Prescription Electronic Reporting System (KASPER) An Update on the Kentucky All Schedule Prescription Electronic Reporting System (KASPER) David R. Hopkins KASPER Program Manager Office of Inspector General Kentucky Cabinet for Health and Family Services Kentucky Academy of Family Physicians September 16, 2016

Disclosure David R. Hopkins No relevant financial relationships. No conflicts of interest. Cabinet for Health and Family Services

Contents Controlled Substance Abuse KASPER Program Update Legislative Changes Affecting Provider Use of KASPER Enhancements to eKASPER Provider Shopping and Diversion House Bill 1 Results Buprenorphine/Naloxone and KASPER Cabinet for Health and Family Services

Controlled Substance Abuse

Misuse, Abuse, Diversion ( SAMHSA) incorrect use of a controlled substance medication by a patient (wrong time, wrong dose, wrong reason) Abuse: maladapted pattern of controlled substance use leading to significant impairment or distress Diversion: controlled substance medication leaving the legal distribution channels (manufacture, transport, pharmacy, patient) Cabinet for Health and Family Services

Kentucky’s Prescription Drug Abuse Strategy Office of Drug Control Policy Require physician ownership of pain management facilities Limit C-II prescriber dispensing to 48 hour supply Require 7.5% of CME in addiction, pain management or KASPER Increase public awareness Increase drug disposal opportunities Enhance use of Prescription Drug Monitoring Program Require daily reporting to KASPER Mandate KASPER registration and usage Pharmacists must register Controlled substance prescribers must register and query under certain circumstances Utilize KASPER Advisory Council to identify inappropriate or illegal controlled substance prescribing Cabinet for Health and Family Services

Painkiller Prescription Rates by State CDC Vitalsigns July 2014, Source: IMS, National Prescription Audit (NPAtm), 2012 Cabinet for Health and Family Services

Adderall & Ritalin Cabinet for Health and Family Services

Top 10 State Drug Overdose Death Rates – 2014 Rank State Number of Drug Overdose Deaths Age-Adjusted Drug Overdose Death Rate per 100,000 or Population 1 West Virginia 627 35.5 2 New Mexico 547 27.3 3 New Hampshire 334 26.2 4 Kentucky 1,077 24.7 5 Ohio 2,744 24.6 6 Rhode Island 247 23.4 7 Utah 603 22.4 8 Pennsylvania 2,732 21.9 9 Delaware 189 20.9 10 Oklahoma 777 20.3 United States 47,055 14.7 Data source: Increases in Drug and Opioid Overdose Deaths – United States, 2000-2014. Rudd, Aleshire, Zibbell and Gladdin, CDC Morbidity and Mortality Weekly Report, December 18, 2015 Cabinet for Health and Family Services

Kentucky Drug Overdose Deaths Sources: 2015 Data: 2015 Overdose Fatality Report. Kentucky Justice and Public Safety Cabinet, June 2016. 2005-2014 Data: U.S. Centers for Disease Control, Multiple Cause of Death Data (CDC Wonder Online Database) Cabinet for Health and Family Services

Top 10 State Drug Overdose Death Rates – 2014 Cabinet for Health and Family Services

Controlled Substance Usage 2015 Cabinet for Health and Family Services

Story reported by Ann Bowden, WLKY.com, December 8, 2014 Heather Pereira -Investigators believe Allen gave his son the narcotic on the night of his death Story reported by Ann Bowden, WLKY.com, December 8, 2014 Cabinet for Health and Family Services

Louisville Courier-Journal, August 29, 2014 Danielle Cogswell Louisville Courier-Journal, August 29, 2014 Cabinet for Health and Family Services

Amanda Foster and Douglas Allen -Investigators believe Allen gave his son the narcotic on the night of his death Cabinet for Health and Family Services

Prince Story by Ralph Ellis and Sarah Sidner, CNN, June 3, 2016 , Photo by Los Angeles Times Cabinet for Health and Family Services

KASPER Program Update

Status of Prescription Drug Monitoring Programs (PDMPs) VT ME WA MT ND NH MA RI CT NJ DE MD DC MN NY OR WI SD ID MI WY PA IA NE OH IL IN NV WV UT VA CO KS KY CA MO NC TN OK SC AZ NM AR GA MS AL TX LA AK FL Operational PDMPs Enacted PDMP legislation, but program not yet operational Legislation pending HI GU Research is current as of February 1, 2012

2011 KASPER Reports Requested Cabinet for Health and Family Services

Annual KASPER Records Total / Per Person 2.39 2.43 2.65 2.65 2.72 2.72 2.47 2.43 2.41 Number of Controlled Substance Prescriptions per Person Cabinet for Health and Family Services

