Rx15 pdmp tues_330_1_brown_2fondario_3quesinberry

PDMPs as Public Health Surveillance Tools:

Early Lessons from CDC’s Prevention Boost

Sheryll Brown, MPHOklahoma State Department of Health

Anna Fondario, MPHUtah Department of Health

Dana Quesinberry, JDKentucky Department for Public Health

Noah Aleshire, JDCenters for Disease Control

and Prevention

Disclosure Statement

Sheryll Brown, MPH; Anna Fondario, MPH; Dana Quesinberry, JD; and Noah Aleshire, JD, have disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Disclosure Statement

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– Kelly Clark – Employment: Publicis Touchpoint Solutions;

Consultant: Grunenthal US– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center– Carla Saunders – Speaker’s bureau: Abbott Nutrition

Learning Objectives

• Outline prescription drug overdose prevention programs developed by five states through Prevention Boost cooperative agreements with CDC.

• Describe the PDMP components of four state programs.

• Evaluate three state programs using Prevention Boost to leverage PDMPs as public health surveillance tools.

Prescription Drug Overdose:Boost for State Prevention

• Advance and evaluate comprehensive state-level interventions for preventing prescription drug overdose in 3 areas:

• Enhancing and maximizing PDMPs

• Improving and evaluating public insurer mechanisms

• Evaluating state-level laws, policies, and regulations

Oklahoma Prescription Drug Overdose Prevention Program

Sheryll Brown, MPH

Injury Prevention Service

Oklahoma State Department of Health

Overdose Mortality in Oklahoma

• Rates per 100,000 population more than doubled in the U.S. and increased nearly fourfold in OK since 1999.1

• Oklahoma has the 8th highest drug overdose death rate in the U.S.1

1. Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/injury/wisqars/index.html.

Age-adjusted Motor Vehicle Crash and Poisoning Death Rates, Oklahoma, 1999-2013

0

5

10

15

20

25

1999 2001 2003 2005 2007 2009 2011 2013

Rat

e p

er 1

00,0

00 P

op

ula

tio

n

MVC All poisoning Drug poisoning Unintentional drug poisoning

Source: CDC WONDER http://wonder.cdc.gov/.

Unintentional Opioid-related Overdose Death Rates1 and Opioid Sales per Person,2 Oklahoma,

2000-2012

0

200

400

600

800

1000

1200

0

2

4

6

8

10

12

14

2000 2002 2004 2006 2008 2010 2012

Mo

rph

ine

mg

eq

uiv

alen

ts/p

erso

n

Dea

th R

ate

per

100

,000

po

pu

lati

on

Death rate Opioid sales

1. Oklahoma State Department of Health, Injury Prevention Service, Unintentional Poisonings Database. 2. Department of Justice, Drug Enforcement Administration, Automation of Reports and Consolidated Orders

System, Report 4.

UP surveillance system created

OK Injury Prevention ServiceDrug Overdose Data Sources

• Unintentional Poisoning Surveillance System

• Office of the Chief Medical Examiner– Statewide centralized system

– Receive reports for all non-natural deaths

– Narratives, autopsies, toxicology

• Vital Statistics death certificate data

• Hospital inpatient discharge data

• OK National Violent Death Reporting System

Most Common Prescription Drugs by Year of Death, Unintentional Poisonings, Oklahoma, 2007-2013

Source: Oklahoma State Department of Health, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports).

0

20

40

60

80

100

120

140

160

180

2007 2008 2009 2010 2011 2012 2013

Nu

mb

er o

f D

eath

s

Year of Death

Hydrocodone

Oxycodone

Alprazolam

Methadone

Morphine

PMP checks mandated for methadone

State Plan• Education

• Disposal/Storage

• Tracking and Monitoring

• Regulation and Enforcement

• Treatment and Interventions

OK Prescription Monitoring Program (PMP)

• System within Bureau of Narcotics and Dangerous Drugs Control (OBNDDC)

• Established in 2006 – Includes Schedules II, III, IV and V

• Reporting requirements for dispensers– 2006 to 2010 = Reported to PMP every 30 days

– 2010 to 2012 = Reported to PMP every 24 hours

– 2012 to Today = Reported to PMP within 5 minutes of delivery to patient

PMP Utilization

QTR 32010

QTR 42010

QTR 12011

QTR 22011

QTR 32011

QTR 42011

QTR 12012

QTR 22012

QTR 32012

QTR 42012

QTR 12013

QTR 22013

Doctor 112,346 120,190 141,086 173,052 196,016 202,346 244,168 273,163 303,317 309,411 345,730 377,059

Pharmacy 8,895 8,267 9,023 12,856 15,647 14,020 20,416 23,592 26,442 26,075 44,073 104,554

LE/Regulatory 3,332 4,655 5,585 5,958 6,294 5,531 8,076 8,293 7,391 7,663 8,946 7,582

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

Number of Patient Reports

Real Time Reporting Begins

WalgreenPolicy Change

Source: Oklahoma Bureau of Narcotics and Dangerous Drugs Control.

