New Developments in PDMPs:South Carolina, Wisconsin and Florida

Presenters:• Christie Frick, RPh, Director, Prescription Monitoring Program, South

Carolina Department of Health and Environmental Control• Chad Zadrazil, JD, Managing Director, Wisconsin Department of Safety and

Professional Services• Chris Delcher, PhD, Assistant Professor, University of Florida• Bruce Goldberger, PhD, Chief, Division of Forensic Medicine, University of

Florida College of Medicine

PDMP Track

Moderator: Karen H. Perry, Co-Founder and Executive Director, Narcotics Overdose Prevention and Education (NOPE) Task Force, and Member, Rx and Heroin Summit National Advisory Board

Disclosures

Chris Delcher, PhD; Christie Frick, RPh; Bruce Goldberger, PhD; Chad Zadrazil, JD; and Karen H. Perry have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare 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:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest:

Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center

Learning Objectives

1. Describe how two states improved integration of PDMP data into electronic health IT systems.

2. Identify challenges states may face when integrating PDMP data into electronic health IT systems.

3. Explain the operation and findings of Florida’s nascent drug surveillance systems.

4. Provide accurate and appropriate counsel as part of the treatment team.

New Developments in PDMPs: South Carolina, Wisconsin and

Florida

Christie Frick, RPh, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Learning Objectives:

1. Describe how two states improved integration of PDMP data into electronic health IT systems.

2. Identify challenges states may face when integrating PDMP data into electronic health IT systems.

8

• In 2012 South Carolina joined the PMP InterConnect to facilitate interoperability and interstate data sharing between state PMPs.

• Currently sharing with 20 states. MI

AZ

NM

ND

KS

OH

SC

VAKY

SD

LA

IL

CT

DE

MS

ID

IN

WI

TN

MN

CO

AR

NJ

WV

NV

PMP InterConnect: A Nationwide PMP Data Sharing Platform

9

Pharmacists

Prescribers

Health Exchanges

MI

AZ

NM

ND

KS

OH

SC

VAKY

SD

LA

IL

CT

DE

MS

ID

IN

WI

TN

MN

CO

AR

NJ

WV

NV

PMP Gateway: A Health IT Connectivity Platform for PMP Data

South Carolina’s Integrations

• Palmetto Health System (Cerner EMR)• Lexington Medical Center (Epic EMR)

• Rx Care Plus Pharmacies (QS 1)• Kroger Pharmacy

Patient searches between October 1- December 31, 2015

Palmetto Health Emergency Departments (3 locations) 54,443Lexington Medical Center Emergency Department 1,543

So….what’s the big deal?

54,443 + 1,543 = 55,98655,986 x 3 mins = 167,958 mins = 2,799 hours

of time saved in the Emergency Room in 3 months!!

So…why isn’t everyone integrating?

•Get in line for a health system IT project•Cost (SC was fortunate enough to get a SAMHSA grant for funding)•Legal Agreements/Contracts•Authorizing Users – Must they be signed up separately with PMP (Need for Privacy Statement)

13

Agreements in Place

PMPs

State PMPs have MOUs in place with PMP InterConnect.

A contract is in place between Appriss/PMP Gateway and NABP/InterConnect.

Healthcare entity must have a contract in place with Appriss/PMP Gateway.

PMPs

PMPs

SC

In SC, PMP must also have a contract with each entity receiving funds.

Is it worth it?

