andrew holt, pharmd. controlled substance monitoring database
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Controlled Substance Monitoring Database Prescription Drug Abuse Prevention Conference September 19, 2014. Andrew Holt, PharmD. Controlled Substance Monitoring Database. Disclosure Information- Andrew Holt, PharmD. I have no financial relationships to disclose - PowerPoint PPT PresentationTRANSCRIPT
Controlled Substance Monitoring Database
Prescr ipt ion Drug Abuse Prevent ion ConferenceSeptember 19, 2014
Andrew Holt, PharmD.Controlled Substance Monitoring
Database
Disclosure Information- Andrew Holt, PharmD
• I have no financial relationships to disclose
• I will not discuss off label use and/or investigational use in my presentation
Opioid Prescription Rates by County, TN 2007
Source: Tennessee Department of Health internal files, Baumblatt, et al
Opioid Prescription Rates by County, TN 2008
Source: Tennessee Department of Health internal files, Baumblatt, et al
Opioid Prescription Rates by County, TN 2009
Source: Tennessee Department of Health internal files, Baumblatt et al
Opioid Prescription Rates by County, TN 2010
Source: Department of Health internal files, Baumblatt et al
Opioid Prescription Rates by County, TN 2011
Source: Tennessee Department of Health internal files, Baumblatt et al
C-II Controlled Substance Utilization by State
Rank State Rx per Capita
1 Delaware 0.8127
2 Tennessee 0.6828 3 District of Columbia 0.6329 4 Massachusetts 0.6330 5 Maine 0.6231
Source: IMS Health
C-II Controlled Substance Growth by State2013 vs. 2012
Rank State Change 1 Wyoming 7.1% 2 South Dakota 6.1% 3 Idaho 5.1% 4 Louisiana 5.0% 31 Tennessee 0.3%
Source: IMS Health
Oxycodone Utilization by State
Rank State Rx per Capita 1 Delaware 0.36 2 District of Columbia 0.32 3 Tennessee 0.31 4 Massachusetts 0.29 5 Pennsylvania 0.29
Source: IMS Health
Growth in Oxycodone Utilization by State
Rank State Change 1 Wyoming 5.1% 2 Mississippi 2.7% 3 South Dakota 2.5% 4 Idaho 2.3% 37 Tennessee -4.4%
Source: IMS Health
C-III Controlled Substance Utilization by State
Rank State Rx per Capita 1 Alabama 1.10 2 Tennessee 0.92 3 Mississippi 0.91 4 West Virginia 0.91 5 Kentucky 0.89
Source: IMS Health
C-III Controlled Substance Growth by State2013 vs. 2012
Rank State Change 1 Vermont -0.2% 2 Arkansas -0.5% 3 South Dakota -0.9% 4 North Dakota -1.0% 31 Tennessee -5.0%
Source: IMS Health
Opioid Prescribing Analysis:Analysis of Specialty/Profession Type in Tennessee
0
500
1,000
1,500
2,000
2,500
3,000
TTot
al Di
spen
sed
Pres
crip
tions
(000
's)
Tennessee Opioid Prescribing Volume by SpecialtyYear ended August 2013
CSMD History
• Law Enacted in 2002• Began collecting data in 2005• Became searchable by practitioners
in 2006
Controlled Substance Monitoring Database Committee
• Board of Medical Examiners• Board of Nursing • Board of Pharmacy • Board of Osteopathic Examination• Committee on Physician Assistants • Board of Veterinary Medical Examiners• Board of Optometry • Board of Podiatric Medical Examiners • Board of Dentistry
Most Commonly Prescribed CS in TN
Table 3. Comparison of the 10 most frequently prescribed products in 2012 and 2013 in CSMD
Rank 2013 2012
1 Hydrocodone products Hydrocodone products
2 Alprazolam Alprazolam
3 Oxycodone products Oxycodone products
4 Zolpidem Zolpidem
5 Tramadol Tramadol
6 Clonazepam Clonazepam
7 Lorazepam Lorazepam
8 Diazepam Diazepam
9 Morphine products Buprenorphine products
10 Buprenorphine products Morphine products
Source: CSMD Annual Report to the 108th General Assembly, 2014
Prescription Safety Act of 2012
• Mandatory PDMP registration• Mandatory PDMP usage• Shortened PDMP reporting window• Mandatory reporting of doctor shoppers
to law enforcement by practitioners• Enabled interstate data sharing• Established delegate
accounts-”extenders”• Increased administrative staffing
Prescriber CSMD Survey Results
• 71% changed a treatment plan after viewing a CSMD report
