initiatives to combat prescription drug abuse in kentucky: an update on kasper david r. hopkins...
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Initiatives to Combat Prescription Drug Abuse in Kentucky:
an Update on KASPER
David R. HopkinsKASPER Program ManagerOffice of Inspector GeneralKentucky Cabinet for Health and Family Services
The Different Faces of Substance AbuseJanuary 28, 2014
Cabinet for Health and Family Services
Contents
• Pill Mills
• KASPER Program Review
• House Bill 1 Preliminary Results and Evaluation
Pill Mills
Cabinet for Health and Family Services
Jeff and Chris George
Photos from Palm Beach Post
Cabinet for Health and Family Services
Dr. Paul H. Volkman
Story: Bill Estep, Lexington Herald-Leader, February 14, 2012. AP Photo released by U.S. Marshals Service (undated)
Cabinet for Health and Family Services
Care More Pain Management Clinic
Photo: Scott Utterback, Louisville Courier-Journal, January 25, 2012
Cabinet for Health and Family Services
Care More Pain Management Clinic
Photo: Scott Utterback, Louisville Courier-Journal, January 25, 2012
Cabinet for Health and Family Services
Ernest William Singleton
Photo: Lexington Community Corrections, January 2013
Cabinet for Health and Family Services
Kitson Clothing Collection
Story: WXIX Fox 19 Digital Media Staff, June 21, 2013
Cabinet for Health and Family Services
Kitson Clothing Collection
KASPER Program Review
Status of Prescription Drug Monitoring Programs (PDMPs)
Research is current as of February 1, 2012
AK
AL
AR
CACO
ID
IL INIA
MN
MO
MT
NENV
ND
OH
OK
OR
TN
UT
WA
AZ
SD
NM
VA
WYMI
GA
KS
HI
TX
ME
MS
WINY
PA
LA
KYNC
SC
FL
NHMARICTNJDEMD
DC
VT
WV
Operational PDMPs
Enacted PDMP legislation, but program not yet operational
Legislation pending
GU
2011 KASPER Reports Requested
Cabinet for Health and Family Services
Cabinet for Health and Family Services
KASPER Operation
• KASPER tracks most Schedule II – V substances dispensed in KY
– Over 10 million controlled substance prescriptions reported to the system each year
• KASPER data is 1 to 3 days old– Dispensers have 1 business day to report
• Reports available to authorized individuals– Available via web typically within 15 seconds
(97% of requests)– Available 24/7 from any PC with Web access
Annual KASPER Records Total / Per Person
Cabinet for Health and Family Services
2.39 2.43 2.65 2.65 2.72 2.72 2.47Number of Controlled Substance Prescriptions per Person
KASPER Reports Requested
Cabinet for Health and Family Services
Cabinet for Health and Family Services
Top Prescribed Controlled Substances byTherapeutic Category by Doses - 2013
Hydrocodone 41.3% LortabLorcetVicodin
Alprazolam 11.2%Xanax
Tramadol 6.8%Ultram
Oxycodone 15.4% OxyContinPercodanPercocet
Clonazepam 6.7%Klonopin
Diazepam 4.3%Valium
Amphetamine 3.1%
Adderall
Zolpidem 3.4%Ambien
Testosterone 3.5%
AndroGel
Lorazepam 4.0%Ativan
KASPER Stakeholders• Licensing Boards – to investigate potential inappropriate
prescribing by a licensee. • Practitioners and Pharmacists – to review a current
patient’s controlled substance prescription history for medical or pharmaceutical treatment.
• Law Enforcement Officers, OIG employees, Commonwealth’s attorneys, county attorneys - to review an individual’s controlled substance prescription history as part of a bona fide drug investigation or drug prosecution.
• Medicaid – to screen members for potential abuse of pharmacy benefits and to determine “lock-in”; to screen providers for adherence to prescribing guidelines for Medicaid patients.
• A judge or probation or parole officer – to help ensure adherence to drug diversion or probation program guidelines.
