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Lobby Poll

Which of the public health uses of PDMP Information are you most interested in learning more about today?

CAPT WEBINAR

Preventing the Non-Medical Use of Prescription Drugs: Using the PDMP and Other Strategies for SuccessThomas Clark, Manager, PDMP Center of Excellence Clearinghouse

Joshua Esrick, Policy Analyst, Carnevale and Associates

Meelee Kim, Project Consultant, PDMP Center of Excellence

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Facilitator

Gisela RotsCoordinator

CAPT Northeast Resource Team

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Technical Information

This webinar is being recorded and archived, and will be available to all webinar participants. Please

contact the webinar facilitator if you have any concerns or questions.

This training was developed under the Substance Abuse and Mental Health Services Administration’s

Center for the Application of Prevention Technologies task order. Reference

#HHSS283201200024I/HHSS28342002T.

For training use only.

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Objectives

• Identify categories of strategies for preventing the non-medical use of prescription drugs

• Describe how Prescription Drug Monitoring Program (PDMP) data can be leveraged to address the non-medical use of prescription drugs at multiple levels

• Describe limitations of PDMP data

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Roadmap

Strategies to address NMUPD

Strategies to address NMUPD

Use of PDMP in substance

abuse prevention

Use of PDMP in substance

abuse prevention

Key recommendations

for PDMP use

Key recommendations

for PDMP use

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Presenters

Joshua EsrickPolicy Analyst

Carnevale and Associates

Meelee KimProject Consultant

PDMP Center of Excellence

Thomas ClarkManager

PDMP Center of Excellence Clearinghouse

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Factors That May Influence Strategy Implementation

• Staff capabilities and capacity• Cultural competence, lived experience, familiarity with strategy

components

• Availability of training and technical assistance• T/TA to the local entity from federal/state/non-profit organization

• T/TA to involved stakeholders from the local entity

• Stakeholder support

• Organizational leadership

• Evaluation feedback mechanisms

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Taking Action: Implementing a Combination of Strategies

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Categories of Strategies

Tracking and Monitoring

Enforcement

Disposal

Education

Multi-Component

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Education Strategies

• Patient education1

• Prescriber education2,3

• Social marketing campaigns4,5

• Information dissemination campaigns6

• Prescription Safe Campus Initiative7

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Enforcement Strategies

• Tip and reward programs8

• Law enforcement training on supply reduction9,10

• Law enforcement training on harm reduction11

• Enforcement against doctor shopping12

• Enforcement against pill mills13

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Multi-Component Strategies

• Local community coalitions14

• PROSPER/college and university partnerships15

• Harmful legal product prevention project16,17,18

• Project Lazarus/Overdose prevention programs19,20

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Multi-Component Strategies: Common Components

• Collecting relevant local assessment data

• Building capacity and determine feasibility

• Engaging with key stakeholders

• Developing relationships throughout the community

• Implementing strategies across socio-ecological domains

school-based curricula + parent education + community intervention + patient education + prescriber education + law enforcement training

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Disposal Strategies21 • Take-back programs

and events

• Permanent drop-off sites

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Tracking and Monitoring Strategies

• Physical exams prior to issuing prescriptions24

• Follow-ups prior to renewing prescriptions25

• Patient ID checks prior to dispensing prescriptions26

• Prescription Drug Monitoring Programs (PDMPs)22

• Mandatory use of PDMPs23

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PollWhat strategies are being implemented in your state, tribal community, or jurisdiction?

Prescription Drug Monitoring Programs

May 31, 2016

Presented by:

PDMP Center of Excellence, Brandeis University

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Webinar overview• Overview of PDMPs

• PDMP data for • Epidemiological purposes

• Targeting interventions

• Evaluating interventions

• Other potential uses

• Key recommendations for PDMPs

• Resources

Source: PDMP TTAC: http://www.pdmpassist.org/content/state-profiles

Source: PDMP Training and Technical Assistance Center at Brandeis University

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PDMP: What data are in the system?