“I am working and one of the attendings came over and said ‘your new drug check’ just saved a man’s

life. Its a long story, but it was the highest narc score we had seen. He was here for a pseudo medical

problem that seemed legit and he likely would have gotten more meds from what he was saying. Since

NarcRx popped up right as soon as the doc looked at his chart, the doctor went back into the room and the whole story changed. He is now getting help with his

drug abuse. “

New Developments in PDMPs: South Carolina, Wisconsin and Florida

Experience in Wisconsin

March 30, 2016

Disclosure

Chad Zadrazil, JD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Learning Objectives

1. Describe how two states improved integration of PDMP data into electronic health IT systems.

2. Identify challenges states may face when integrating PDMP data into electronic health IT systems.

18

PMPi

October 2013 Connection

PMP Gateway

September 2014 Connections

October 2015 Connection

EHR Integration in Wisconsin

19

20

MCIS PDMP Interface

FICTITIOUS DATA

21

MCIS PDMP Interface

FICTITIOUS DATA

Barrier to Integration

Legal Definition of “access”

Original Definition:To obtain access to PDMP information, pharmacists, pharmacist delegates, practitioners, and practitioner delegates shall create an account with the board on a form provided by the board.

Solution: Additions to “Access” Definition

• Create an account with a pharmacy or other entity at which pharmacists dispense or administer monitored prescription drugs in the course of professional practice with which the board has determined to have at least equivalent capability to maintain the confidentiality of PDMP information or that is connected to and lawfully obtains data from the state-designated entity under ch. 153, Stats.

• Create an account with a hospital or other entity at which practitioners prescribe, dispense, or administer monitored prescription drugs in the course of professional practice with which the board has determined to have at least equivalent capability to maintain the confidentiality of PDMP information or that is connected to and lawfully obtains data from the state-designated entity under ch. 153, Stats. Cite: Wisconsin Administrative Code CSB 4.09

Updated Definition of “Access”

Recognizes and authorizes:• Integration into pharmacy dispensing software• Integration into electronic medical records

and prescribing modules• Integration into the Wisconsin Statewide

Health Information Network (WISHIN), the HIE in WI

2016: A Year of WI PDMP Evolution

In addition to our current and future PDMP-HIT integration projects…

2016: A Year of WI PDMP Evolution• H.O.P.E. Agenda Bills (AB 364):

– Increases data submission frequency from 7 days to 1 day

– Requires prescribers to review PDMP data prior to issuing a prescription order for a controlled substance (some exceptions)

– Allows law enforcement agencies and prosecutorial units to request PDMP data without a court order

– Adds access for non-prescriber healthcare and substance abuse professionals

2016: A Year of WI PDMP Evolution• H.O.P.E. Agenda Bills (AB 365):

– Requires law enforcement agencies to report any of the following to the PDMP for dissemination to PDMP users:

• A suspected violation of the CSA involving a prescription drug

• A person who is undergoing or who immediately prior experienced an opioid-related overdose event

• A person who may have died as a result of using a narcotic drug

• A report of a stolen controlled substance prescription

Development of the WI ePDMP

• The primary emphasis of the design of the enhanced WI PDMP (“ePDMP”) is:• value-added clinical workflow integration• improved data quality capabilities• maximized public safety use

• Stakeholders and users are closely involved in every step of the process

Development of the WI ePDMP• Possible due to federal support and inter-agency

collaboration:

• 2014 Harold Rogers PDMP Enhancement Grant

• 2015 Harold Rogers PDMP Enhancement Grant

• 2015 CDC Prescription Drug Overdose Prevention Grant (in partnership with WI Department of Health Services)

Development of the WI ePDMP

• Iterative Design and Development Process• Modular, user-centered focus

• Continual user input and testing

• Feedback loop with stakeholders and subject matter experts

DRAFT

DRAFT

DRAFT

DRAF

T

FICT

ITIO

US

DATA

DRAF

T

FICT

ITIO

US

DATA

New Developments in PDMPs: South Carolina, Wisconsin and Florida

PDMP Track

Disclosure Statement• Bruce Goldberger, PhD, Professor, has disclosed no relevant,

real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

• Chris Delcher, PhD, Assistant Professor, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Learning Objectives• Describe how two states improved integration of PDMP data

into electronic health IT systems.• Identify challenges states may face when integrating PDMP

data into electronic health IT systems.• Explain the operation and findings of Florida’s nascent drug

surveillance systems.• Provide accurate and appropriate counsel as part of the

treatment team.