2013 OK Legislation Enacted (HB 1781)

Effective November 1, 2013, Mental Health and Substance Abuse Services and State Department of Health given access to the PMP for statistical, research, substance abuse prevention or educational purposes (O.S., Title 63, Section 2-309D)

Oklahoma Prescription Drug Overdose Prevention Program

• CDC Prevention Boost grant recipient

• Strategy 1. Expand and maximize the PDMP as a public health surveillance system

• Strategy 2. Develop and apply metrics for inappropriate prescribing and identify high-risk groups among the insured

OK Prevention Boost Data PartnersP

MP

Dat

a

Bureau of Narcotics and Dangerous Drugs Control

Hea

lth

Ou

tco

me

Dat

a

State Department of Health

Stat

e M

edic

aid

Cla

ims

Dat

a

Health Care Authority

Men

tal H

ealt

h D

ata

Department of Mental Health and Substance Abuse Services

Office of Management Enterprise Services –Information Technology Services

Data Oversight

Committee QI Project

Expand and Maximize the PMP as a Public Health Surveillance System – Activities

• Link PMP data to health outcome data

• Conduct public health surveillance with the PMP data, calculate measures and monitor trends

– Brandeis Prescription Behavior Surveillance System

– CDC Indicators

• Epidemiologic analyses and reporting

– Enhance proactive reporting criteria

– Inform data quality; improve PMP system

Intermediate Outcomes

↓Percent of patients receiving high doses of opioids (>100 mme1/day) and dangerous drug combinations

↓Multiple provider episodes for opioids↓Opioid-naïve patients receiving long-acting or

extended-release opioids

↑Use of PMP↑Providers checking PMP the first time opioid

Rx is written1. Morphine milligram equivalents.

Long-Term Outcomes

↓Hospitalizations for drug-related poisonings and opioid-related poisonings

• OK Hospital Inpatient Discharge Database

↓Mortality due to drug-related poisonings, prescription drug-related poisonings, and deaths from opioid painkillers

• Unintentional poisoning surveillance data, medical examiner data, Vital Statistics death data

Successes and Challenges• Successes

– Receipt of PMP data 2010-2013– Technical support and IT support available– Partner with OBNDDC to support PMP quality tools– Brandeis PDMP Prescription Behavior Surveillance

System SAS code

• Challenges – ~10 million records per year in PMP– Data quality– Time, increased demands on system– Secured server space– High-powered computers– Subset to test analyses/programs

PDMPs as Public Health Surveillance Tools: Early Lessons from CDC’s

Boost for State Prevention Grant

Utah’s ExperienceAnna Fondario, MPHInjury Epidemiologist

Utah Department of HealthViolence and Injury Prevention Program

0

50

100

150

200

250

300

350

Nu

mb

er

of

De

ath

s

Year

Rx Opioids

Motor Vehicle Crash

Heroin & Cocaine

ONEcause of injury deaths

in Utah

87

%are prescription opioids

70

%are prescription drugs

and of these

Poisoning is the

number

Number of unintentional and undetermined deaths by year and selected cause, Utah 2000-2013

Date Source: Utah Office of Vital Records and Statistics and Utah Office of the State Medical Examiner

0

50

100

150

200

250

300

350

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Nu

mb

er

of

De

ath

s

Year

Pro

gram

Fu

nd

ed

Fun

din

g El

imin

ated443%

Number of occurrent prescription opioid deaths by year, Utah 2000-2013

28%

Date Source: Utah Office of Vital Records and Statistics and Utah Office of the State Medical Examiner

% Increase or Decrease by Sex 2000-2010 2007-2010 2010-2012

Men 271% 28% 21%

Women 483% 27% 2%

Overall 293% 28% 11%

Date Source: Utah Office of Vital Records and Statistics and Utah Office of the State Medical Examiner

Pain Medication Management and Education

• Investigate causes, risk factors and solutions for deaths and of prescription opiate use and misuse using the CSD

• Provide recommendations on the use of the CSD to identify and prevent:

– Misuse of opiates

– Inappropriate prescribing; and

– Adverse outcomes of prescription opiate medications

Legislative Actions

2008

• Public education, misuse of the CSD a third degree felony, real-time reporting and access pilot program

2009• Expands access to CSD (designee)

2010

• All prescribers register to use the CSD, take a tutorial, pass a test

• Hospital / DUI impaired driving reporting of overdose to DOPL who then must notify each prescriber

• Expands access to CSD (UDOH)

2011• Four hours of controlled substance prescribing

education

PDMP has the potential to be an informative public health data source

Data Information Action

Utah’s Controlled Substance Database

• Purpose is to serve as a resource to aid in the prevention, enforcement, and treatment of prescription controlled substance misuse and diversion.