• 73% are more likely to discuss substance abuse issues or concerns with a patient
• 57% are more likely to refer a patient for substance abuse treatment
• 79% feel that the CSMD is useful for decreasing doctor shopping
Technological Innovations
• Color-coded risk icons on patient report for:
– Pharmacy Shopper– Doctor Shopper– High MME Dose
• Automated username and password retrieval
• Batch requests for high-volume clinics
CSMD Technology
CSMD Technology – Risk Indicators
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
CSMD Searches by DelegatesCSMD Searches by Prescibers
Mandating CSMD Checking Resulted in More Queries in Tennessee
Source: Tennessee Department of Health Internal Files, February 2014
Mandated checking began April 1, 2013
Mandated registration began April 1, 2013
Number of High Utilization Patients* in PDMP 2012-2014
1st quarter 2nd quarter 3rd quarter 4th quarter0
500
1000
1500
2000
2500
2012
2013
2014
*Individual who obtained controlled substance prescriptions from five or more pre -scribers and utilized five or more pharmacies within the quarter
Source: Tennessee Department of Health Internal files, May 2014
More PDMP Queries, Fewer High Utilization Patients
2010 2011 2012 20130.0
500,000.0
1,000,000.0
1,500,000.0
2,000,000.0
2,500,000.0
3,000,000.0
3,500,000.0
4,000,000.0
4,500,000.0
5,000,000.0
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
Number of Searches Made by Prescibers, Dispensers, and Delegates
High Utilization Patients: Pa-tients filled 5 or more prescrip-tions with dif-ferent DEA Pre-scribers at 5 or more different DEA dispensers within 90 days.
Source: Tennessee Department of Health Internal Files, Feb-ruary 2014
Pati
en
t R
eq
uest
s (i
n M
illion
s)
Hig
h U
tiliza
tion
Pati
en
ts
Statistics
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec500,000,000
550,000,000
600,000,000
650,000,000
700,000,000
750,000,000
800,000,000
850,000,000
900,000,000
MME by Month for non-VA Dispensers
20132014
Reducing Neonatal Abstinence Syndrome
• Pink NAS reminder messaging on all females of childbearing age
NAS Messaging in CSMD
• Pink cautionary statement on patient report for females of childbearing age– “Please remember that narcotic
prescriptions for women of child bearing age could result in Neonatal Abstinence Syndrome (NAS) should pregnancy occur; please discuss with your patient methods to prevent unintended pregnancy.”
Future CSMD Activities
• Integrate into clinical workflow• Enhanced analysis– $1.4 million CDC grant awarded in 2014
• Increased interstate data sharing
Chronic Pain Management Guidelines
Prescr ipt ion Drug Abuse Prevent ion ConferenceSeptember 19, 2014
Andrew Holt, PharmD.Controlled Substance Monitoring
Database
Public Chapter 430
• Chronic Pain Guidelines written by January 1, 2014
• All prescribers with DEA 2 hours CME every 2 years
• Prescribe 30 days at a time Schedule II-IV
Process Began on January 28, 2013
• Selected the Panel of Experts
• Selected the Steering Committee
• First Meeting Steering Committee Meeting July 1, 2013
Chronic Pain Guidelines Steering Committee
Worker’s CompensationAbbie Hudgens
Office of General CounselAndrea Huddleston, J.D.
Controlled Substance Monitoring Database
Andrew Holt, D.Ph.
Department of HealthBruce Behringer, MPHDavid Reagan, M.D.Larry Arnold, M.D.
Mitchell Mutter, M.D.
Department of TennCareVaughn Frigon, M.D.
Board of Medical ExaminersDr. Michael Baron
TN Department of Mental HealthRodney Bragg, M.A., M.Div.
Tennessee Medical Foundation
Dr. Roland Gray
Special Thanks To:Ben E. Simpson, J.D.
Tracy Bacchus
Chronic Pain Guideline Panel Members
Autry Parker, M.D.Brett Snodgrass,
APNC. Allen Musil, M.D.Carla Saunders, APNCharles McBride,
M.D.James Choo, M.D.Jason Carter, DPhJeffrey Hazlewood,
M.D.Jim Montag, PA-CJohn Culclasure,
M.D.Katie Liveoak, D.Ph.
Michael O'Neil, D.Ph.Paul Dassow, M.D.Raymond McIntire,
DPhRett Blake, M.D.Stephen Loyd, M.D.Ted Jones, PhDThomas Cable, M.D.Tracy Jackson, M.D.W. Clay Jackson,
M.D.William Turney, M.D.
