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Atlanta Marrio+ Marquis Atlanta, Georgia

April 22, 2014

Disclosure Statements  Mike Small has disclosed no relevant, real or apparent personal or professional financial rela3onships.

 Tina Kim has disclosed no relevant, real or apparent personal or professional financial rela3onships.

 Roneet Lev has disclosed no relevant, real or apparent personal or professional financial rela3onships.

 Patrick Zarate has disclosed no relevant, real or apparent personal or professional financial rela3onships.

Learning ObjecGves 1.  Explain how using PDMP data can develop a

Rx drug abuse program strategy

2.  Outline strategies in unifying emergency departments under uniform controlled substance Rx prescribing protocols

3.  Demonstrate how a state PDMP can partner with cri3cal local efforts to reduce Rx drug overdose deaths.

Tina Kim, Ph.D. Los Angeles County Department of Public Health

In Los Angeles County…  Drug overdose is the 2nd leading cause of injury-‐related death

 1 out of 20 adults and 1 out 5 teens misuse prescrip3on drugs

 Rx drug abuse cause: 500+ Deaths

1200 + Treatment Admissions

3000 + HospitalizaGons

5000 + Emergency Department Visits

PrescripGon Drugs Filled in LAC, 2012 (Scheduled II-‐IV)

OTHER, 4.2 HORMONES

3.2 MUSCLE RELAXANTS

1.9

STIMULANTS 6.6

SEDATIVES 40.3

HYDROCODONE 67.0

OXYCODONE 10.9

CODEINE 10.6

MORPHINE3.9

FENTANYL 2.1

OTHER 5.6

OPIOIDS 43.9

(N = 9,763,887)

~27% of Prescribers wrote 95% of prescripGons (Scheduled II-‐IV)

37.0%

0.5%

36.4%

4.5%

20.0%

27.1%

6.6%

68.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Prescribers PrescripGons

Very Frequent Prescribers 500-‐17,019 Rx/Year

Frequent Prescribers 50-‐499 Rx/Year

Occasional Prescribers 4-‐49 Rx/Year

Rare Prescribers 1-‐3 Rx/Year

26.6%

95%

Doctor Shopping   Defined as paGents who received

prescripGon opioids from at least 4 prescribers AND at least 4 pharmacies in 2012

CURES/PDMP Data for Opioid PrescripGons in 2002

 4,142,662 million prescrip3ons filled

 1,533,099 million unique pa3ents

 55,819 unique prescribers  4,621 unique pharmacies

5,153 (0.3%) patients were identified as doctor shoppers.

Gender Difference

42.0% 41.9%

58.0% 58.1%

0%

10%

20%

30%

40%

50%

60%

70%

Doctor Shoppers Non-‐Doctor Shoppers

Male

Female

Age Difference

0%

5%

10%

15%

20%

25%

30%

≤17 years 18-‐24 years

25-‐34 years

35-‐44 years

45-‐54 years

55-‐64 years

≥65 years

Doctor Shoppers Non-‐Doctor Shoppers

Payment Method

50%

15%

8%

3%

24%

52%

14% 8%

3%

24%

0%

10%

20%

30%

40%

50%

60%

Commercial Insurance

Private Pay Medicare Medicaid Other/Unknown

Doctor Shopper Non-‐Doctor Shopper

Short-‐acGng vs Long-‐acGng

88.6%

11.4%

91.4%

8.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Short-‐Ac3ng Long-‐Ac3ng


Morphine Equivalent Dose per Day

86.7%

13.3%

89.9%

10.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

≤ 100 MED per Day > 100 MED per Day


Top Opioid Prescribed

64%

14%

6% 5% 4% 3%

67%

10% 11%

3% 2% 2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Hydrocodone Oxycodone Codeine Morphine Hydromorphone Fentanyl


Opioid PrescripGons per PaGent

Per PaGent Doctor

Shoppers Non-‐doctor Shoppers

Number of Pills 1017.9 159.6

Number of PrescripGons

15.6 2.7

Days of Supply 239.8 40.2

Morphine Equivalent Doses (MED)

946.2 157.3

Extreme Cases of Opioid PrescripGons

PaGent with… Value Gender Age

Highest number of opioid prescripGons

203 Male 44

Highest number of prescribers

79 Male Female

48 40

Highest number of pharmacies

32 Male 33

Highest number of opioid pills 30,000 Unknown 13

Highest opioid dosage per day (MED)