Florida Medical Examiners Commission

• Temporal Coverage– Drug-related death data available since 2000

• Submission Source– District Medical Examiners

• Autopsy, toxicology results, decedent's drug use history, physical evidence, etc.

• Cause of death versus present in the body at the time of death• Accidental, natural, suicide, homicide and undetermined

• Specificity– Data collected in 2014 (# of drugs reported)

• Amphetamines (2), Benzodiazepines (13), Ethanol, Hallucinogenics (3), Inhalants (4), Opioids (12), Other (9)

Florida Prescription Drug Monitoring Program

• Implementation– September 2011

• Controlled substance schedules monitored– II, III, IV

• Voluntary registration• On-going updates

– Veteran’s Administration began reporting on October 1, 2014.

Period 1: 2003 - 2009

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

1.3

4.4 (+233.8%)

0.7

0.7 (0%)1.4

0.5 (-62.2%)1.3

1.6 (+26.2%)1.8

6.4 (+264.6%)

Alprazolam Fentanyl Heroin Morphine Oxycodone

Deat

h Ra

te (p

er 1

00,0

00 p

opul

ation

)

The original controlled-release formula-tion OxyContin® was approved in De-cember 1995 (launched in 1996).

Oxycodone is one of the most frequently abused prescription opioids (Cicero et al. 2005)

Percent change shown reported in (Goldberger et al., 2011)

Period 1 con’t: 2010

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

1.3

5.2

0.70.6

1.4

0.31.3

1.4

1.8

8.0

Alprazolam Fentanyl Heroin Morphine Oxycodone

Deat

h Ra

te (p

er 1

00,0

00 p

opul

ation

)

Oxycodone and alprazolam-caused death rate peaked in 2010Heroin death rate reached its lowest in 2010(Lee et al., 2014)

Period 2: “PILL Zone” (Interventions)

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

1.3

5.2

0.7

0.6

1.4

0.3

1.3

1.4

1.8

8.0

Alprazolam Fentanyl Heroin Morphine Oxycodone

Deat

h Ra

te (p

er 1

00,0

00 p

opul

ation

)

IndustryReformulated OxyContin® came on the market in August 2010 Legislative Actions1Jan 2010: Pain clinics must register2Oct 2010: Pain clinic regulation expanded3July 2011: Physician dispensing prohibited/strike forces activated4Sep 2011: Florida PDMP implemented5July 2012: Wholesale distributor regulations expandedLaw Enforcement (DEA Actions)Operation Pill Nation 6Feb 2010, 7Feb 2011, 8Aug 2012(Johnson et al., 2014)

PDMP Implementation

PILL: Public Health, Industry, Legislation, Law Enforcement

Period 3: 2010 – 2014 (Effects)

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

5.20535772985276

2.86025991568919 (-45.1%)

0.604903956374327

1.99564707650019 (+229.9%)

0.254696402683927

2.05094208365763 (+705.2%)1.39021786464977

3.5439072769084 (+154.9%)

8.04416138476736

2.36260485127227 (-70.6%)

Alprazolam Fentanyl Heroin Morphine Oxycodone

Deat

h Ra

te (p

er 1

00,0

00 p

opul

ation

)

Legislative and Regulatory Effect• Rx drug overdose deaths -23.2%, 2010-2012 (Johnson et al., 2014)• Rx opioid diversion declined, 2009-2012 (Surratt et al., 2014)• Oxycodone-caused mortality abruptly declined 25% month after PDMP

(Delcher et al., 2015)• Opioid prescriptions -1.4%, volume -2.5%, MME/transaction -5.6%,

2011-2012 (Rutkow et al, 2015)• ~1,029 lives saved from rx opioid overdose, 2010-2012

(Kennedy-Hendricks et al., 2016)Heroin• Connection b/w nonmedical use of prescription opioids and heroin use

(Compton et al., 2016)

PDMP Implementation

2003 - 2014

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

Alprazolam Fentanyl Heroin Morphine Oxycodone

Deat

h Ra

te (p

er 1

00,0

00 p

opul

ation

)

Surveillance Opportunities: Time

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 20150

20

40

60

80

100

120

140

160

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Alprazolam (Deaths) Oxycodone (Deaths) Alprazolam (Rx)Oxycodone Long Acting (Rx) Oxycodone Short Acting (Rx)

Deat

hs, N

o.