• Schedule II-V prescription records

• Over 47 million records

• Over 600 pharmacies

• Data due every seven days

981 1,013 1,455 2,0382,958

9,899

13,46014,415

15,553

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014

Nu

mb

er

of

Re

gist

ere

d P

ract

itio

ne

rs

Fiscal Year

2010 Legislation requiring prescriber registration

Number of Registered Practitioners for the Controlled Substance Database, Utah FY2006-FY2014

Date Source: Division of Occupational and Professional Licensing, Utah Controlled Substance Database

0.0

50.0

100.0

150.0

200.0

250.0

300.0

2004 2005 2006 2007 2008 2009 2010 2011 2012

Rat

e o

f d

eat

hs

pe

r 1

00

,00

0 p

resc

rip

tio

ns

Year

Methadone Fentanyl Oxycodone Hydrocodone

Rate of occurrent deaths per 100,000 prescriptions by year and prescription type, Utah, 2004-2012

Date Source: Utah Department of Health Violence and Injury Prevention Program, Prescription Pain Medication Program Database, Division of Occupational and Professional Licensing, Utah Controlled Substance Database

0%

10%

20%

30%

40%

50%

60%

Indicated Drug Only

Other Drugs Involved

Percentage of occurrent deaths by selected prescription pain medication deaths, Utah, 2000-2012

Date Source: Utah Department of Health Violence and Injury Prevention Program, Prescription Pain Medication Program Database, Division of Occupational and Professional Licensing, Utah Controlled Substance Database

15.5

20.6

8.9

29.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Methadone Fentanyl Oxycodone Hydrocodone

% C

han

gePercent change in the rate of occurrent prescription pain medication deaths by drug type, Utah, 2009-2012

Date Source: Utah Department of Health Violence and Injury Prevention Program, Prescription Pain Medication Program Database, Division of Occupational and Professional Licensing, Utah Controlled Substance Database

Date Source: Christina A. Porucznik, Jacob Crook, Erin M. Johnson, Robert T. Rolfs, Brian C. Sauer, Poster Physician Specialty and Opioid Prescribing in the Utah Controlled Substance Database 2005-2009

PDO: Boost For State Prevention

Expanding and maximizing the CSD

as a public health surveillance tool

Evaluate policy implementation

activities and create lessons

learned

Support policy evaluation activities

through multi-agency

collaboration

Increased proactive reporting

Short-term Intermediate Long-term

Decreased rate of high-dose opioids by providers

Increased use of standard CSD reports for surveillance and to inform policy evaluation efforts

Decreased rate of dangerous drug combinations

Decreased drug overdose death rate

Increased use of CSD by providers, law enforcement, licensure boards

Increased enforcement actions against outlier providers

Decreased rate of patients using multiple providers for opioid prescriptions

Decreased prescribing patterns inconsistent with guidelines/rules

Decreased rate of ED visits due to misuse or abuse of controlled prescription drugs

CSD Goal Short-term,

Intermediate, and Long-term

Outcomes

Emergency Department

Hospitalization Outpatient/Inpatient

Vital Records Births/Deaths

Child Health Databases

Medicaid

All Payer Claims Database

Immunization

Mas

ter

Pe

rso

n

Ind

ex

• Linked data in addition to data on:• multiple-provider episode rates• prescription volumes by prescribers and pharmacies• mean daily opioid dosage prescribed• distance travelled• prescriber and patient behavior trends with a focus on

geographic, sex, and age disparities• Opportunity to collaborate with researchers• Utilize Use Only as Directed media initiatives

Thank You

Kentucky Prescription Drug Overdose Prevention Program

Dana Quesinberry, JDKentucky Injury Prevention and Research Center

University of KentuckyKentucky Department for Public Health

April 7, 2015

Prescription Drug Abuse in Kentucky

• In 2012, Kentucky had the 2nd highest age-adjusted drug overdose fatality rate in the nation at 23.5 drug overdose fatalities/ 100,000 population. CDC WONDER data

• Rate of drug overdose fatalities has more than quadrupled since 1999

• In 2012, Kentucky recorded 1,031 drug overdose deaths (23.9/100,000)

