
  campaigns	
  
•  Campaign	
  One:	
  	
  
–  Goal:	
  Increase	
  awareness	
  of	
  risk	
  of	
  opioid	
  anal...
Summary	
  
•  PMPs	
  can	
  be	
  used	
  as	
  a	
  public	
  health	
  surveillance	
  
tool	
  to	
  understand	
  pa...
Improving	
  Outcomes	
  
while	
  Deterring	
  
Misuse,	
  Abuse,	
  &	
  
Diversion	
  
Tom	
  Kelly,	
  R.Ph.,	
  B.Sc....
Disclosures	
  
•  Thomas	
  Kelly	
  has	
  financial	
  rela7onships	
  with	
  
proprietary	
  en77es	
  that	
  produce...
Learning	
  Objec7ves	
  
1.  PMP's	
  and	
  PDMP's	
  are	
  valuable	
  clinical	
  tool	
  
promo7ng	
  improved	
  ou...
How	
  Did	
  We	
  Get	
  Here?	
  
•  1980	
  prehistoric	
  
•  1996	
  Oxycon7n	
  launched	
  “less	
  poten7al	
  fo...
The	
  Strange	
  Down	
  Stream	
  Trends	
  
•  Viola7ons	
  everywhere,	
  wholesale	
  distributors:	
  
“But	
  how	
...
Unfortunate	
  Reali7es	
  
•  Growing	
  popula7ons	
  trends	
  for	
  chronic	
  pain	
  pa7ents	
  
–  Advanced	
  tra...
Its	
  busy,	
  What	
  Can	
  I	
  Do?	
  (opportuni7es)	
  
•  Promote	
  and	
  u7lize	
  PMPs	
  as	
  a	
  tool	
  to...
But	
  What	
  Can	
  I	
  Do?	
  	
  
Con7nued…	
  (more	
  opportuni7es)	
  
•  Market	
  topically	
  compounded	
  ana...
Provide	
  Naloxone	
  Rescue	
  Kits	
  
(opportunity)	
  	
  
•  A	
  lille	
  work	
  results	
  in	
  most	
  significa...
Educa7on	
  Opportuni7es:	
  Pharmacy	
  
Student	
  and	
  Technician	
  Training	
  
•  Establish	
  and	
  teach	
  cli...
Big	
  Ideas-­‐	
  Opportuni7es	
  to	
  do	
  beler?	
  
•  Develop	
  systems	
  for	
  ease	
  of	
  use	
  for	
  busy...
DEA	
  Na?onal	
  Drug	
  Take	
  Back	
  Day	
  
Who	
  Knew	
  Grandma	
  Kept	
  a	
  Stash!	
  
Partnership	
  for	
  a	
  Drug	
  Free	
  New	
  Jersey	
  
A	
  local	
  church	
  adver?zed	
  on	
  OUR	
  prescrip?on	
  bags!	
  
Thank	
  you!	
  
	
  Tom	
  Kelly,	
  R.Ph.,	
  B.Sc.	
  
	
  PPTP.net/Medicine	
  To	
  Go	
  Pharmacies	
  
	
  PO	
  B...
Ph 2 paulozzi paone_kelly
Ph 2 paulozzi paone_kelly
Ph 2 paulozzi paone_kelly
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Ph 2 paulozzi paone_kelly