Chapters of the TN Treatment Guidelines
• Introduction • Before initiating chronic opioid
therapy (over 90 days) • Screening (including TN risk
model), non-opioid therapies, referral to MH, others
• Informed consent• Women's special considerations
• Initiating chronic opioid therapy • Standard therapy, combination
therapy• Special considerations
• Methadone/buprenorphine • UDS - qualitative &
quantitative• CSMD• Documentation in decision
making• Follow up therapy
• UDS - qualitative & quantitative• CSMD• ED visits for OD• What constitutes a failure of
standard therapy?• Referral to pain specialist• Taper / discontinuation of opioids• Documentation of decision
making
• Appendices• Pain Medicine Specialist• Risk Assessment Tools• Pregnant women • Use of Opioids in Worker's
Compensation Medical Claims• Tapering protocol• Sample Informed consent• Sample Patient Agreement• Controlled Substance
Monitoring Database• Medication Assisted Treatment
Program• Morphine equivalents dose• Psychological Assessment
Tools• Prescription Drug Disposal• Safety Net• Definitions• Table of Frequently Prescribed
Pain Medications• Urine Drug Testing • Special Consideration: Women
of Child Bearing Age
Section I: Prior to Initiating Opioid Therapy
• Non Opioid Treatment if Possible• All Newly Pregnant Women Should• Complete evaluation: History and
Physical• Testing documented in medical record
prior• Chronic Pain shall not be treated via
telemedicine• Co-Morbid Mental Conditions• There shall be the establishment of a current diagnosis that justifies a need for opioid therapy
Section I: Prior to Initiating Opioid Therapy (cont.)
• Risk for Abuse• Validated Risk Tools• CSMD• UDT• Goals for Treatment• Treatment plan for opioid and non-opioid
treatment• Increase function, not to eliminate pain• Documentation in medical record
Section II: Initiating Opioids
• Maximum four doses of short-acting opioids per day• Non pain medicine specialist should not
prescribe methadone• Prescribers shall not prescribe
buprenorphine in oral or sublingual for chronic pain • Avoid benzodiazepines• Document reasons for deviation from
guidelines in record
Section II: Initiating Opioids (cont.)• Therapeutic trial• Lowest possible dose• Opioid Naïve• Informed Consent• Treatment Agreement female patient• Continually monitor for abuse, misuse,
or diversions• CSMD and UDT
Section II: Initiating Opioids (cont.)
• Women’s Health• Birth Control Plans• Informed Consent• Ask regarding pregnancy each visit• Before starting opioids – in women
shall have pregnancy test
Section III: Treatment with Opioids
• Single provider and pharmacy • Opioids used at lowest effective dose
• Ongoing Therapy• Greater than 120 MEDD (Morphine
Equivalent Dose) should refer to Pain Specialists• Greater than 120 MEDD shall refer• UDT twice/year• Continual assessment via 5A’s UDT, CSMD• Emergency Physician, Primary Provider
Communication• Discontinue when risk greater than benefits
ABPM
• Recognizes boards in the following certification as qualified to sit for Board Exam
• Anesthesia• Psychiatry• Neurology• Neurosurgery • Physical Medicine and Rehabilitation
• 50 hours CME in Pain Medicine past two (2) years
• Substantial, recent and comprehensive clinical practice experience
Pain Specialist
• Board of Medical Specialties (ABMS) primary physician certification organization in US
• ABMS certifies pain medicine fellowship programs in Anesthesia, Physical Medicine and Neurology
• American Board of Pain Medicine (ABPM) is not ABMS and does not oversee fellowship training programs.
• ABPM offers practice – related examinations to qualified candidates. Diplomates of ABPM have certification in Pain Medicine
• AOA Certification
Pain Specialist (cont.)
• Patients requiring less than 120 MEDD
a. Must have valid license by respective board and DEA
b. CME pertinent to pain management directed by regulatory board
c. Recommend (do not require) 3 year residency and be ABMS eligible or certified
Pain Specialist (cont.)
• Patients requiring ≥ 120 MEDDa. 11 times more likely to have adverse event such
as overdose deathb. Consultation with pain consultant who has
additional in pain medicine is recommended1. Pain Consultant up to 7/1/2016 shall have
unencumbered license with no prior actions unless an exception is approved by the respective board
2. Two year experience3. Minimum 25 CME hours in pain management
every 12 months4. Pain consultants after 7/1/2016 shall have ABPM
diplomate status or ABMS Boards
Websites
Prescription for Success http://tn.gov/mental/prescriptionforsuccess/
Pain Clinic Websitehttp://health.state.tn.us/Boards/PainClinicRegistry.shtml
Pain Clinic Guidelines http://health.state.tn.us/Downloads/ChronicPainGuidelines.pdf
2014 Legislative Reporthttp://health.state.tn.us/boards/Controlledsubstance/PDFs/CY%202013%20CSMD%20Report%20to%20the%20General%20Assembly%20Post.PDF
Andrew Holt, PharmDControlled Substance Monitoring Database
Tennessee Department of [email protected]
615-253-1300
Questions and Contact Information