157,377 Unknown 13

Doctor Shoppers in LAC…  Doctor Shoppers are more common among:

–  Females –  Residents aged 35-‐64 years

 Compared to non-‐doctor shoppers, doctor shoppers are more likely to: –  Pay for their opioids with private pay –  Use long-‐ac3ng opioids –  Use higher drug dosages (MED > 100) –  Use oxycodone, morphine, and hydromorphone

–  Obtain a significantly greater number of pills and prescrip3ons and longer days of supply

To Reduce Doctor Shopping/Over-‐Prescribing in LAC…

  Promote CURES/PDMP enrollment and u3liza3on  Send out Rx for Preven3on ar3cles to physicians  Con3nuing Medical Educa3on Courses

  Develop standards on opioid use in Eds  LAC Prescrip3on Drug Abuse Medical Task Force

  Explore policy op3ons to become an authorized user of iden3fied CURES data   Send out e-‐mail alerts who are over-‐prescribing or

have a high number of doctor shopping pa3ents

Prescription Drug Abuse

Roneet Lev, MD FACEP

Providers Need Drug Rehab Before They Can Lead Our Nation

Into Recovery

PDA TF and

PDA Medical Task Force

PDA Report Card

San Diego CURES Report

EMERGENCY and

URGENT CARE GUIDELINES

PAIN AGREEMENT

–  For Chronic Pain = 3 months of short ac3ng or anyone requiring long ac3ng opioids

– Only 1 provider and 1 pharmacy

– No ED visit – No refills – Do not drive if impaired

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Sandiegosafeprescribing.org

//////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////BRIEFLY NOTED

6 F EB RUA RY 2014

NEW MEMBERS

Maria T. Carriedo-Ceniceros, MDFamily MedicineSan Diego • (619) 662-4103

Jack G. Copeland, MDCardiothoracic SurgeryLa Jolla • (858) 657-7086

Robert B. Eisenberg, MDUrologyLa Mesa (619) 697-2456

Lewis R. Greenstein, MDAnesthesiologyEscondido (858) 673-6100

Melissa N. Kagnoff, MDNeurologyCardiff by the Sea (619) 582-2595

Brian W. Meyerhoff, MDInternal MedicineEscondido (760) 745-1551

SDCMS!CMA MEMBERSHIP

Susanna J-A Park, MDReproductive EndocrinologySan Diego (858) 794-6363

Kari L. Purcott, MD, FACOGObstetrics and GynecologyOceanside (619) 278-3300

Rebecca A. Samuels, DOInternal MedicineEscondido (760) 745-1551

Nicole Tremain, MDInternal MedicineEscondido (760) 745-1551

Ryan B. Viets, MDDiagnostic RadiologyLa Mesa (619) 460-2770

Welcome New and Rejoining SDCMS-CMA Members!

REJOINING MEMBERS

Samuel A. Bozzette, MDInfectious DiseaseSan Diego (619) 929-4313

David W. Brunsting, MDInternal MedicinePoway (619) 472-1000

Franklin Galef, MDInternal MedicineVista (760) 806-5820

Joshua K. Greenstein, MDNephrologyEscondido (760) 745-1551

Emmet W. Lee, MDInternal MedicineEscondido (760) 745-1551

www.SanDiegoSafePrescribing.orgThe No. 1 cause of unintentional deaths in San Diego County is from drugs, with almost one person a day dying in our county from this preventable cause.

The San Diego and Imperial County Prescription Drug Abuse Medical Task Force is a coalition of medical leaders who have joined efforts to reduce deaths and addiction due to prescription drugs. The task force includes pain specialists, internal medicine physicians, emergency physicians, psychiatrists, dentists, pharmacists, hospital administrators, health department administrators, and our local DEA. The task force also includes broad health partners, including Kaiser Permanente, Scripps Health, Sharp HealthCare, UC San Diego Health System, Palomar Health, and the Community Clinics. The task force encourages all medical practitioners to use the materials provided at www.SanDiegoSafePrescribing.org to improve patient care.

SDCMS features member physicians for their noteworthy accomplishments in these pages. If you would like to be considered for our next “Featured Member” spotlight, please email [email protected]. Thank you for your membership in SDCMS and CMA!

Become an SDCMS Featured Member!

ERRATUM

AFFORDABLE CARE ACT

In the Nov. 2013 San Diego Physician issue’s “My Journey in the World of Medicine” article, the author, Carlos J. Sanchez, MD, who joined SDCMS-CMA in 1974, was identified as retired. Dr. Sanchez is in fact still a practicing physician. Our sincere apologies to Dr. Sanchez.