Pres

crip

tions

, No.

PDMP Implementation

Surveillance Opportunities: Person

18-24 25-34 35-44 45-54 55-64 65 and older

050

100150200250300350400450

Stimulants

FemaleMale

# of

Rx

per 1

,000

pop

ulati

on

18-24 25-34 35-44 45-54 55-64 65 and older

0200400600800

1,0001,2001,4001,600

Benzodiazepines

# of

Rx

per 1

,000

pop

ulati

on

18-24 25-34 35-44 45-54 55-64 65 and older

0

200

400

600

800

1,000

1,200

1,400

Opioids

# of

Rx

per 1

,000

pop

ulati

on

Surveillance Opportunities: PlaceOPIOIDS

OPIOIDS Prescriptions per 1,000 Population, RY2014 OPIOIDS-Caused Deaths per 100,000 Population, CY2014 OPIOIDS-Related Deaths per 100,000 Population, CY2014

Rate (Quartile)5.180 - 13.15313.636 - 18.05018.076 - 24.61024.699 - 39.532

Rate (Quartile)0.899 - 6.3916.688 - 8.4788.839 - 11.51611.536 - 23.266

Rate (Quartile)283.080 - 705.693709.511 - 891.902913.402 - 1072.8581092.324 - 1451.318

OPIOIDS Prescriptions per 1,000 Population, RY2014 OPIOIDS-Caused Deaths per 100,000 Population, CY2014 OPIOIDS-Related Deaths per 100,000 Population, CY2014

Rate (Quartile)5.180 - 13.15313.636 - 18.05018.076 - 24.61024.699 - 39.532

Rate (Quartile)0.899 - 6.3916.688 - 8.4788.839 - 11.51611.536 - 23.266

Rate (Quartile)283.080 - 705.693709.511 - 891.902913.402 - 1072.8581092.324 - 1451.318

Surveillance Opportunities: PlaceOPIOIDS

Surveillance Opportunities con’t: PlaceBENZODIAZEPINES

BENZODIAZEPINES Prescriptions per 1,000 Population, RY2014 BENZODIAZEPINES-Caused Deaths per 100,000 Population, CY2014 BENZODIAZEPINES-Related Deaths per 100,000 Population, CY2014

Rate (Quartile)4.993 - 9.1519.173 - 13.49713.584 - 19.17319.304 - 51.238

Rate (Quartile)0.673 - 2.4322.488 - 4.0064.044 - 6.0536.391 - 32.939

Rate (Quartile)262.371 - 461.706463.866 - 518.818520.136 - 625.355626.343 - 795.535

BENZODIAZEPINES Prescriptions per 1,000 Population, RY2014 BENZODIAZEPINES-Caused Deaths per 100,000 Population, CY2014 BENZODIAZEPINES-Related Deaths per 100,000 Population, CY2014

Rate (Quartile)4.993 - 9.1519.173 - 13.49713.584 - 19.17319.304 - 51.238

Rate (Quartile)0.673 - 2.4322.488 - 4.0064.044 - 6.0536.391 - 32.939

Rate (Quartile)262.371 - 461.706463.866 - 518.818520.136 - 625.355626.343 - 795.535

Surveillance Opportunities con’t: PlaceBENZODIAZEPINES

US and State Rx Opioid Poisoning Mortality, 1999-2014

US Rate

Source: National Center for Health Statistics, CDC WONDER Online Database, released 2015.