• Medical Examiners engaged in a death investigation
Cabinet for Health and Family Services
House Bill 1 Preliminary Resultsand Evaluation
Cabinet for Health and Family Services
Controlled Substance Dispensing – One Year Comparison
Drug August 2011 through
July 2012
August 2012through
July 2013
Change
Hydrocodone 239,037,354 214,349,392 -10.3%
Oxycodone 87,090,503 77,022,586 -11.6%
Oxymorphone 1,753,231 1,138,817 - 35.0%
Alprazolam 71,669,411 62,088,568 -13.4%
Methylphenidate 10,659,840 11,454,025 + 7.5%
Amphetamine 13,795,147 15,065,833 + 9.2%
All Controlled Substances 739,263,679 676,303,581 -8.5%
Figures shown in doses dispensed
Cabinet for Health and Family Services
HydrocodoneHydrocodone
Cabinet for Health and Family Services
OxycodoneOxycodone
Cabinet for Health and Family Services
AlprazolamAlprazolam
Cabinet for Health and Family Services
MethadoneMethadone
Cabinet for Health and Family Services
OxymorphoneOxymorphone
Cabinet for Health and Family Services
TramadolTramadol
Cabinet for Health and Family Services
BuprenorphineBuprenorphine
Cabinet for Health and Family Services
Controlled Substance Prescribing 2013
Cabinet for Health and Family Services
Controlled Substance Usage 2013
Cabinet for Health and Family Services
House Bill 1 Impact Study
• Comprehensive assessment of HB1’s impact on patients, prescribers, and other stakeholders
• Overall goals:– Evaluate the impact of HB1 on reducing prescription
drug abuse and diversion in Kentucky– Identify unintended consequences associated with
implementation of HB1 that impact patients, providers and citizens of the Commonwealth
– Develop recommendations to improve effectiveness of HB1 and mitigate identified unintended consequences
• Final study report planned for July 2014
Jul 2
009
Sep 2
009
Nov 2
009
Jan
2010
Mar
201
0
May
201
0
Jul 2
010
Sep 2
010
Nov 2
010
Jan
2011
Mar
201
1
May
201
1
Jul 2
011
Sep 2
011
Nov 2
011
Jan
2012
Mar
201
2
May
201
2
Jul 2
012
Sep 2
012
Nov 2
012
Jan
2013
Mar
201
3
May
201
3
Jul 2
013
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
KASPER Prescriber Accounts, 2009-2013
Re
gis
tra
nts
Kentucky Prescribers
Non-KYPrescribers
Jul 2
009
Sep 2
009
Nov 2
009
Jan
2010
Mar
201
0
May
201
0
Jul 2
010
Sep 2
010
Nov 2
010
Jan
2011
Mar
201
1
May
201
1
Jul 2
011
Sep 2
011
Nov 2
011
Jan
2012
Mar
201
2
May
201
2
Jul 2
012
Sep 2
012
Nov 2
012
Jan
2013
Mar
201
3
May
201
3
Jul 2
013
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
KASPER Pharmacist Accounts, 2009-2013
Re
gis
tra
nts
Kentucky Pharmacists
Non-KY Pharmacists
Jul
Sep Nov Jan
Mar
May Ju
lSep Nov Ja
nM
arM
ay Jul
Sep Nov Jan
Mar
May Ju
lSep Nov Ja
nM
arM
ay Jul
0
200
400
600
800
1,000
1,200
1,400
1,600
KASPER Law Enforcement Accounts, 2009-2013
Re
gis
tra
nts
Non-KY
Kentucky
• Stakeholder interviews were conducted to inform the development of a KASPER registrant survey instrument– Board of Pharmacy– Board of Nursing – Board of Medical Licensure – Board of Dentistry– Kentucky Coalition of Nurse Practitioners and Nurse Midwives– Kentucky Dental Association– Kentucky Pharmacists Association – Kentucky Medical Association– Operation UNITE– National Association Drug Diversion Investigators (NADDI)– Medicaid, Office of Inspector General– Kentucky Sheriff’s Association– Kentucky Narcotic Officers Association
Initiatives to Combat Prescription Drug Abuse in Kentucky:
an Update on KASPER
Van IngramExecutive DirectorOffice of Drug Control PolicyKentucky Justice and Public Safety Cabinet
The Different Faces of Substance AbuseJanuary 28, 2014
Contents
• Legislative Update
• 2013 National Survey on Drug Use and Health
• HB1 Provider Training
• Kentucky Overdose Data
Justice & Public Safety Cabinet
Legislative Update
HB 1 – Pain Management Facilities
• Physician ownership requirement on all pain management facilities (PMF)
• Exception for those health facilities operating as a PMF on April 24, 2012
• No sanctions or convictions imposed on facility or employees
Justice & Public Safety Cabinet
PMF Oversight
• KBML responsible for licensure standards for physician-owned pain management facilities.
• OIG, Division of Health Care is responsible for licensure standards for existing pain management facilities that qualify for the physician-ownership exemption of HB 1.
Justice & Public Safety Cabinet
Non-Physician Owned PMFs
Justice & Public Safety Cabinet
• 29 non-physician owned PMFs were identified April 24, 2012 (HB1 passage date)
• 8 closed prior July 20, 2012 (HB1 effective date)• 12 closed after the HB1 effective date• 2 illegal or non-physician owned PMFs discovered
after HB 1 effective date• 4 PMFs were sent cease and desist letters• 7 PMFs are being reviewed for compliance and
certification by the Cabinet for Health and Family Services
KASPER Reporting KRS 218A.202
• Controlled substance administration or dispensing must be reported within one day effective July 1, 2013
Justice & Public Safety Cabinet
KASPER Accounts – KRS 218A.202
• KASPER registration is mandatory for Kentucky practitioners or pharmacists authorized to prescribe or dispense controlled substances to humans.