  1. 1. Pharmacy  Track   Panel  Discussion:   Trends  in  Prescribing  Prac7ces     Presenters:   Len  Paulozzi,  MD,  MPH   Denise  Paone,  EdD   Tom  Kelly,  R.Ph.,  B.Sc   Moderator:  Andrew  Kolodny,  MD  
  2. 2. Disclosures   •  Len  Paulozzi   •  Denise  Paone  has  no  financial  rela7onships  with   proprietary  en77es  that  produce  health  care  goods   and  services   •  Thomas  Kelly  has  financial  rela7onships  with   proprietary  en77es  that  produce  health  care  products   and  services.  These  financial  rela7onships  are:     –  President/C.E.O.  Medicine  To  Go  Pharmacies   •  Retail  pharmacies     –  President/C.E.O./Partner,  PPTP.net,  LLC   •  Online  due  diligence  tool  for  preven7on  of  misuse,  abuse,  and   diversion  
  3. 3. Learning  Objec7ves   1.  Describe  current  trends  in  effec7ve   prescribing  habits.     2.  Outline  best  prac7ces  for  u7lizing  data  and   PDMPs  as  effec7ve  tools  in  dispensing   controlled  substances.     3.  Evaluate  opportuni7es  for  pharmacists  to   collaborate  with  prescribers  to  create  an   effec7ve  treatment  plan  for  their  pa7ents.  
  4. 4. TM Centers for Disease Control and Prevention National Center for Injury Prevention and Control Trends  in  Prescribing  of     Controlled  Substances,     United  States,  2007-­‐2012   Len  Paulozzi,  MD,  MPH   Centers  for  Disease  Control  and  Preven7on   Na7onal  Prescrip7on  Drug  Summit   Atlanta,  GA          April  22,  2014  
  5. 5. 5   Overview   Trends  in  mortality   Trends  in  prescribing  of  controlled  substances   Conclusions  
  6. 6. Motor  vehicle  traffic,  poisoning,  and     drug  poisoning  death  rates,  United  States,     1980-­‐-­‐2010   0   5   10   15   20   25   1980   1985   1990   1995   2000   2005   2010   Deaths  per  100,000  popula?on   Motor  vehicle  traffic   Poisoning   Drug  poisoning   CDC/NCHS  Na7onal  Vital  Sta7s7cs  System  accessed  through  CDC  WONDER.  
  7. 7. Drug  overdose  deaths  by  major  drug  type,   United  States,  1999-­‐2010   CDC/NCHS  Na7onal  Vital  Sta7s7cs  System,  CDC  WONDER     0   2,000   4,000   6,000   8,000   10,000   12,000   14,000   16,000   18,000   1999   2000   2001   2002   2003   2004   2005   2006   2007   2008   2009   2010   Number  of  Deaths   Year   Opioids   Heroin   Cocaine   Benzodiazepines   16,651  
  8. 8. 8   Rates  of  opioid  overdose  deaths,  sales  and  treatment   admissions,    U.S.,  1999-­‐2010   National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS 0   1   2   3   4   5   6   7   8   1999   2000   2001   2002   2003   2004   2005   2006   2007   2008   2009   2010   Rate   Opioid  Sales  KG/10,000     Opioid  Deaths/100,000   Opioid  Treatment  Admissions/10,000  
  9. 9. 9   Prescrip7on  Data  Source     Purchase  from  IMS   •  Na7onal  Prescrip7on  Audit  (NPA)  2007-­‐2012   •  Data  from  38,000/57,000  pharmacies   •  Includes  retail,  mail-­‐order,  and  long-­‐term  care   •  Na7onal-­‐level  counts  for  prescrip7ons  and  units  (e.g.,  pills)   es7mated  using  a  proprietary  method   •  CDC  converted  to  popula7on-­‐based  rates   •  Non-­‐Butrans  buprenorphine  excluded  from  opioid  rates  
  10. 10. 10   Total  prescrip7on  rate,     United  States,  2007-­‐2012   128,000   129,000   130,000   131,000   132,000   133,000   134,000   135,000   136,000   2007   2008   2009   2010   2011   2012   Prescrip?ons  per  10,000   Source:  IMS  Na7onal  Prescrip7on  Audit  (NPA)®  Extracted  July,  2013   Increase  from  13.1  to  13.5   prescrip7ons  per  person  from   2007  to  2012.  
  11. 11. 11   Opioid  analgesic  prescrip7on  and  unit  rates,     United  States,  2007-­‐2012   7,500   8,000   8,500   9,000   9,500   10,000   0   100,000   200,000   300,000   400,000   500,000   600,000   2007   2008   2009   2010   2011   2012   Prescrip?ons  per  10,000   Units  per  10,000   Unit  rate   Prescrip7on  rate   1%  drop  from  2010   Source:  IMS  Na7onal  Prescrip7on  Audit  (NPA)®  Extracted  July,  2013.  Excludes  buprenorphine   other  than  BuTrans  products.    Units  limited  to  solid  dosage  forms.   1%  increase  from  2010  
