PDMP Track: Combining PDMP and Other Data to Combat Rx Drug Abuse Presenters: • Richard Stripp, PhD, Chief Scientific and Technical Officer, Cordant Health Solutions • Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital Emergency Department, and Chair, San Diego County (CA) Rx Drug Abuse Medical Task Force • Jonathan Lucas, MD, Chief Deputy Medical Examiner, San Diego County (CA) Moderator: Connie M. Payne, Executive Officer, Statewide Services, Administrative Office of the Courts, and Member, Operation UNITE Board of Directors
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PDMP Track:Combining PDMP and Other Data
to Combat Rx Drug AbusePresenters:
• Richard Stripp, PhD, Chief Scientific and Technical Officer, CordantHealth Solutions
• Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital Emergency Department, and Chair, San Diego County (CA) Rx Drug Abuse Medical Task Force
• Jonathan Lucas, MD, Chief Deputy Medical Examiner, San Diego County (CA)
Moderator: Connie M. Payne, Executive Officer, Statewide Services, Administrative Office of the Courts, and Member, Operation UNITE Board of Directors
Disclosures
• Richard Stripp, PhD – Employment: Cordant Health Solutions (formerly Sterling Healthcare Services)
• Roneet Lev, MD; Jonathan Lucas, MD; and Connie M. Payne have disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
Disclosures
• 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
1. Identify reasons and methods for combining PDMP data with other data.
2. Evaluate the effectiveness of combining laboratory and PDMP data to identify patients who are not taking Rx medication responsibly, based on a nationwide study.
3. Describe a San Diego collaborative project that combines PDMP and medical examiner data.
Combining PDMP and Other Data to Combat Rx Drug Abuse
Disclosure
• Richard Stripp, Chief Scientific & Technical Officer, wishes to disclose he is an employee of Cordant Health Solutions. He will present this content in a fair and balanced manner.
Learning Objectives
1. Identify reasons and methods for combining PDMP data with other data.
2. Evaluate the effectiveness of combining laboratory and PDMP data to identify patients who are not taking Rx medication responsibly, based on a nationwide study.
The Problem: Isolated Pharmacy and Laboratory Databases
• Tens of millions of urine drug tests are performed annually in the United States, but when and if drug tests are performed often is based on little data beyond the prescribers "feel" for the patient.
Kelly, S. (2014, October 8). Survey: 50% of Physicians Never Check the PDMP when Prescribing Controlled Substances. Retrieved from Imprivata: http://www.imprivata.com/blog/survey-50-physicians-never-check-pdmp-when-prescribing-controlled-substances
A recent survey shows 50% of physicians never check the PDMP when prescribing controlled substances
The Problem: Not all patients are created equal
• Without guidance based on patient-specific data on who and when to test, physicians struggle with drug testing.
The downstream effects of this are:
• Underutilization• Overutilization• Inflated drug testing
costs
The Problem: Isolated Pharmacy and Laboratory Databases
Laboratory Pharmacy
Lacks visibility of all
medications prescribed to
the patient
Cannot
communicate if
medications came
from multiple
sources
Cannot always differentiate
if medication was
prescribed or illegally
acquired
The Problem: Isolated Pharmacy and Laboratory Databases
Laboratory Pharmacy
Cannot determine
adherence to drug
therapy
Lacks visibility of illicit
drug use
Does not identify use of
non-prescribed
medications
Patient Case Study #1
• Prescription– Oxycodone– Alprazolam
• Prescriptions were filled per PDMP– Report shows 30 day supplies of both oxycodone and alprazolam filled
every month at one local pharmacy• Oxycodone – 30 MG, TAB (filled 11/04) 30 day supply• Oxycodone – 15 MG, TAB (filled 11/04) 30 day supply• Alprazolam – 1 MG, TAB (filled 11/04) 30 day supply
• PDMP results: High Risk– Combining prescriptions totaled 180 MEDs– Prescribed benzodiazepines in combination with an opioid
PDMP data tells one story while the lab results tell another
Patient Case Study #1
• Combined Report Review:– By combining both PDMP data and toxicology results, we
know the prescriptions were filled and have been filled consistently over the past year, but are not being taken.
– Additionally, the other non-disclosed medications were not in the PDMP report. Meaning the patient is most likely getting them from an illegal source.
What PDMP Identified What Drug Test Identified
Oxycodone
Alprazolam
Lorazepam
Buprenorphine
Patient Case Study #2
• Prescription– Oxycodone
• Prescriptions were filled per PDMP– The patient is taking more than one opioid from more than
one prescriber• Oxycodone – 10 MG, TAB (filled 11/18) 28 day supply• Oxycodone – 15 MG, TAB (filled 11/04) 15 day supply
• PDMP results: High Risk– >1 opioid filled within 4 weeks from more than one
prescriber
PDMP review helps complete the story of the lab test
Patient Case Study #2
• Combined Report Review:– With the combination of drug test results and PDMP data, the
prescriber can see that the unexpected medication (alprazolam) is not being prescribed and can discuss with the patient about the source and need for the medication.
– A drug test alone would not have supplied enough information for the physician.
– Having combined access to PDMP data and lab data allows the provider to have a more informed conversation with the patient.
What PDMP Identified What Drug Test Identified
Oxycodone
Alprazolam
Of course the results of one or two case studies cannot predict the behavior of an entire population.
How does combining pharmacy & laboratory data work to identify high risk patients everywhere?