KASPER Reports Requested Cabinet for Health and Family Services

Buprenorphine-Naloxone 3.1% Top Prescribed Controlled Substances by Therapeutic Category by Doses - 2015 Amphetamine 3.9% Adderall Zolpidem 3.2% Ambien Buprenorphine-Naloxone 3.1% Suboxone Lorazepam 4.0% Ativan Hydrocodone 37.6% Lortab Vicodin Diazepam 4.0% Valium Clonazepam 7.1% Klonopin Tramadol 9.8% Ultram Alprazolam 10.4% Xanax Oxycodone 16.9% OxyContin Percocet Cabinet for Health and Family Services

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

Legislative Changes Affecting Provider Use of eKASPER

eKASPER Reporting Controlled substance administration or dispensing must be reported within one day Not required for patients in hospitals, long term care facilities, child caring facilities, jails, correction facilities, juvenile detention facilities Cabinet for Health and Family Services

KASPER Data KASPER tracks: Retail pharmacies dispensing into KY (in-state, mail order, Internet) Hospital pharmacies if dispensing any C-II or more than a 72 hour supply of a C-III through C-V Physician administering or dispensing a C-II through C-V in the office Dispensing from Department for Veterans Affairs pharmacies Cabinet for Health and Family Services

KASPER Data KASPER does not track Methadone administered at a federally regulated methadone clinic Controlled substances dispensed for administration to a patient in a hospital, long-term care facility, jail, correctional facility or juvenile detention facility Pseudoephedrine (tracked separately via NPLEx) Dispensing by military pharmacies Schedule I or other illegal drugs Cabinet for Health and Family Services

eKASPER Accounts eKASPER registration is mandatory for Kentucky practitioners or pharmacists authorized to prescribe or dispense controlled substances to humans. Cabinet for Health and Family Services

eKASPER Prescriber Usage - KRS 218A.172 Query eKASPER for previous 12 months of data: Prior to initial prescribing or dispensing of a Schedule II controlled substance No less than every three months Review data before issuing a new prescription or refills for a Schedule II controlled substance Additional rules/exceptions included in licensure board regulations Cabinet for Health and Family Services

KBML Controlled Substance Prescribing Regulation Cabinet for Health and Family Services

KBML Controlled Substance Prescribing Regulation Cabinet for Health and Family Services

eKASPER Review - 201 KAR 9:260 Initial prescribing to treat acute, non-cancer pain. Including in Emergency Department Commencement of long term prescribing (after 90 days) to treat non-cancer pain Continued long term prescribing for non-cancer pain: every three months. More frequently or immediately if indicated Initial treatment of non-pain conditions http://kbml.ky.gov/hb1/Pages/House-Bill-1-Ordinary-Regulations.aspx http://www.lrc.ky.gov/kar/201/009/260.htm Cabinet for Health and Family Services

eKASPER Query Exceptions In an emergency situation (disaster or mass casualties) Patients in hospitals and long term care facilities (C-III through C-V) Patients in Hospice care or being treated for cancer pain Single doses of anxiety medicine prior to a procedure Schedule V controlled substances Cabinet for Health and Family Services

To Request an eKASPER Report Via secure WEB application. Application accessible from any PC with WEB access. Practitioners and pharmacists can receive a report often within 30-45 seconds (as long as the report does not require further review by the KASPER staff). Available 24 / 7. URL: https://ekasper.chfs.ky.gov. Cabinet for Health and Family Services

eKASPER Report Processing 96% of reports auto-matched by eKASPER Manual Queue: Processed 8:00 a.m. to 4:30 p.m. Monday through Friday Weekday manual reports typically available within one hour Cabinet for Health and Family Services

eKASPER Report Request - Master Cabinet for Health and Family Services

eKASPER Report Request – State Selection Cabinet for Health and Family Services

What if I cannot “Query” KASPER? If eKASPER indicates “manual process” Record the eKASPER report request number in the patient’s chart If the eKASPER system is unavailable or Internet access unavailable Document circumstances why eKASPER could not be queried (201 KAR 9:260) If eKASPER outage, record the date and time, and eKASPER system outage logs will confirm lack of system availability Cabinet for Health and Family Services

What’s New with eKASPER! Cabinet for Health and Family Services

KASPER Tips (www.chfs.ky.gov/KASPER) Cabinet for Health and Family Services

Morphine Equivalent Dose (MED) Cabinet for Health and Family Services

eKASPER Prescriber Reports CS prescribers can obtain an eKASPER report on themselves (reverse KASPER): To review and assess the individual prescribing patterns To determine the accuracy and completeness of information contained in eKASPER To identify fraudulent prescriptions Prescriber Peer Comparison Report Cabinet for Health and Family Services

KASPER Case Study

eKASPER Prescriber Report Request Cabinet for Health and Family Services

Providing Reports to Patients eKASPER reports can be shared with the patient or person authorized to act on the patient’s behalf eKASPER 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 Cabinet for Health and Family Services

eKASPER Error Correction Patient or provider should contact the dispenser to correct records in error Inaccurate eKASPER reports due to system errors should be reported to the Drug Enforcement and Professional Practices Branch 502-564-7985 Cabinet for Health and Family Services

eKASPER Support Help desk e-mail ekasperhelp@ky.gov Help desk phone (502) 564-2703 Account assistance: ekasper.admin@ky.gov Cabinet for Health and Family Services

