PRESCRIPTION MONITORING PROGRAMS Promoting Appropriate Use of Controlled Substances I am an active user of the PMP: Yes/No The PMP’s primary purpose is to identify doctor-shopping behavior: True or False The primary users of PMP data are law enforcement/regulatory entities: T or F Virginia is interoperable with other State PMPs: Yes/No Virginia’s Prescription Monitoring Program www.dhp.virginia.gov

Prescription Monitoring Program Virginia Cancer Pain Initiative From The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction (Annu.Rev.Public Health 2015.36:559–74) www.dhp.virginia.gov

Source: NSDUH 2013 www.dhp.virginia.gov

Prescription Monitoring Program From The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction (Annu.Rev.Public Health 2015.36:559–74) www.dhp.virginia.gov

Figure 3: Fatal Overdose in Virginia: Prescription Opioids and Heroin The graphs on the map above compare the proportion of the state’s population that lived in that Division in 2014 (black bar) to the proportion of drug cases submitted to DFS in CY 2014, for the listed drug types. For example, about 5% of Virginia’s population in 2014 lived in Division 4, but that Division submitted about 26% of benzodiazepine cases. Data Source: OCME Fata Drug Overdose Quarterly Report http://www.vdh.virginia.gov/medExam/ForensicEpidemiology.htm

Figure 6: Virginia Prescription Opioid Data Comparing Hospitalizations to Fatal Overdoses Statewide, benzodiazepine cases submitted to DFS increased 187% between CY 2001 and 2014. Between 2013 and 2014, they decreased 3%. Although Division 4 has consistently had the highest number of submissions, the number of cases from other Divisions is growing faster. In 2001, 42% of benzodiazepine submissions were from Division 4. That dropped to 26% in 2014. Data Sources: OCME Fata Drug Overdose Quarterly Report (2015 data are projected, preliminary figures); OFHS response to data request 12/30/2015.

Public Health Impact of Opioid Analgesic Use For every 1 overdose death there are 35 161 Estimated $193 billion in economic costs for illicit drug abuse in the U.S. in 2007 Hansen et al estimate costs of non-medical use of prescription opioids was $53.4 billion in 20061 Oxycodone, hydrocodone, propoxyphene, and methadone accounted for two-thirds of costs Opioid abusers generate, on average, annual direct health care costs 8.7 times higher than nonabusers2 461 Treatment admissions are for primary use of opioids from Treatment Exposure Data set Emergency department (ED) visits are from DAWN,Drug Abuse Warning Network, https://dawninfo.samhsa.gov/default.asp Abuse/dependence and nonmedical use in the past month are from the National Survey on Drug Use and Health

Prescription Monitoring Program Prescription Monitoring Programs (PMP) are systems in which controlled prescription drug data are collected in a database and made available to authorized users to promote the appropriate use of controlled substances for legitimate medical purposes, while deterring the misuse, abuse, and diversion of controlled substances. What it is not intended to do Not to prevent people from getting drugs for legitimate medical purposes Not to decrease the number of prescriptions for pain management Not to target patients, prescribers, or pharmacies for investigation www.dhp.virginia.gov www.dhp.virginia.gov

PRESCRIPTION MONITORING PROGRAMS 49 states and DC have authorizing legislation 49 state programs are operational* Programs may vary as to drugs collected and who has access Some standardization is occurring www.dhp.virginia.gov www.dhp.virginia.gov

Who May Get PMP Information? Prescription Monitoring Program Who May Get PMP Information? Prescribers and Pharmacists for their patients Investigators for licensing boards, if there is an open investigation Certain law enforcement agents, if there is an open investigation Patients for their own prescription history www.dhp.virginia.gov

ELEMENTS OF DATA COLLECTION Prescription Monitoring Program ELEMENTS OF DATA COLLECTION What Drugs Are Reported? Who Must Report? Exemptions To Reporting? Drugs: Oxycontin, methadone, morphine, Ritalin (SCHEDULE II) Lortab, Vicodin, testosterone, Tylenol with Codeine (SCHEDULE III) Valium, Xanax, Ambien (SCHEDULE IV) Who must report: Pharmacies, non-resident pharmacies (mail order), dispensing physicians Exemptions: Dispensing of manufacturer’s samples Dispensing pursuant to a manufacturer’s indigent patient program Dispensing in a bona fide medical emergency Administering of covered substances Dispensing within an appropriately licensed narcotic maintenance treatment program Dispensing to inpatients in hospitals or nursing homes (does not include assisted living) Dispensing to inpatients in hospices Dispensing by veterinarians to animals www.dhp.virginia.gov www.dhp.virginia.gov