• Patient identification

• Prescriber information

• Dispensing pharmacy information

• Drug information

• Source of payment (some states)

Note: No patient diagnoses are collected.

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PDMPs: Who uses them?

PDMP authorized users Number of states*Prescribers 49Dispensers 49Law enforcement 47Regulatory licensing boards 45

Researchers 44Patients 38Medical examiners/Coroners 36Substance abuse treatment providers 12Drug courts 12

*Missouri does not have legislation to enable a PDMP.

• Epidemiological surveillance: Determining incidence and prevalence of certain medical and non-medical uses of controlled pharmaceuticals statewide, by county, region or city, and over time.

• Prevention: Enabling health care providers to avoid prescribing duplicate therapies and creating deterrents to drug diversion; providing needs assessment and evaluation data for community coalitions.

Public health uses of PDMP information

• Early intervention: Detecting patients at risk of drug abuse at initial stages of drug-seeking behavior.

• Education: Providing information on prescribing trends and raising general awareness of the prescription drug abuse epidemic.

Public health uses of PDMP information

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Strengths of PDMP data

• Timeliness vs. health outcome data

• Patient, prescriber, and pharmacy identifiers*

• Transactions located in time and space

• Detailed information on controlled substance dispensed – name, dosage, days’ supply, refills

• Includes all methods of payment

*Identifiers are anonymized for research and evaluation purposes but potentially linkable to other health data.

PDMP Data for Epidemiological Purposes

Prescription Behavior Surveillance System (PBSS)• De-identified PDMP data from participating states – 12 currently

submitting data

• Prescribing rates by age/gender/drug/quarter/year, plus risk measures for patients, prescribers and dispensers

• Products:

• Updated tables of measures for each state by quarter and year

• Annual reports of major trends by state

• Data and issue briefs for individual states, multi-state comparisons

• Special analyses, e.g., validating prescriber risk measures

• MMWR papers on prescribing trends, mandates (forthcoming)30

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Source: Brandeis University, Prescription Behavior Surveillance System

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Multiple Provider Episodes (MPE)• Defined in PBSS as the number of patients with CS

prescriptions from 5 or more prescribers and 5 or more pharmacies in a 3-month period, per 100,000 state residents – a measure of “doctor/pharmacy shopping”

• Differences in how states determine which prescription records belong to the same patient preclude comparisons between states in MPE levels

• We can, however, compare state MPE trends• Simeone reported decreasing trends nationally 2008 – 2012• Decline in MPEs in many PBSS states

Source: Brandeis University, Prescription Behavior Surveillance System

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Geographic variation• State comparisons: trends in mean daily opioid dose

• Maine: County level – percent change in opioid rate

• Kentucky: Regional level - NAS cases and opioid rates

• Massachusetts: Town level

• Opioid overdose rates

• Multiple provider episode rates

• California: Zip code level

• Multiple provider episode rates

• Data can inform allocation of prevention and treatment resources

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Data source: Maine Prescription Drug Monitoring Program, Office of Substance Abuse & Mental Health Services

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2005 O p io id -re la ted H e alth P ro b lem sR ate p er 100 ,000 b y T o w n

Ra te per 100,000 Q uin t iles00.01 - 19 .8219.82 - 37 .537.5 - 56 .9256.92 - 225 .51

2005 P re scr ip tio n s A sso c iated w ith Q u e stio n a b le Ac tiv ity(R ates p er 10 0,00 0 P re scr ip tio n s ) b y Ph a rm a cy T o w n

Q u es tion ab le a ct iv ity ra tes01 - 10 9510 96 - 1 8 9718 98 - 2 8 8228 83 - 1 4 18 4

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California 2012: Multiple Provider Episode Rates by Zip Code

MPE rates, Zip Code quintiles00.01 - 4.844.85 - 7.897.9 - 12.3512.36 - 625

Multiple Provider Episode Rates, 2012:Enlargement of Greater Los Angeles

MPE rates, Zip Code quintiles00.01 - 4.844.85 - 7.897.9 - 12.3512.36 - 625

PDMP Data for Targeted Interventions

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Project Lazarus prevention initiative (NC)• Presentations to community groups included county- and

state-level data on prescriber PDMP enrollment and utilization, prescribing rates, and doctor shopping.