  12. 12. 12   Percent  change  in  prescrip7on  rates,  all  drugs  versus   opioid  analgesics,  U.S.,  2007-­‐2012   -­‐1   -­‐0.5   0   0.5   1   1.5   2   2.5   3   3.5   2008   2009   2010   2011   2012   Percent  change   All  rx   Opioids   Source:  IMS  Na7onal  Prescrip7on  Audit  (NPA)®  Extracted  July,   2013  
  13. 13. 13   Hydrocodone  and  oxycodone  prescrip7on  rate,     United  States,  2007-­‐2012   0   500   1,000   1,500   2,000   2,500   3,000   3,500   4,000   4,500   5,000   2007   2008   2009   2010   2011   2012   Prescrip?ons  per  10,000   Hydrocodone   Oxycodone   OxyCon7n®   reformulated  ,   September,  2010   Source:  IMS  Na7onal  Prescrip7on  Audit  (NPA)®  Extracted  July,  2013  
  14. 14. 14   Other  major  opioids  prescrip7on  rate,     United  States,  2007-­‐2012   0   100   200   300   400   500   600   2007   2008   2009   2010   2011   2012   Prescrip?ons  per  10,000   Morphine   Fentanyl   Methadone   Codeine   Oxymorphone   Source:  IMS  Na7onal  Prescrip7on  Audit  (NPA)®  Extracted  July,  2013  
  15. 15. 15   Other  major  opioids  prescrip7on  rate,     United  States,  2007-­‐2012   0   100   200   300   400   500   600   2007   2008   2009   2010   2011   2012   Prescrip?ons  per  10,000   Morphine   Fentanyl   Methadone   Codeine   Oxymorphone   Source:  IMS  Na7onal  Prescrip7on  Audit  (NPA)®  Extracted  July,  2013   Methadone  increased  sharply  to   2008,  when  DEA  compelled  restricted   use  of  the  largest  formula7on.    Rate  in   2012  same  as  rate  in  2007.  
  16. 16. 16   Oxymorphone  prescrip7on  rate,     United  States,  2007-­‐2012   0   10   20   30   40   50   60   2007   2008   2009   2010   2011   2012   Prescrip?ons  per  10,000   Source:  IMS  Vector  One® Na7onal  (VONA)  Extracted  July,  2013   Abuse-­‐resistant  extended-­‐release  formula7on   (Opana  ER)  came  on  market  February,  2012.     Rate  dropped  19%  from  2011  to  2012.  
  17. 17. 17   Opioid  analgesic  prescrip7on  rate  by  payment,     United  States,  2007-­‐2012   0   1,000   2,000   3,000   4,000   5,000   6,000   7,000   8,000   9,000   10,000   2007   2008   2009   2010   2011   2012   Prescrip?ons  per  10,000   Total   Cash   Cash  17%  of   all     opioid  rx   Source:  IMS  Na7onal  Prescrip7on  Audit  (NPA)®  Extracted  July,  2013   Excludes  buprenorphine  other  than  BuTrans  products   Cash  9%   of  all   opioid  rx  
  18. 18. 18   Hydrocodone  and  oxycodone  prescrip7on  rate  paid   with  cash,  United  States,  2007-­‐2012   0   100   200   300   400   500   600   700   800   900   2007   2008   2009   2010   2011   2012   Prescrip?ons  per  10,000   Hydrocodone   Oxycodone   48%  drop  from   20077   39%  drop   Source:  IMS  Na7onal  Prescrip7on  Audit  (NPA)®  Extracted  July,  2013  
  19. 19. 19   Benzodiazepine  prescrip7on  and  unit  rates,     United  States,  2007-­‐2012   200,000   205,000   210,000   215,000   220,000   225,000   230,000   235,000   240,000   2,500   2,700   2,900   3,100   3,300   3,500   3,700   3,900   4,100   4,300   2007   2008   2009   2010   2011   2012   Units  per  10,000   Prescrip?ons  per  10,000   Prescrip7on  rate   Unit  rate   Source:  IMS  Na7onal  Prescrip7on  Audit  (NPA)®  Extracted  July,  2013  
  20. 20. 20   Major  benzodiazepine  prescrip7on  rate,     United  States,  2007-­‐2012   0   200   400   600   800   1,000   1,200   1,400   1,600   1,800   2007   2008   2009   2010   2011   2012   Prescrip?ons  per  10,000   Alprazolam   Clonazepam   Lorazepam   Diazepam   Temazepam   Source:  IMS  Na7onal  Prescrip7on  Audit  (NPA)®  Extracted  July,  2013  
  21. 21. 21   Carisoprodol  prescrip7on  rate,     United  States,  2007-­‐2012   290   300   310   320   330   340   350   360   370   2007   2008   2009   2010   2011   2012   Prescrip?ons  per  10,000   Source:  IMS  Na7onal  Prescrip7on  Audit  (NPA)®  Extracted  July,  2013   DEA  places  carisoprodol  in   Schedule  IV,  Jan  2012;   11%  drop  