Justice & Public Safety Cabinet
KASPER Prescriber Usage - KRS 218A.172
• Query KASPER for previous 12 months of data:
– Prior to initial prescribing or dispensing of a Schedule II controlled substance, or a Schedule III controlled substance containing hydrocodone
– No less than every three months– Review data before issuing a new prescription or
refills for a Schedule II controlled substance or a Schedule III controlled substance containing hydrocodone
• Additional rules/exceptions included in licensure board regulations
Justice & Public Safety Cabinet
KASPER Regulations – Licensure Boards
• 201 KAR 5:130– Kentucky Board of Optometric Examiners KASPER
requirements• 201 KAR 8:532
– Kentucky Board of Dentistry KASPER requirements• 201 KAR 9:230, 201 KAR 9:260
– Kentucky Board of Medical Licensure KASPER requirements
• 201 KAR 20:057– Kentucky Board of Nursing KASPER requirements
• 201 KAR 25:090– Kentucky Board of Podiatry KASPER requirements.
Justice & Public Safety Cabinet
KASPER Institutional Accounts - KRS 218A.202
• Hospitals and long term care facilities can establish “facility” KASPER accounts–eKASPER institutional master account
established by Chief Medical Officer or designated employee
– If no CMO, a designated physician employee may create master account
–79 institutional master accounts currently established
Justice & Public Safety Cabinet
KASPER Prescriber Reports – KRS 218A.202
• CS prescribers can obtain a KASPER report on themselves:
– To review and assess the individual prescribing patterns
– To determine the accuracy and completeness of information contained in KASPER
– To identify fraudulent prescriptions
Justice & Public Safety Cabinet
Providing Reports to Patients – KRS 218A.202
• KASPER reports can be shared with the patient or person authorized to act on the patient’s behalf
• KASPER reports can be placed in the patient’s medical record, with the report then being deemed a medical record subject to disclosure on the same terms and conditions as an ordinary medical record
Justice & Public Safety Cabinet
Federal Actions - Hydrocodone
• Hydrocodone combination products to be rescheduled from CIII to CII
– Approved by FDA– Pending recommendation to HHS and approval
by HHS and DEA
• FDA approved CII pure hydrocodone product– Zohydrotm ER manufactured by Zogenix, Inc.– Available 1Q 2014– Not abuse-resistant formulation
Justice & Public Safety Cabinet
National Survey onDrug Use and Health
January 8, 2013
NATIONAL TRENDS
States with Rates between 5.33 and 6.37
1 Oregon 6.37 5.25-7.71
2 Colorado 6.00 4.96-7.24
3 Washington 5.75 4.76-6.92
4 Idaho 5.73 4.74-6.91
5 Indiana 5.68 4.68-6.89
6 Arizona 5.66 4.60-6.94
7 Nevada 5.62 4.57-6.89
8 Delaware 5.61 4.61-6.82
9 Arkansas 5.55 4.60-6.68
10 New Mexico 5.45 4.47-6.64
Justice & Public Safety Cabinet
States with Rates between 4.80 and 5.32
11 Alaska 5.32 4.41-6.42
12 Oklahoma 5.19 4.26-6.30
13Rhode Island 5.18 4.26-6.27
14 Vermont 5.13 4.24-6.19
15 Michigan 5.11 4.57-5.72
16 Ohio 5.00 4.49-5.56
17 Tennessee 5.00 4.14-6.02
18 Louisiana 4.87 4.09-5.80
19 Montana 4.84 4.02-5.80
20 Missouri 4.83 4.03-5.78
NATIONAL TRENDS
Justice & Public Safety Cabinet
States with Rates between 4.46 and 4.79
21 West Virginia 4.79 3.97-5.75
22 California 4.68 4.13-5.30
23District of Columbia 4.68 3.79-5.76
24 Wyoming 4.68 3.85-5.68
25 South Carolina 4.62 3.81-5.59
26 Virginia 4.60 3.79-5.58
27 Minnesota 4.57 3.79-5.49
28 New Hampshire 4.57 3.77-5.53
29 Kansas 4.56 3.77-5.50
30 Wisconsin 4.51 3.68-5.52
31 Kentucky 4.48 3.70-5.41
NATIONAL TRENDS
Justice & Public Safety Cabinet
Among persons aged 18 to 25, the ratesof past year nonmedical use of pain relievers declined in 14 states:
Florida, Kentucky, Louisiana, Maine,Massachusetts, Michigan, New Hampshire, New York, Ohio, Oklahoma, Rhode Island, Texas, Utah, and West Virginia.