• PDMP data were associated with health data related to Rx abuse: Outcomes partially a function of PDMP utilization.

• Data presentation motivated Wilkes County residents to take steps to increase PDMP enrollment and utilization.

• Outcomes: Increase in PDMP utilization, decline in doctor shopping, reduction in overdose deaths in Wilkes County.

Arizona prescriber report cards• Peer comparisons by prescriber specialty sent quarterly

via email; pilot in four counties.

• Measures: Prescriptions for carisoprodol, benzodiazepines, hydrocodone, oxycodone, and other pain relievers

• Prescriber identified as an “outlier” if one, two or three standard deviations from mean on measures

• Outcomes: Increased PDMP enrollment and utilization, reductions in outlier status

• Now expanding report cards to entire state

• Need data on prescriber specialty for report cards

Arizona’s PDMP prescriber “report cards”

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Interventions for “at-risk” prescribers

• Universal educational campaigns vs targeted educational efforts

• Prescribing volume by prescriber decile: Proportion of total prescriptions accounted for by prescriber 10% groupings

• Top prescribers responsible for disproportionate amount of opioid prescribing

• See Center of Excellence (COE) briefing on interventions with at-risk prescribers

Tennessee letters to top 50 prescribers• State law mandating annual letters to top 50 prescribers

asking them to justify prescribing – started 2012

• Sent by TN Department of Health, reply requested in 15 days

• Outcomes:

• 18% reduction in opioid prescribing

• 36% (18) of recipients no longer among the top 50

• Program expanded in 2015 to include letters to top 10 prescribers in combined county regions.

• Pros: Easy analysis, simple intervention

• Cons: Burden on legitimate prescribers to justify practice

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North Carolina licensing board initiative• Collaboration between NC medical board, NC mental

health, NC public health and UNC injury prevention center

• Measures of at-risk prescribing were validated by examining PDMP data of practitioners who had prescribed to opioid overdose decedents within 30 days of death

• Predictive measures: > 100 daily MMEs; simultaneous opioid and benzo combinations; overlapping prescriptions

• Prescribers meeting these criteria are subject to investigation by licensing board

• Evaluation: What proportion of prescribers identified are engaged in legitimate practice (false positives)?

Source: Asbun, Kirby, Ringwalt, Schiro (2016). PDMP TTAP Webinar Presentation

PDMP Data for Needs Assessments and

Evaluation

Source: Brandeis University, Prescription Behavior Surveillance System

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Example: Project Lazarus in Wilkes County, NC

Source: Project Lazarus, http://www.projectlazarus.org/project-lazarus-results-wilkes-county

Example: Florida’s PDMP (E-FORCSE)

Source: http://pdmpexcellence.org/content/data-briefs

Kentucky’s PMDPPrescriber Queries to KASPER & CS II-IV Prescriptions Dispensed by County, FY10

Prescriber Queries to KASPER & CS II-IV Prescriptions Dispensed by County, FY13

Source: Freeman PR, et al., Kentucky House Bill 1 Impact Evaluation, March 2015.

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PollHow has your state used PDMP data to target or evaluate interventions?