  22. 22. Conclusions    Drug  overdose  epidemic  driven  by  overdoses  of  prescrip?on   opioids,  oPen  combined  with  benzodiazepines  and/or  muscle   relaxants    Opioid  overdose  rates  parallel  prescrip?on  rates    Steady  increase  in  opioid  prescribing  rate  since  1999  has   finally  leveled  off    Abuse-­‐resistant  formula?on,  scheduling  change  appear  to  be   associated  with  largest  declines  in  certain  drugs    Overall  declines  alone  likely  too  small  to  reduce  prescrip?on   overdose  mortality  aPer  2010  
  23. 23. Comments or questions: Len Paulozzi, MD, MPH lpaulozzi@cdc.gov The  findings  and  conclusions  in  this  report  are  those  of  the  author  and  do  not  necessarily  represent  the  official   posi6on  of  the  Centers  for  Disease  Control  and  Preven6on/the  Agency  for  Toxic  Substances  and  Disease  Registry.   The  presenter  has  no  conflicts  of  interest  to  report. Acknowledgements: Jinnan Liu, PhD Karin Mack, PhD Chris Jones, PharmD, MPH
  24. 24. Prescrip?on  Monitoring  Program   (PMP)  in  New  York  City   Denise  Paone,  EdD   Director  of  Research  and  Surveillance     Bureau  of  Alcohol  and  Drug  Use     Preven7on,  Care,  and  Treatment   New  York  City  Department  of  Health  and  Mental  Hygiene  
  25. 25. Disclosure  Statement   Denise  Paone  has  no  financial  rela7onships  with   proprietary  en77es  that  produce  health  care   goods  and  services   25  
  26. 26. PMP:  Background     •  Historically  ,  seen  as  a  law  enforcement  tool:   –  To  iden7fy  pa7ents  and  prescribers  engaged  in  possible  aberrant  behavior     –  To  iden7fy  “doctor  shoppers”     –  To  inves7gate  drug  diversion  &  fraud   •  NYC  DOHMH  using  PMP  as  a  public  health  surveillance  tool:   –  To  iden7fy  and  describe  palerns  of  opioid  analgesic  use  at  pa7ent  and  prescriber   levels     –  To  iden7fy  pa7ents  at  risk  for  fatal  and  non-­‐fatal  overdose   –   To  reduce  prescrip7on  drug  misuse  and  diversion   –   As  a  drug  epidemic  warning  system   •  NYC  DOHMH  uses  PMP  as  a  pa7ent  care  tool:     –  To  iden7fy  pa7ents  with  possible  substance  use  disorders     –  To  avoid  risky  drug  Interac7ons   –  To  iden7fy  and  reduce  pa7ent  visits  to  mul7ple  prescribers   •  PMP  not  meant  to  infringe  on  the  legi7mate  prescribing  of     controlled  substances   Source: http://www.pmpalliance.org/content/prescription-monitoring-frequently-asked-questions-faq
  27. 27. PMP:  public  health  surveillance  tool   •  Number  of  prescrip7ons,  pa7ents,  prescriber,   pharmacies   •  Rate  of  opioid  analgesic  prescrip7ons  filled  overall   and  by  drug  type   •  Median  day  supply   •  Rate  of  pa7ents  filling  opioid  analgesic  prescrip7ons   •  Rate  of  high  dose  opioid  analgesic  prescrip7ons  filled  
  28. 28. PMP  surveillance  used  to  inform  public   health  ini?a?ves   •  Opioid  prescribing  guidelines     •  City  Health  Informa7on  (CHI)  –  primary  care     •  Emergency  Department  guidelines   •  Staten  Island  detailing  campaign   •  Focused  on  prescribers   •  Morphine  milligram  equivalent  calculator   •  Media  campaign   •  Public  Service  Announcement    on  “prescrip7on   painkiller  use”  
  29. 29. Analy?c  methods   •  Focus  on  schedule  II  prescrip7on  opioid   analgesics  (excluding  codeine-­‐cII)   •  Exclude  missing  pa7ent  or  prescriber  IDs,   veterinarians,  or  ins7tu7onal  licenses   •  Report  rates  per  1,000  residents  and   adjust  to  2000  US  Standard  popula7on  
  30. 30. Descrip?ve  sta?s?cs   •  Demographic  characteris7cs  of  pa7ent  (gender,   age,  residence,  payment)   •  Prescriber  profession,  specialty  (if  available),   license  loca7on   •  Pharmacy  loca7on  
  31. 31. Prescrip?on  variables   •  Dura7on  of  ac7on   –  Long-­‐ac7ng  or  short-­‐ac7ng   •  Day  supply   •  Morphine  Equivalent  Dose  (MED)     –  Conversion  of  the  daily  dose  of  an  opioid  analgesic   prescrip7on  to  its  morphine  milligram  equivalent     –  High  MED,  or  high  dose,  prescrip7ons  confer   increased  risks  of  overdose,  specifically  when  MED  ≥   100.  