The Study
• Scope
– In April through June 2014, Cordant conducted 257 toxicology screens on 237 injured workers across 48 states.
– Test subjects were selected from the pool of patients meeting key risk identifiers according to PBM data.
The Study
• The Process– Cordant applied the several parameters to the study
group using their pharmacy data to identify potential risk.
– Risk criteria identified about 1/4th of the injured worker population as potentially “high risk”.
– Once patients were identified as potentially high risk, urine samples were collected at the doctor’s office during their next visit and sent to one of Cordant’s five laboratories for testing.
The Results70.9% of patients tested in the study produced
inconsistent results
The Results
• Of patients tested, 45.6% were deemed high risk due to meeting one or more of the following criteria:– Prescribed medication not detected– Detection of an illicit drug or alcohol– Exhibiting other aberrant results or
behavior
• Patients were deemed medium risk if non-reported prescription medications were detected
• Low risk if tests showed the expected results.
The Results
• Toxicology testing revealed high degrees of inconsistent test results among the tested claimants who fit these parameters:
– Prescribed a high medication dosage: 70.9%inconsistent test results.
– On the prescribed opioid for more than two months: 73.8% inconsistent test results.
(Claimants in this group were often prescribed higher doses and for a longer duration than claimants in other groups.)
Conclusion
• Combining pharmacy and laboratory data is extremely effective in identifying high-risk opioid users.– Reduces inflated drug testing costs by identifying those most
likely to abuse or misuse medications.– Improves patient outcomes by giving the physician a more
complete picture
• Getting the right medication to the Patient at the right time, in the right dose, and with the right monitoring requires a combination of:– care coordination– lab and prescription data integration– and clinical expertise
Thank You
Medical Examiner and CURES Correlations
San Diego 2013
Roneet Lev, MD Scripps Mercy HospitalSean PetroOren Lee
Jonathan Lucas, MD San Diego Medical Examiner
24
Disclosures
• Roneet Lev, MD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
• Jonathan Lucas, MD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
About the Data
• ME Data– 254 deaths with
prescriptions as cause of death
– Could be with alcohol, illicit, over the counter
• CURES Data (aka PDMP)– Outpatient pharmacies– Does Not Include
OTHER SINGLE MEDICATIONSDiazepam (1)Fluoxetine (1)Ketamine (1)Opioid (1)Quetiapine (1)Acetaminophen (2)Clonazepam (2)Hydrocodone (2)Tramadol (2)Venlafaxine (2)
PDMP MatchRx 2 months before death matches ME report
• PDMP Match, No Alcohol, No Illicit, No Doc Shop (42 patients)– 64% Female– 51 years Ave (older) – More Rx– Less Providers– Less Pharmacies– More Single Rx– More Opioids, Sleep
Aids, High Morphine Equivalents, Long Acting
254Total Deaths
100 (40%)PDMP Match
68 (27%)
Match + No Alcohol or Illicit
42 (16.5%) Match +
No Illicit + No Shoppers
37
Rx Types and PDMP MatchBy Number of Patients
75
77
38
Opioids - 190
PDMP Match
PDMP No Match
No PDMP
32
38
23
Benzodiazepines - 93
1
2
Stimulants - 3
5632
24
Other - 112
No one died of Rx for ADD/ADHD
38
Opioids + Benzodiazepines
• All PDMP Reports – 54% (100 patients)
• ME Deaths – 21% (55)
• ME/PDMP Match – 71% (39)
39
16
ME Reports – 254 patients21% = Opioids + Benzodiazepines
Dentistry Emergency Psychiatry Average Primary Care Pain Surgery
Pills/Rx
Specialists and Medication Types
Emergency6%
Primary Care69%
Surgery11%
Dentistry3%
Psychiatry3%
Pain8%
Opioids (63%) Emergency
Primary Care
Surgery
Dentistry
Psychaitry
Pain
Emergency3%
Primary Care47%
Surgery2%
Dentistry1%
Psychiatry47%
Benzodiazepines (25%)
Emergency0%
Primary Care62%
Surgery0%
Dentistry1%
Psychiatry35%
Pain2%
Sleep Aids (3%)
Primary Care34%
Psychiatry66%
Stimulants (1%)
50
Who is Prescribing Hydrocodone?
• 95,821 pills
• 990 Rx
• 123 Patients
Emergency
2%
Primary Care63%
Surgery28%
Dentistry
1%
Psychiatry
3%
Pain
4%
51
Take Home Messages“Death Dairy” to Safe Prescribing
1. Providers – Check CURES2. Pharmacies – Check CURES3. Don’t Mix Opioids and Benzos4. Use Medication Agreement5. Subtract ER Doses From Regular Rx6. Functional Assessment verses Pain
Scale7. Escalating dosages? Methadone? or
Addiction Referral8. Insurance Paying?9. DEA Watching?10. ME office giving feedback
52
PDMP Track:Combining PDMP and Other Data
to Combat Rx Drug AbusePresenters:
• Richard Stripp, PhD, Chief Scientific and Technical Officer, CordantHealth Solutions
• Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital Emergency Department, and Chair, San Diego County (CA) Rx Drug Abuse Medical Task Force
• Jonathan Lucas, MD, Chief Deputy Medical Examiner, San Diego County (CA)
Moderator: Connie M. Payne, Executive Officer, Statewide Services, Administrative Office of the Courts, and Member, Operation UNITE Board of Directors