Other Uses of PDMP Data

Other uses of PDMP data• Drug take-back days/drop boxes: Identifying “hot spots”

of high rates of dispensed Rx by ZIP codes or towns/cities

• Public awareness campaigns of opioid/prescription drug abuse/misuse: Using PDMP data and other data sources (i.e., YRBS) to drive informed discussion (Norfolk County, MA)

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Other uses of PDMP data• Drug courts: Monitoring abstinence, proper Rx use

(KY NFF)

• Medical examiners: Determining cause of death (VA NFF)

• CMS and workers compensation: Patient lock-ins (WA NFF)

• Opioid use disorder: Monitoring Rx use by OTP patients (COE Briefing on OTP use of PDMP data)

Key Recommendations of PDMP Data

Recommended PDMP Key Practices• Data quality: Completeness, accuracy, timeliness

• Integration of PDMP with health information systems

• Patient data summaries, prescriber “report cards”

• Mandates to query database (COE briefing)

• Proactive alerts or reports (COE guidance document)

• Cross-border integration/cooperation

• Secure funding

• Use data for public health surveillance and policy evaluation, e.g., PBSS, HB1 evaluation

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Limitations of PDMP data

• No unique identifier for patients: record linking procedures vary by PDMP

• Probabilistic vs. deterministic record linking

• PDMP relies on pharmacy submissions for data accuracy

• Practices to assess and ensure data quality vary by PDMP

• Recording of PRN prescriptions subject to pharmacist discretion (e.g., 30 pills may be recorded as 30 days’ supply)

Resources

• State administrators contact information for each PDMP: http://pdmpassist.org/node/400

• Technical assistance, PDMP-related guides and publications: PDMP TTAP: www.pdmpassist.org, www.pdmpexcellence.org

State Epidemiological Workgroups

• Federal partners: Bureau of Justice Assistance (BJA)

Centers for Disease Control and Prevention (CDC)

Food and Drug Administration (FDA)

Contact Information

Meelee Kim

mlkim@brandeis.edu

781-736-3978

Tom Clark

twclark@brandeis.edu

781-736-3970

www.pdmpexcellence.orgwww.pdmpassist.org

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PollWhich recommended key practices of the PDMP are you interested in learning more about?

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Questions?

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Evaluation

Please click on the link below to provide feedback on this event:

www.surveymonkey.com/r/feedback-CAPT-1361

Your feedback is very important to us!

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References

1. American College of Preventive Medicine. (2011). Use, abuse, misuse and disposal of prescription pain medicine clinical reference. www.acpm.org/?UseAbuseRxClinRef

2. U.S. Department of Health and Human Services (2013). Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. 23. www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf

3. Cochella, S. & Bateman, K. (2012). Provider detailing: an intervention to decrease prescription opioid deaths in Utah. Pain Medicine, 12(Suppl 2) S73-S76.

4. Grier, S. & Bryant, C. A. (2005). Social marketing in public health. Annual Review of Public Health, 26, 319–339.

5. SAMHSA (n/d). Understanding social marketing. Center for the Application of Prevention Technologies. http://captus.samhsa.gov/access-resources/understanding-social-marketing

6. Ferri, M., Allara, E., Bo, A., Gasparrini, A., & Faggiano, F. (2013). Media campaigns for the prevention of illicit drug use in young people. The Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD009287.http://researchonline.lshtm.ac.uk/967502/1/ferri_Cochrane2013.pdf

7. Clinton Foundation. (2013). CHMI works with partners to address the prevalence of prescription drug misuse.Retrieved February 6, 2015, from www.clintonfoundation.org/main/clinton-foundation-blog.html/2013/05/06/chmi-works-with-partners-to-address-the-prevalence-of-prescription-drug-misuse

8. RxPatrol. (2012). What’s RxPatrol? www.rxpatrol.com/aboutrxpatrol/

9. U.S. Department of Justice (DOJ). (n/d). Domestic training - State and local training. Drug Enforcement Administration. www.dea.gov/ops/Training/StateLocal.shtml

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References

10. Brandeis University. (2013). Prescription drug monitoring program administrators guide for training law enforcement.Prescription Drug Monitoring Program Training and Technical Assistance Center. www.pdmpassist.org/pdf/LE_USE_OF_PDMP_CURRICULUM_Final.pdf