  32. 32. USING  PMP  TO  DESCRIBE  PATTERNS  OF   OPIOID  ANALGESIC  PRESCRIPTION  USE   IN  NEW  YORK  CITY    
  33. 33. Opioid  analgesic  (OA)  prescrip?ons  NYC,   2008–2012   0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 2008 2009 2010 2011 2012 NumberofPrescriptions YearSource: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2008–2012 Opioid analgesic prescriptions Oxycodone Hydrocodone Note:  Schedule  II  opioid  analgesics  
  34. 34. From  2008–2012  there  was  a  17%  increase  in  the   number  of  pa?ents  filling  OA  prescrip?ons   0 100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 2008 2009 2010 2011 2012 Numberofprescriptions Year Patient Prescriber Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2008-2012
  35. 35. 15%  of  prescribers  wrote  83%  of   opioid  analgesic  prescrip?ons   48% 2% 37% 15% 14% 49% 1% 34% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Prescribers Prescriptions Prescribing frequency Very Frequent Prescribers 530-10,185 Rx/year Frequent Prescribers 50-529 Rx/year Occasional Prescribers 4-49 Rx/year Rare Prescribers 1-3 Rx/year Prescrip7ons  filled  by  NYC  residents,  2012   15% 83% Percent Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2012 35   Note:  Schedule  II   opioid  analgesics  
  36. 36. In  2012,  10%  of  prescribers  (n  =  5,384)   wrote  75%  of  prescrip?ons  (n  =1,623,157)   0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Percentofprescriptions Percent of prescribers Note: Schedule II opioid analgesics Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2012
  37. 37. Two-­‐thirds  of  pa?ents  filled  only  one  prescrip?on;   one-­‐third  filled  78%  of  all  opioid  analgesic   prescrip?ons   63% 22% 14% 9% 5% 6% 8% 14% 10% 49% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Patients Prescriptions Prescription Frequency 15 prescriptions 5 prescriptions 3 prescriptions 2 prescriptions 1 prescription Prescrip7ons  filled  by  NYC  residents,  2012   Percent Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2012 37   37% 78% Note:  Schedule  II  opioid   analgesics  
  38. 38. Pa?ents  visi?ng  mul?ple  prescriber  and   mul?ple  pharmacies  are  rare   •  In  2012,  1.2%  (9,137)  of  pa7ents  visited  4+   prescribers  and  4+  pharmacies   – Filled  7.9%  (170,282)  of  all  prescrip7ons   – Visited    15,042  unique  prescribers   – Visited  2,913  unique  pharmacies   Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2012
  39. 39. Two-­‐thirds  of  opioid  analgesic  prescrip?ons   filled  were  paid  with  commercial  Insurance   67%   14%   8%   6%   4%   1%   Commercial  Insurance   Private  Pay  (Cash,  Charge,   Credit  Card)   Medicare   Other   Medicaid   Workers  Comp   Note:  Schedule  II  opioid  analgesics   Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2012
  40. 40. Staten  Islanders  filled  OA  prescrip?ons  at   higher  rates  in  2012   0 50 100 150 200 250 300 350 400 450 500 NYC Bronx Brooklyn Manhattan Queens Staten Island Age-adjustedrateofprescriptionsfilledper 1,000residents Borough of Residence Opioid Analgesics Oxycodone Hydrocodone Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2012 Note:  Schedule  II  opioid  analgesics   Rates are adjusted to 2000 US Census population    
  41. 41. OA  prescrip?ons  filled  by  Staten  Islanders  have   longer  median  day  supply   0 5 10 15 20 25 30 NYC Bronx Brooklyn Manhattan Queens Staten Island MedianSupply,Days Borough of ResidenceSource: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2012 Note:  Schedule  II  opioid  analgesics       Median  day  supply  is  calculated  from  day  supply  of  each  prescrip7on  filled  in  the  year.    