Top Two Causes of Unintentional Injury Deaths in Kentucky

0

200

400

600

800

1000

1200

2008 2009 2010 2011 2012 2013

Year

Unintentional MV Traffic Unintentional Poisoning

2012 State Medical Examiner Most Frequently Detected Substances in Autopsy Cases

2012 Year of Legislative Action

Kentucky passes ground-breaking PDO-related laws within HB 1

– Pain clinics– Decedent controlled

substances testing when the underlying cause of death is not known

– Expand annual report on drug-related deaths to include drugs involved in deaths and method by which they were obtained, if known

HB 1 PDMP-related Components

Mandatory prescriber querying

Linkage to other state

PDMPs

Mandated Prescriber

Registration

Kentucky PDO Boost Activities

1) Enhance and maximize KASPER’s effectiveness by

a. expanding and improving proactive KASPER reporting

b. expanding and maximizing KASPER as a public health surveillance system

2) Evaluate Kentucky laws designed to prevent prescription drug misuse, diversion, and overdose by

a. evaluating and performing an economic analysis of the regulations that require KASPER querying when prescribing schedule II-IV controlled substances

b. evaluating and performing an economic analysis of the law that requires decedent controlled substance testing when no other cause of death has been established

Expanding and Increase Proactive Reporting

Data sharing with border states

Added Data Fields

Strengthening data quality and completeness

Enhanced analysis and reports

Multi-Source Drug Overdose Fatality Surveillance System

OVS

Medical Examiner/Elected

Coroners

KASPER

Conduct Non-Fatal Prescription Drug Overdose Surveillance

• Inpatient hospitalization Data

• Emergency Department Data

Evaluate KASPER Querying Regulations Laws by Clinical Professions

• Examine the effectiveness of the law to change prescriber and patient behaviors

• Delineate implementation facilitators and barriers

• Analyze economic impact on cost bearers

Evaluate Decedent Controlled Substance Abuse Testing Law

• Examine effectiveness of law

• Delineate implementation facilitators and barriers

• Determine process changes after law implementation

• Analyze economic impact on cost bearers

1,020

1,032

980

950

960

970

980

990

1,000

1,010

1,020

1,030

1,040

2011 2012 2013

Kentucky Resident Drug Overdose Deaths, 2011 - 2013

Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky Vital Statistics electronic death certificate file. Data extract as of October 2014. Data are provisional and subject to change.

4225

538

431

365

129

50

471

362

285

200

74

423

318

238

0

100

200

300

400

500

600

Heroin Cocaine Pharmaceutical Opioids Benzodiazepines Combination of Rxopioids and

benzodiazepines

Kentucky Resident Drug Overdose Deaths, 2011 - 2013

2011

2012

2013

Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky Vital Statistics electronic death certificate file. Data extract as of October 2014. Data are provisional and subject to change.

6,4226,371

5,590

5,000

5,200

5,400

5,600

5,800

6,000

6,200

6,400

6,600

2011 2012 2013

Kentucky Resident Drug Overdose Hospitalizations

Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky inpatient hospitalization discharge data, Office of Health Policy. Data are provisional and subject to change.

62

213

1,610

1,885

705

175219

1,504

1,709

619

263204

1,151

1,339

409

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Heroin Cocaine PharmaceuticalOpioids

Benzodiazepines Combination of Rxopioids and

benzodiazepines

Kentucky Resident Drug Overdose Hospitalizations

2011

2012

2013

Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky inpatient hospitalizationdischarge data, Office of Health Policy. Data are provisional and subject to change.

8,0018,292

7,627

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

2011 2012 2013

Kentucky Resident Drug Overdose Emergency Department Visits

Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky Outpatient Services Database, Office of Health Policy. Data are provisional and subject to change.

278

96

1,048

1,310

312

865

116

991

1,213

257

1,111

120

772

853

150

0

200

400

600

800

1,000

1,200

1,400

Heroin Cocaine PharmaceuticalOpioids

Benzodiazepines Combination of Rxopioids and

benzodiazepines

Kentucky Resident Drug Overdose Emergency Department Visits

2011

2012

2013

Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky Outpatient Services Database, Office of Health Policy. Data are provisional and subject to change.

Contact Information

Dana Quesinberry, JDHealth Policy and Program Evaluator; Kentucky Injury Prevention and Research CenterUniversity of Kentucky,College of Public Health333 Waller Ave., Suite 242Phone: [email protected]

Terry Bunn, PhDAssoc Professor, Dept of Prev Medicine & Environ Health; Director, Kentucky Injury Prevention and Research Center,University of Kentucky, College of Public Health333 Waller Ave., Suite 242Lexington, KY 40504Phone: [email protected]