WHO MAY GET INFORMATION? Prescription Monitoring Program WHO MAY GET INFORMATION? Prescribers and Pharmacists Licensing boards Certain law enforcement agents Patients for their own prescription history Others Patient must be over 18 and provide a notarized request by mail or in person. www.dhp.virginia.gov www.dhp.virginia.gov

Prescription Monitoring Program 2013-2015 Legislation Prescribers may request their own prescribing history for the previous 90-day period (2013) Mandatory PMP registration and use of PMP under certain circumstances for prescribers (2014) Automatic registration for prescribers and pharmacists (2015) 2012 LEGISLATION Add method of payment as a required element Remove restriction on number of licensed delegates a prescriber may have Provide authority for federal law enforcement with drug diversion investigative authority to request PMP information when there is an open investigation (restricted to DEA currently) Provide authority to send unsolicited reports to State Police Drug Diversion Agents on patients exhibiting extreme “doctor shopping” or forgery indications www.dhp.virginia.gov www.dhp.virginia.gov

2016 Legislation Mandatory requests Unsolicited reports Continuing education Expanded access Daily reporting to be required 1/1/2017 www.dhp.virginia.gov

Prescription Monitoring Program INITIATIVES 2015-2016 Morphine Equivalent Dose Score Automatic Registration Mandatory Requests Increase Interoperability Integration with EHR systems and Pharmacy applications www.dhp.virginia.gov www.dhp.virginia.gov

IMPACT-DOCTOR SHOPPING Prescription Monitoring Program IMPACT-DOCTOR SHOPPING The 10 and 10 number for the first half of 2016 was 8. www.dhp.virginia.gov www.dhp.virginia.gov

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Figure 15: Opioids Prescribed in Virginia Six Drugs Represent 90% of Opioid Prescriptions in First Half of 2015 Data Sources: Brandeis University report, 11/23/2015. That report used Virginia Prescription Monitoring Program database as its source.

DATACENTER LOG-IN SCREEN Prescription Monitoring Program DATACENTER LOG-IN SCREEN www.dhp.virginia.gov www.dhp.virginia.gov

SUBMIT REQUEST SCREEN www.dhp.virginia.gov

Prescription Monitoring Program HOW TO LOCATE REPORTS Click on Patient’s name to view request screen and obtain report www.dhp.virginia.gov www.dhp.virginia.gov

Prescription Monitoring Program Days supply Pay: 01 = Private Pay 02 = Medicaid 03 = Medicare 04 = Commercial Ins. 05 = Military Inst. and VA 06 = Workers Comp 07 = Indian Nations 99 = Other www.dhp.virginia.gov www.dhp.virginia.gov

Prescriber: Pharmacist: Dispense controlled substance Prescribe as planned Contact pharmacy Discuss concerns Change treatment plan Refer to specialist Refer to substance abuse treatment Discharge from practice File complaint with law enforcement Pharmacist: Dispense controlled substance Contact prescriber Discuss concerns Contact pharmacy Decline to dispense File complaint with law enforcement www.dhp.virginia.gov

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Prescription Monitoring Program Virginia’s Prescription Monitoring Program adds MEDD score to Patient Reports New information was added to PMP patient reports on June 2, 2015. An “Active Cumulative Morphine Equivalent” score will be displayed just to the right of the patient information section of the report if the patient has active prescriptions for opioids. Also commonly known as the Morphine Equivalent Daily Dose (MEDD), this feature is meant to readily identify the potency among different opioids as a single score describing the equivalent dose of morphine taken on a daily basis. At the end of the PMP report a morphine equivalent table will be displayed as well as a table computing the patient’s unique score based on the patient’s active prescriptions. This score represents only opioids dispensed to a patient. It does not reflect any information on the use of any other type of controlled substance such as benzodiazepines or stimulants. If a patient does not have an active opiate prescription, no cumulative score is provided. www.dhp.virginia.gov www.dhp.virginia.gov

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Prescription Monitoring Program Source: Appriss.com, NARxCHECK Product Sheet www.dhp.virginia.gov

POST-QUESTIONS The PMP’s primary purpose is to identify doctor-shopping behavior: True or False The primary users of PMP data are law enforcement/regulatory entities: T or F Virginia is interoperable with other State PMPs: Yes or No www.dhp.virginia.gov

Prescription Monitoring Program PROGRAM HOME PAGE http://www.dhp.virginia.gov/dhp_programs/pmp/default.asp Reports and Statistics Laws and regulations Brief introduction and Use Instructions Contact Information www.dhp.virginia.gov www.dhp.virginia.gov

Prescription Monitoring Program CONTACT INFORMATION Phone #: 804-367-4514 or 367-4409 Fax 804-527-4470 Email- ralph.orr@dhp.virginia.gov www.dhp.virginia.gov/dhp_programs/pmp/default.asp www.dhp.virginia.gov www.dhp.virginia.gov