  42. 42. OA  prescrip?ons  filled  by  Staten  Islanders  are   more  frequently  high  dose  (>100  MED)   0 20 40 60 80 100 120 140 160 NYC Bronx Brooklyn Manhattan Queens Staten Island Age-adjustedrateofhighdoseprescriptions filledper1,000residents Borough of Residence 2008 2009 2010 2011 2012 Note:  Schedule  II  opioid  analgesics     High  dose  is  any  opioid  analgesic  prescrip7on  with  a  calculated   morphine  equivalent  dose  (MED)  greater  than  100.  Among   pa7ents  receiving  opioid  prescrip7ons,  overdose  rates   increase  with  increasing  doses  of  prescribed  opioids.   Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2008–2012 Rates are adjusted to 2000 US Census population    
  43. 43. PMP  PUBLIC  HEALTH  SURVEILLANCE   AND  DATA  DRIVEN  INITIATIVES  
  44. 44. Neighborhoods  with  high  rates  of  OA  prescrip?ons   have  high  rates  of  uninten?onal  (overdose)  deaths   involving  opioid  analgesics       *Paone D, Bradley O’Brien D, Shah S, Heller D. Opioid analgesics in New York City: misuse, morbidity and mortality update. Epi Data Brief. April 2011. Available at http://www.nyc.gov/html/doh/downloads/pdf/epi/epi-data-brief.pdf . OA PRESCRIPTION RATES OA MORTALITY RATES
  45. 45. Opioid  prescribing  guidelines   •  Less  oqen:  avoid  prescribing  opioids  for   chronic  non-­‐cancer,  non-­‐end-­‐of-­‐life  pain     e.g.,  low  back  pain,  arthri7s,  headache,   fibromyalgia   •  Shorter  dura7on:  when  opioids  are   warranted  for  acute  pain,  3-­‐day  supply   usually  sufficient   •  Lower  doses:  if  dosing  reaches  100   Morphine  Milligram  Equivalents  (MME)  ,   reassess  and  reconsider  other   approaches  to  pain  management   •  Avoid  whenever  possible  prescribing   opioids  in  pa7ents  taking   benzodiazepines   Cita7on:  Paone  D,  Dowell  D,  Heller  D.  Preven7ng  misuse  of  prescrip7on  opioid  drugs.  City  Health  Informa7on.  2011;  30(4):  23-­‐30   New  York  City  Opioid  Treatment  Guidelines,  Clinical    Advisors:  Nancy  Chang,  MD;  Marc  N.  Gourevitch,  MD,  MPH;  Mark  P.  Jarrel,  MD,   MBA;  Andrew  Kolodny,  MD;  Lewis  Nelson,  MD;  Russell  K.  Portenoy,  MD;  Jack  Resnick,  MD;  Stephen  Ross,  MD;  Joanna  L.  Starrels,  MD,   MS;  David  L.  Stevens,  MD;  Anne  Marie  S7lwell,  MD;  Theodore  Strange;  MD,  FACP;  Homer  Venters,  MD,  MS     45  
  46. 46. New  York  City  Emergency  Department  Discharge  Opioid  Prescribing  Guidelines  Clinical  Advisory  Group:  Jason  Chu,   MD,  Brenna  Farmer,  MD,  Beth  Y.  Ginsburg,  MD,  Stephanie  H.  Hernandez,  MD,  James  F.  Kenny,  MD,  MBA,  FACEP,  Nima   Majlesi,  DO,  Ruben  Olmedo,  MD,  Dean  Olsen,  DO,  James  G.  Ryan,  MD,  Bonnie  Simmons,  DO,  Mark  Su,  MD,  Michael   Touger,  MD,  Sage  W.  Wiener,  MD.   Emergency  Department  guidelines   Released   January,  2013   Adopted  by  35   NYC  emergency   departments   46  
  47. 47. Staten  Island  public  health   “detailing”  campaign   •  1-­‐on-­‐1  “detailing”  visits  from   Health  Department  representa7ves   •  Deliver  key  prescribing   recommenda7ons,  clinical  tools,   pa7ent  educa7on  materials   •  ~1,000  Staten  Island  physicians,   nurse  prac77oners,  physicians   assistants   •  June–August  2013   •  PMP  data  analyzed  to  evaluate   prescribing  palerns  pre-­‐  and  post-­‐ campaign   47  
  48. 48. 48  
  49. 49. Morphine  Milligram  Equivalent  (MME)   calculator   •  A  tool  to  calculate  total  MME  per  day   •  Gives  alert  for  dosages  >100  MME   •  Quick  and  easy  to  use   •  Web-­‐based  applica7on   –  Search  for  “NYC  MME  Calculator”   hlp://www.nyc.gov/html/doh/html/mental/MME.html   •  Smartphone  app   49  
  50. 50. 50  
  51. 51. Media  campaigns   •  Campaign  One:     –  Goal:  Increase  awareness  of  risk  of  opioid  analgesic  overdose   –  Ran  twice  (2012,  2013)   •  Campaign  Two:     –  Goal:  Reduce  s7gma  and  raise  awareness  of  opioid  analgesic   misuse   –  2  tes7monials   •  Mom  lost  son  to  opioid  analgesic  overdose   •  NYC  resident    in  recovery   –  Ran  2013  and  2014   51  