NATIONAL TRENDS
Justice & Public Safety Cabinet
HB1 Provider Training
ODCP, OPERATION UNITE and KENTUCKY COALITION OF NURSE PRACTITIONERS/NURSE MIDWIVES HAVE SPONSORED 4 TRAININGS
HB 1 TRAININGS
Justice & Public Safety Cabinet
Overview of HB1 and Regulations
C. Lloyd Vest, JD
How to Recognize Drug Abuse and Dependence in Patients
Gregory Jones, MD
How to Discuss Drug Issues with a Patient
Gregory Jones, MD
An Update on KASPER - Post House Bill 1
David Hopkins
Opioid Therapy: Risks vs. Rewards
Gregory Jones, MD
HB 1 TRAININGS
Justice & Public Safety Cabinet
MOREHEAD
119 TRAINEES
83 PRESCRIBERS
PAINTSVILLE
147 TRAINEES
55 PRESCRIBERS
BOWLING GREEN
239 TRAINEES
170 PRESCRIBERS
MANCHESTER
110 TRAINEES
80 PRESCRIBERS
HB 1 TRAININGS
Justice & Public Safety Cabinet
615 TOTAL TRAINEES 388 PRESCRIBERS AVAILABLE ONLINE MEETS LICENSING BOARDS
REQUIREMENTS
HB 1 TRAININGS
Justice & Public Safety Cabinet
HB 1 TRAININGS
Justice & Public Safety Cabinet
The Good, Bad, and Ugly of Addiction
Justice & Public Safety Cabinet
Kentucky Overdose Data
1004 OVERDOSE FATALATIES IN 2012
19 FEWER THAN 2011. THE FIRST DECLINE IN OVER A DEACDE
• 888 UNINTENTIONAL• 59 SUICIDES• 57 UNDETERMINED
2012 OVERDOSE DATA
Justice & Public Safety Cabinet
LARGEST INCREASE CAMPBELL COUNTY. FROM 25 IN 2011 TO 54 IN 2012
LARGEST DECREASE, FLOYD COUNTY WITH 23 FEWER DEATHS IN 2012 THAN 2011
MOST PER 100,000 LESLIE COUNTY WITH RATE OF 85 PER 100,000
2012 OVERDOSE DATA
Justice & Public Safety Cabinet
DEATHS ATTRIBUTABLE TO HEROIN ROSE 550%
ALPROZOLAM MOST DETECTED SUBSTANCE AT 41.44% OF ALL MEDICAL EXAMINER CASES
2012 OVERDOSE DATA
Justice & Public Safety Cabinet
YOUNGEST OD DEATH AGE 16 OLDEST 72 AVERAGE AGE 40 MALE 58% FEMALE 42%
2012 OVERDOSE DATA
Justice & Public Safety Cabinet
FIRST 3 QUARTERS OF 2013
639 TOTAL OVERDOSE DEATHS REPORTED DURING three quarters OF 2013
170 OR 26% HAVE HEROIN IN THE TOXICOLOGY REPORT
OVERWHELMING MAJORITY POLY DRUG
Cabinet for Health and Family Services
2013
JEFFERSON 94 FAYETTE 26 KENTON 26 BOONE 20 CAMPBELL 8 FRANKLIN 5 17 COUNTIES 1 or 2 97 COUNTIES NONE
Cabinet for Health and Family Services
HEROIN
Cabinet for Health and Family Services
HEROIN
Cabinet for Health and Family Services
HOW DID WE GET HERE? LONG HISTORY OF OPIOD/PAINKILLER
ABUSE INCREASING NUMBERS OF IV DRUG
USAGE ABUSE DETERRANT FORMULATIONS CRACKDOWN ON ROUGUE PAIN CLINICS GREATER AWARENESS FROM
PRESCRIBERS ESTABLISHED DRUG CARTELS
RECOGNIZING DEMANDCabinet for Health and Family Services
HOW DID WE GET HERE?
PRICE
AVAILABILITY
PERCEPTION OF RISK
PUBLIC ATTITUDES
Cabinet for Health and Family Services
HOW DO WE ADDRESS IT?
PUBLIC EDUCATION INCREASED ACCESS TO
TREATMENT ENHANCED PENALTIES FOR MAJOR
TRAFFICKERS GREATER ACCESS TO NALOXONE
Cabinet for Health and Family Services
Van IngramKentucky Justice and Public Safety Cabinet
125 Holmes StreetFrankfort, KY 40601
David HopkinsKentucky Cabinet for Health and Family Services
275 East Main Street, 5EDFrankfort, KY 40621
502-564-2815 ext. [email protected]