Surviving the First Months of Covered California: A Tip Sheet for PhysiciansON JAN. 1, 2014, California’s health benefit exchange, Covered California, began providing health coverage to more than 400,000 patients statewide. With that figure expected to grow by the end of the 2014 open enrollment period, it is critical that physicians and their sta! know what to expect. To that end, the California Medical Association (CMA) has published a tip sheet, “Surviving the Second Month of Covered California,” available free to SDCMS-CMA members. To receive this tip sheet, members can email [email protected].

DATA SUPPORTING ACTION – VENTURA COUNTY PORTING ACTION – VENTURA COUNTY

data suppor3ng ac3on – Ventura county

DATA SUPPORTING ACTION – VENTURA COUNTY

Selected Data Sources – mobilizing LOCAL action

•  State PDMP: C.U.R.E.S. data ongoing •  State California Healthy Kids Survey bi-annual •  Local Medical Examiner/Coroner annual update •  Local Adolescent Treatment survey new/unique •  Local Jail Inmate survey new/unique



VENTURA’S RX DRUG ABUSE WORKGROUP

Convened in early 2012, including Alcohol and Drug Programs (ADP) Public Health Department Sheriff’s Department County Office of Education County Health Care Agency/Ambulatory Care Subject Matter Experts by invitation

Focused on nature and scope of the LOCAL problems KEY: Membership rank- can speak for their agencies



DATA-INFORMED STRATEGIES

1.  LOCAL MATTERS! – data speak to your needs, and community direction

2.  USE MULTIPLE INDICATORS – use PDMP and other sources; see our “Ventura County Responds” report

3.  PARTNERSHIP MAKES THINGS POSSIBLE – examples: custom survey administration in jails; data sharing agreements, “mining” existing data

TARGETS FOR ACTION

Rx & HEROIN ABUSE: Ventura County RESPONDS

TARGET 1: PROFESSIONAL DEVELOPMENT GOAL: Expand professional training and development opportunities across all sectors.


GOAL: Expand professional training and development opportunities across all sectors.

ACTIONS

1.1 Prescriber Training

Problem: Low utilization of PDMP among prescribers locally.

Local Action: Training for Health Professionals (DDS, RN, MD)

Case Example: Elinore McCance-Katz, MD, PhD, Chief Medical Officer, Substance Abuse and Mental Health Services Administration (SAMHSA), presented one of the first in a projected series of health care professional trainings, What Every Prescriber Should Know About Addiction to Pain Medicines.



ACTIONS

1.1 Prescriber Training (cont’d.)

Problem: Limited opportunities for facilitated enrollment in CURES

Local Action: C.M.E. events, Grand Rounds, physician registration

Case Example: Medical Director for Behavioral Health hosting medical education with emphasis on importance of CURES, and ‘value added’ opportunity for real-time registration by attendees



“Health care professionals who prescribe...are in a key position to balance the benefits of prescribing opioid analgesics to treat pain against the risks of serious adverse outcomes including addiction, unintentional overdose, and death. Opioid misuse and abuse, resulting in injury and death, has emerged as a major public health problem. Appropriate prescribing practices and patient education are important steps to help address this public health problem.”

– FDA Blueprint for Prescriber Education, 2013

In Ventura County, we believe LOCAL ACTION matters…



TARGET 2: ENFORCEMENT & SECURITY

GOAL: Support law enforcement, monitoring and security to enhance public safety by deterring drug misuse, abuse and diversion.


ACTIONS

2.1 Safe and Secure Rx Disposal

Safe and confidential Rx disposal bins now actively used and supported by law enforcement in all 10 cities across the county.

Board Supervisors raised local standard by unanimously declaring Every Day is Take Back Day in Ventura County.


Ventura County Board of Supervisors declaration: Every Day is Take Back Day


2.3 Ventura County Interagency Pharmaceutical Crimes Unit

Problem: Illegal prescribing of Rx opioids at the local level

Local Action: Established Pharmaceutical Crimes Task Force, Ventura County Sheriff’s Office (VCSO), the Ventura County Pharmaceutical Crimes Unit includes members of law enforcement from VCSO, Simi Valley PD, DA’s Office, others.

Case Example: The main mission of the task force is combating the transfer of legal medication to the illegal market.