2000 2005 2010 2015 2000 2005 2010 2015 2000 2005 2010 2015 2000 2005 2010 2015

0

10

20

30

0

10

20

30

0

10

20

30

Florida1.5

5.8

Kentucky1.2

11.5

Nevada

5.6

9.6

New Mexico

8.7

14.5

Oklahoma2.6

12.2

Oregon1.2

5.1

South Carolina1.0

9.3

Utah

6.0

16.0

Vermont4.0

7.0

Washington2.7

5.5

West Virginia1.5

24.7

Wisconsin1.1

6.9

Year

Age Adjusted Rate (per 100,000 population)

ReferencesCicero, T. J., Inciardi, J. A., & Muñoz, A. (2005). Trends in abuse of Oxycontin and other opioid analgesics in the United States: 2002-2004. The Journal of Pain: Official Journal of the American Pain Society, 6(10), 662–672.

Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016). Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. The New England Journal of Medicine, 374(2), 154–163.

Delcher, C., Wagenaar, A. C., Goldberger, B. A., Cook, R. L., & Maldonado-Molina, M. M. (2015). Abrupt decline in oxycodone-caused mortality after implementation of Florida’s Prescription Drug Monitoring Program. Drug and Alcohol Dependence.

Goldberger, B., Thogmartin, J., Johnson, H., Paulozzi, L., Rudd, R., & Ibrahimova, A. (2011). Drug Overdose Deaths — Florida, 2003–2009. Morbidity and Mortality Weekly (MMWR), 60, 869–872.

Johnson, H., Paulozzi, L., Porucznik, C., Mack, K., Herter, B., & Hal Johnson Consulting and Division of Disease Control and Health Promotion, Florida Department of Health. (2014). Decline in drug overdose deaths after state policy changes - Florida, 2010-2012. MMWR. Morbidity and Mortality Weekly Report, 63(26), 569–574.

Kennedy-Hendricks, A., Richey, M., McGinty, E. E., Stuart, E. A., Barry, C. L., & Webster, D. W. (2016). Opioid Overdose Deaths and Florida’s Crackdown on Pill Mills. American Journal of Public Health, 106(2), 291–297.

Lee, D., Delcher, C., Maldonado-Molina, M. M., Bazydlo, L. A. L., Thogmartin, J. R., & Goldberger, B. A. (2014). Trends in licit and illicit drug-related deaths in Florida from 2001 to 2012. Forensic Science International.

Rutkow, L., Chang, H.-Y., Daubresse, M., Webster, D. W., Stuart, E. A., & Alexander, G. C. (2015). Effect of Florida’s Prescription Drug Monitoring Program and Pill Mill Laws on Opioid Prescribing and Use. JAMA Internal Medicine, 175(10), 1642–1649.

Surratt, H. L., O’Grady, C., Kurtz, S. P., Stivers, Y., Cicero, T. J., Dart, R. C., & Chen, M. (2014). Reductions in prescription opioid diversion following recent legislative interventions in Florida. Pharmacoepidemiology and Drug Safety, 23(3), 314–320.

Acknowledgements

• Florida Medical Examiners Commission (FDLE)• Florida Prescription Drug Monitoring Program

(FDOH)• Prescription Behavioral Surveillance System

(CDC) • BJA Grant #: 2013-PM-BX-0010

New Developments in PDMPs:South Carolina, Wisconsin and Florida

Presenters:• Christie Frick, RPh, Director, Prescription Monitoring Program, South

Carolina Department of Health and Environmental Control• Chad Zadrazil, JD, Managing Director, Wisconsin Department of Safety and

Professional Services• Chris Delcher, PhD, Assistant Professor, University of Florida• Bruce Goldberger, PhD, Chief, Division of Forensic Medicine, University of

Florida College of Medicine

PDMP Track

Moderator: Karen H. Perry, Co-Founder and Executive Director, Narcotics Overdose Prevention and Education (NOPE) Task Force, and Member, Rx and Heroin Summit National Advisory Board