11. New York State Division of Criminal Justice Services. (2014). Opioid overdose and intranasal naloxone training for law enforcement: Trainer’s guide. www.bjatraining.org/sites/default/files/naloxone/Opioid%20Overdose%20Intranasal%20Naloxone%20Training%20-%20Trainer%20Guide.pdf

12. CDC (n/d). Doctor shopping laws. www.cdc.gov/phlp/docs/menu-shoppinglaws.pdf

13. Betses, M. & Brennan, T. (2013). Abusive prescribing of controlled substances: A pharmacy view. New England Journal of Medicine, 369(11), 989-991. http://fmed.uba.ar/depto/toxico1/articulos/1.pdf

14. Community Anti-Drug Coalitions of America (n/d). Handbook for Community Anti-Drug Coalitions. www.cadca.org/sites/default/files/resource/files/coalitionhandbook.pdf

15. PROSPER Partnerships. (n/d). How it works. www.prosper.ppsi.iastate.edu/default.asp?worksOetting, E. R., Plested, B. A., Edwards, R. W., Thurman, P. J., Kelly, K. J., Beauvais, F., & Stanley, L. (2014). Community readiness for community change. Tri-Ethnic Center for Prevention Research. Retrieved February 26, 2015, from http://triethniccenter.colostate.edu/docs/CR_Handbook_8-3-15.pdf

16. Oetting, E. R. et al. (2014). Community readiness for community change. Tri-Ethnic Center for Prevention Research. Retrieved February 26, 2015, from http://triethniccenter.colostate.edu/docs/CR_Handbook_8-3-15.pdf

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References

17. Collins, D. A., Johnson, K. W., & Shamblen, S. R. (2012). Examining a home environmental strategy to reduce availability of legal products that can be misused by youth. Substance use & misuse 47(12): doi:10.3109/10826084.2012.716481. www.ncbi.nlm.nih.gov/pmc/articles/PMC3884673/

18. Johnson, K. W. et al. (2010). Studying implementation quality of a school-based prevention curriculum in frontier Alaska: Application of video-recorded observations and expert panel judgment. Prevention Science 11(3), 275-286.

19. Project Lazarus. (n/db). The Project Lazarus model. http://projectlazarus.org/about-lazarus/project-lazarus-model

20. Community Care of North Carolina (CCNC). (n/d). Project Lazarus: A community-wide response to managing pain.www.communitycarenc.org/population-management/chronic-pain-project/

21. Gray JA, Hagemeier NE. (2012). Prescription drug abuse and DEA-sanctioned drug take-back events: Characteristics and outcomes in rural Appalachia. Archives of Internal Medicine, 172(15),1186-1187.

22. Clark, T., Eadie, J., Kreiner, P., & Strickler, G. (2012). Prescription drug monitoring programs: An assessment of the evidence for best practices. Pew Charitable Trusts. www.pdmpexcellence.org/sites/all/pdfs/Brandeis_PDMP_Report_final.pdf

23. Haffajee, R. L., Jena, A. B. & Weiner, S. G. (2015). Mandatory use of prescription drug monitoring programs. Journal of the American Medical Association. Published online January 26, 2015.

24. U.S. Centers for Disease Control and Prevention. (2015). Prescription drug physical examination requirements.www.cdc.gov/phlp/docs/pdpe-requirements.pdf

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References

25. Oliver, R. L. & Taylor, A. (2003). Chronic opioid rules: Prescribing opioids for chronic pain requires set rules, a written plan, periodic re-evaluation, and vigilance to prevent illegal diversion of controlled substances. Practical Pain Management, 3(2), 1-8. http://www.practicalpainmanagement.com/treatments/pharmacological/opioids/chronic-opioid-rules

26. CDC. (n/d). Menu of state prescription drug identification laws. http://www.cdc.gov/phlp/docs/menu-pdil.pdf