  52. 52. Summary   •  PMPs  can  be  used  as  a  public  health  surveillance   tool  to  understand  palerns  of  opioid  analgesic   prescrip7on  use   •  New  Yorkers  filled  ~2  million  opioid  analgesic   prescrip7ons  per  year  from  2008-­‐2012   •  From  2008-­‐2012  Staten  Island  residents  filled   high  dose  prescrip7ons  (>100  MED)  at  highest   rates   •  High  rates  of  opioid  analgesic  prescrip7on  use   mirror  high  rates  of  opioid  analgesic  overdose   mortality  
  53. 53. Improving  Outcomes   while  Deterring   Misuse,  Abuse,  &   Diversion   Tom  Kelly,  R.Ph.,  B.Sc.   C.E.O./Partner:   Medicine  To  Go  Pharmacies,  PPTP.net  
  54. 54. Disclosures   •  Thomas  Kelly  has  financial  rela7onships  with   proprietary  en77es  that  produce  health  care   products  and  services.    These  financial   rela7onships  are:     •  President/C.E.O.  Medicine  To  Go  Pharmacies   – Retail  pharmacies     •  President/C.E.O./Partner,  PPTP.net,  LLC   – Online  due  diligence  tool  for  preven7on  of  misuse,   abuse,  and  diversion    
  55. 55. Learning  Objec7ves   1.  PMP's  and  PDMP's  are  valuable  clinical  tool   promo7ng  improved  outcomes.   2.  There  is  a  difference  between  healthcare  and   enforcement.  
  56. 56. How  Did  We  Get  Here?   •  1980  prehistoric   •  1996  Oxycon7n  launched  “less  poten7al  for  addic7on  and   abuse”,  chronic  pain  pa7ents  undertreated.   •  Non  profits  funded  by  opiate  pharma  manuf.  (Am.  Pain   Founda7on)   •  8/31/2000  FDA  approves  NDA  for  Roxicodone  15mg  &  30mg   •  Current  Trends:     –  6/3/2011  Fla:  HR  7095  an7-­‐pill  mill  legisla7on  signed  by  Gov.  Rick   Scol     –  DEA  suspends  permits  for  2  CVS  and  6  Walgreens  pharmacies  and   some  independent  pharmacies  in  Fla.     –  DEA  suspends  permits:    3  Cardinal  Health  distribu7on  centers,   Walgreen’s,  Juniper,  Fl.,  AmerisourceBergen,  Orlando,  Fl.,  Harvard   Drug  Group,  Livonia,  Mi.     –  McKesson  pays  $13  million  in  fines  for:  Fl.,  Tx.,  Md.,  Ut.,  Co.,  Ca.  
  57. 57. The  Strange  Down  Stream  Trends   •  Viola7ons  everywhere,  wholesale  distributors:   “But  how  much  can  we  sell?”   •  Blind  speed  limits   •  Contrac7on  in  opioid  analgesic  distribu7on   •  Some  pa7ents  struggle  to  get  medica7ons,  really?   –  4.8%  of  worlds  popula7on  consumes  80%  opioid   analgesics  but  significant  hitches  in  supply  stream   •  Wholesalers  using  numbers,  not  encouraging  or   establishing  the  use  of  sound  clinical  guidelines   –  Place  pharmacist  on  review  team  
  58. 58. Unfortunate  Reali7es   •  Growing  popula7ons  trends  for  chronic  pain  pa7ents   –  Advanced  trauma  care  leading  to  more  survivors    (fortunate  reality)   –     Diabetes  explosion  CDC  1980-­‐2011  2.5  to  6.9%  -­‐  genera7ng  more  neuropathies?   –     Arthri7s  rates  increasing   –     Obesity  increasing   •  As  they  say  in  enforcement:  “Follow  the  money”   –  2008  recession  compounds  problem,  economic  relief  in  black  market   •  60%  of  diverted  medica7ons  sourced  from  friends  and  family,  Get  Rx  for  120,  use   40  divert  80.    Difficult  to  detect.     –  Is  black  market  larger  than  legal  market?     •  #120  oxycodone  15mg  @  $60  legal  via  insurance,  black  market  at  $1/mg  @$1,800       –  Heroin  cheap,  easy  to  turn   •  Prescrip7on  opioid  analgesics  &  heroin  more  valuable  than  cash   •  We  cannot  enforce  our  way  out   •  What  are  liabili7es  for  not  performing  due  diligence?   •  Fewer  Fellowships  offered  in  pain  management,  family  prac7oners   and  GP’s  are  prescribing   –  Only  a  couple  of  extra  pain  pa7ents  per  prescriber  add  up   •  Not  my  pa7ents  