Potential KASPER Changes Scheduling gabapentin as a C-V Addition of non-fatal drug overdose information to prescriber and dispenser reports Addition of drug conviction information to KASPER reports Cabinet for Health and Family Services

Provider Shopping and Diversion

Provider Shopping Provider shopping is when controlled substances are acquired by deception. Acts related to attempting to obtain a controlled substance, a prescription for a controlled substance or administration of a controlled substance, prohibited under KRS 218A.140 include: Knowingly misrepresenting or withholding information from a practitioner. Providing a false name or address. Knowingly making a false statement. Falsely representing to be authorized to obtain controlled substances. Presenting a prescription that was obtained in violation of the above. Affixing a false or forged label to a controlled substance receptacle. Cabinet for Health and Family Services

Practitioner Judgment Practitioners must use their best professional judgment to determine: when they can intervene with a provider shopping patient and provide treatment or refer them to treatment follow Kentucky Board of Medical Licensure guidelines in 902 KAR 9:260 when they need to contact law enforcement to report a provider shopper Cabinet for Health and Family Services

Diversion Diversion involves illegal transfer of controlled substances to an individual other than for whom they were prescribed. Cabinet for Health and Family Services

Diversion What do you do when diversion is suspected? If you suspect an individual is involved in diverting controlled substances, we ask that you please report them to the proper law enforcement authorities. If unsure who to contact please call the Drug Enforcement and Professional Practices Branch of the Office of the Inspector General for assistance. (502) 564-7985 Cabinet for Health and Family Services

Drug Enforcement and Professional Practices Branch DEPPB Phone Number: 502-564-7985 Paula York Jill Lee Stephanie Johnson Carrie Gentry Laura Beth Wells Duncan McCracken Chris Johnson Cabinet for Health and Family Services

Reporting Provider Shoppers/Diverters KRS 218A.280 Controlled substances – Communications with practitioner not privileged. Information communicated to a practitioner in an effort unlawfully to procure a controlled substance, or unlawfully to procure the administration of any controlled substance, shall not be deemed a privileged communication. Cabinet for Health and Family Services

Reporting Provider Shoppers/Diverters 902 KAR 55:110 Section 10 (4) (b): In addition to the purposes authorized under KRS 218A.202(8)(e), and pursuant to KRS 218A.205(2)(a) and (6), a practitioner or pharmacist who obtains KASPER data or a report under KRS 218A.202(6)(e)1. or who in good faith believes that any person, including a patient, has violated the law in attempting to obtain a prescription for a controlled substance, may report suspected improper or illegal use of a controlled substance to law enforcement or the appropriate licensing board. Cabinet for Health and Family Services

House Bill 1 Results

Controlled Substance Dispensing Comparison Drug July 2011 through June 2012 July 2014 through June 2015 Percent Change Hydrocodone 3,303,453 2,603,642 - 21.2% Oxycodone 977,256 937,530 - 4.1% Oxymorphone 24,485 18,459 - 24.6% Tramadol 431,455 542,930 + 25.8% Alprazolam 947,672 769,814 - 18.8% Diazepam 413,983 350,685 - 15.3% Buprenorphine/ Naloxone 269,488 491,130 + 82.2% All Controlled Substances 10,417,237 9,927,621 - 4.7% Whack a mole- started really good. Figures represent number of prescriptions dispensed as reported to KASPER

Hydrocodone Cabinet for Health and Family Services

Oxycodone Cabinet for Health and Family Services

Alprazolam Cabinet for Health and Family Services

Methadone Cabinet for Health and Family Services

Tramadol Cabinet for Health and Family Services

Buprenorphine/Naloxone and KASPER

Buprenorphine Prescribing Must have DEA data waiver to prescribe buprenorphine! Request eKASPER prior to initiating treatment Request eKASPER at least once every three months to help guide the treatment plan 201 KAR 9:270. Professional standards for prescribing or dispensing Buprenorphine-Mono-Product or Buprenorphine-Combined-with-Naloxone.   http://www.lrc.ky.gov/kar/201/009/270.htm Cabinet for Health and Family Services

Reporting of DEA data waiver numbers instead of prescriber DEA numbers Challenges Reporting of DEA data waiver numbers instead of prescriber DEA numbers Electronic prescribing of controlled substances (EPCS) Cabinet for Health and Family Services

Buprenorphine/Naloxone Cabinet for Health and Family Services

Buprenorphine/Naloxone Prescribing 1Q 2016 Cabinet for Health and Family Services

Buprenorphine/Naloxone Usage 1Q 2016 Cabinet for Health and Family Services

Kentucky Cabinet for Health and Family Services QUESTIONS? David R. Hopkins Kentucky Cabinet for Health and Family Services 275 East Main Street, 5ED Frankfort, KY 40621 502-564-2815 ext. 3333 Dave.Hopkins@ky.gov KASPER Web Site: www.chfs.ky.gov/KASPER