* Fifty-four arrests were made in the first six months * 120,000 pharmaceutical pills seized * CURES records important to several recent MD investigations * 49 search warrants to date, with $1.5 million in assets seized, 12 guns

TARGETS FOR ACTION PDMP value begins with prescriber policies, and grows local and even regional inter-agency cooperation.

“The Ventura County Interagency Pharmaceutical Crimes Unit, in conjunction with LA County Health Authority Law Enforcement Task Force (HALT) and the California Medical Board, concluded five month investigation into a “pill mill”. Detectives learned of this criminally operating medical clinic through a tip from a local Simi Valley pharmacist. The had previously contacted every pharmacy in Ventura County during the Summer of 2013 and made them aware of the task force.” One Case: Doctor Shopping, MDs at clinic investigated,

3,000+ scripts written in name of 1 doc, 5 arrests



GOAL: Support law enforcement, monitoring and security to enhance public safety by deterring drug misuse, abuse and diversion.

TARGET 3: EDUCATION & AWARENESS

GOAL: Increase outreach and education for parents, patients and the public to raise awareness of prescription drug and heroin abuse problems and solutions.



3.2 Drug Disposal Campaign A multimedia campaign on the importance of safe and secure drug disposal was directed to the public from a variety of angles, including a billboard on CA Highway 33, newspaper and radio ads, medicine chest reminder magnets, clinic posters and brochures. Concurrent outreach to real estate professionals warned of the risks of medicine chest thefts during open houses.



3.4 Ventura County’s Rx Drug Abuse Summit More than 240 local treatment and prevention professionals, healthcare experts, law enforcement, policymakers and other key stakeholders learned about CURES and local strategies.


TARGET 4: SAFE SCHOOLS

GOAL: Collaborate with schools, PTAs and Ventura County Office of Education (VCOE) to increase communication channels and prevention opportunities for teachers, parents, students

and school personnel.


4.2 Teacher Education Teachers are vital for educating students about substance abuse. A “Working Together” insert was developed especially for teachers as a companion to the “What You Need to Know About Rx Abuse and Heroin” brochure. The materials help teachers deliver concise prevention messaging to students at the most teachable moments.


4.4 Systematic School-based Data Collection The data collected from youth through surveys administered in schools provides invaluable information for effective collaborative prevention efforts. The Rx Workgroup will continue support of systematic school-based data collection and reporting, like the California Healthy Kids Survey, to gauge the prevalence of prescription drug misuse and heroin abuse among students in Ventura County.

LIFETIME USE BY VENTURA COUNTY STUDENTS:

• 14% of 9th graders and 20% of 11th graders reported misusing

Rx painkillers

• 4% of 9th graders and 5% of 11th graders reported using heroin

— California Healthy Kids Survey, Ventura County 2011–2012


TARGET 5: PREVENTION POLICY & RESEARCH

GOAL: Expand Advance continued research and data analysis to develop key policy actions addressing Rx and heroin abuse.


5.1 Tracking Local Data To better understand the prevalence and impacts of prescription drug and heroin abuse in Ventura County, relevant multiagency data from 2008 through 2012 were collected and analyzed. By developing an established baseline, the Rx Workgroup was able to create a tracking tool for ongoing monitoring, analysis and shared reporting of abuse trends over time.

CURES data, in combination with local data, are now being used to: plan educational interventions, measure progress and plan new Targets for Action.


5.2 Special Local Research

HIGHLIGHTS

•  32% of respondents reported heroin use in their lifetime.

•  Of those who reported lifetime heroin use, 45% indicated beginning with Rx opioids, then moving to heroin.

•  Transition from prescription-type opioids to heroin was highest among the respondents in younger age groups.

•  Of respondents who ever misused Rx opioids, 61% bought or received them from a friend or family member.


5.4 Legislative Analysis Active legislative analysis and reporting help inform and shape some Target Actions.

EXAMPLE: Rx Workgroup carefully followed the recent introduction, amendments and approval of CA Senate Bill 809 establishing CURES database funding and expansion.

Improvement of CURES will, in turn, advance Workgroup’s goal to improve data links between physicians, pharmacists and law enforcement, ultimately benefitting public safety.


5.5 Future Policy Actions New policies and projects being studied and considered by the Rx Workgroup include:

- Enhanced E.R. and ambulatory care opioid prescription policies to patients and the public;

- Pharmaceutical product stewardship;

- Overdose education and prevention programs; and

- Drug-impaired driving.

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