  59. 59. Its  busy,  What  Can  I  Do?  (opportuni7es)   •  Promote  and  u7lize  PMPs  as  a  tool  to  achieve  posi7ve  outcomes   (healthcare  term,  not  enforcement,  &  not  an  excuse  to  dispense!)   •  Establish  PMP  review  in  workflow,  promote  states  to  allow  registered   technicians  and  nurses  to  access  data  bases   •  Reduce  liability  with  due  diligence   •  Verify  pa7ent  iden7ty  at  drop  off:  government  issued,  commercial  services   •  Collaborate,  let  prescribers  know  around  the  clock  IR  meds  for  pain  control   not  illegal  but  frowned  upon,  decrease  #  doses  on  the  street,  use  sound   clinical  judgment   •  Collaborate,  perform  random  medica7on  counts  for  pa7ents  exhibi7ng   adherent  behavior  for  your  prescribers   •  Review,  review,  review  clinical  risks  with  pa7ents,  par7cularly  those  who   are  opiate  naive   •  Counsel  all  regarding  secure  storage,  i.e.  dental  rxs,  loaded  gun  in  medicine   cabinet  analogy   •  Ins7tute  a  treatment  agreements,  aka  narco7c  contract  
  60. 60. But  What  Can  I  Do?     Con7nued…  (more  opportuni7es)   •  Market  topically  compounded  analgesics-­‐  far  lower  poten7al  for  abuse   •  Partner  with  adver7zing  vendors  to  include  medica7on  guide  specific  for   commonly  abused  medica7on,  i.e.  LDM  Group,  CarePoints  (slide)   •  Increase  sensi7za7on:  Use  social  media  &  poster  up,  “Who  Knew  Grandma   Kept  a  Stash”,  Partnership  for  a  Drug  Free  New  Jersey,  DEA’s  Na7onal   Prescrip7on  Drug  Take  Back  Day,  etc.  (slide)   •  Partner  with  teaching  ins7tu7ons.    Sponsor  substance  abuse  CE  +  CME’s   for  health  care  providers,  including  pediatricians,  den7sts,  and  oral   surgeons  (slide)   •  Get  involved,  collaborate,  join  work  groups,  encourage  community  based   ac7on,  no  one  group  can  defeat  this  scourge  alone  (slide)   –  Form  local  coali7ons,  churches,  schools,  enforcement,  civic  groups,   etc.     •  Sponsor  a  local  drop  off  box  for  unused  medica7ons   –  www.americanmedicinechest.com/_media/permcollec7on1.pdf  
  61. 61. Provide  Naloxone  Rescue  Kits   (opportunity)     •  A  lille  work  results  in  most  significant   outcomes  alainable   •  Develop  collabora7ve  prac7ce  agreements   •  Trails  already  blazed,  follow  the  footsteps   – hlp://stopoverdose.org/index.htm   – hlp://harmreduc7on.org/   – hlp://prescribetoprevent.org/about-­‐us/  
  62. 62. Educa7on  Opportuni7es:  Pharmacy   Student  and  Technician  Training   •  Establish  and  teach  clinical  guidelines  for  counseling   pa7ents  to  avoid  issues  associated  with  controlled   medica7ons.       •  Encourage  training  in  detec7ng  evidence  of  misuse,   substance  abuse,  addic7on,  pseudo  addic7on,  and   diversion  in  pa7ent  popula7ons.   •  Amplify  the  value  of  PMPs  as  a  clinical  tool.     •  If  a  palern  of  abuse  is  detected,  provide  outline  on   how  to  assist  the  pa7ent  and  associated  healthcare   providers  move  forward  toward  posi7ve  outcomes.    i.e.   addic7on  services,  mental  health  services,  etc.     •  Provide  protocols  on  when  and  how  to  engage   enforcement.  
  63. 63. Big  Ideas-­‐  Opportuni7es  to  do  beler?   •  Develop  systems  for  ease  of  use  for  busy  prac7ces,   pharmacies  and  prescribers  alike.  Current  models  D+   –  Allow  nurses  and  pharmacy  technicians  access?   •  Reward  health  care  professionals  for  accessing  PMPs.   –  Direct  compensa7on,  rebate  professional  license  fees,  tax   credits?     •  Establish    and  encourage  realis7c  reimbursements  to   pharmacies  for  Medica7on  Therapy  Management   (MTM)  reviews  for  chronic  pain  pa7ents.   •  Develop  Accountable  Care  Organiza7on  (ACO)  models   for  how  dispensing  pharmacies  can  partner  with  ACOs     &  manage  chronic  pain  pa7ents  to  improve  outcomes   and  subsequently  reduce  costs.  
  64. 64. DEA  Na?onal  Drug  Take  Back  Day  
  65. 65. Who  Knew  Grandma  Kept  a  Stash!   Partnership  for  a  Drug  Free  New  Jersey  
  66. 66. A  local  church  adver?zed  on  OUR  prescrip?on  bags!  
  67. 67. Thank  you!    Tom  Kelly,  R.Ph.,  B.Sc.    PPTP.net/Medicine  To  Go  Pharmacies    PO  Box  2253    Long  Beach  Branch    Beach  Haven,  NJ  08008    1-­‐609-­‐242-­‐1400  voice    tom.kelly@PPTP.net  email    www.PPTP.net  website  

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