KASPER and Kentucky’s Response to the Opioid Crisis David R. Hopkins KASPER Business Analyst Office of Inspector General Mental Health and Addiction Treatment Symposium October 24, 2019

Disclosure David R. Hopkins No relevant financial relationships No conflicts of interest

Contents Controlled Substance Abuse and the Opioid Crisis KASPER Program Information How KASPER is Used

Controlled Substance Abuse and the Opioid Crisis

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)

Commonwealth of Kentucky RESPONSE TO THE OPIOID EPIDEMIC

Prelude to House Bill 1 Opioid abuse a national epidemic KY controlled substance abuse increasing KY opioid overdose deaths increasing “Pill mills” proliferating Governor, Office of Drug Control Policy, Attorney General and legislators viewed medical community as contributors to the problem Low provider utilization of PDMP (KASPER)

2012 Extraordinary Session HB1 2013 Regular Session HB217

Strategies PRESCRIPTION MONITORING PRESCRIBING REGULATIONS ROGUE PAIN CLINICS DRUG DISPOSAL PRESCRIBER AND PUBLIC EDUCATION

Kentucky’s Prescription Drug Abuse Strategy Office of Drug Control Policy Require physician ownership of pain management facilities Limit prescriber dispensing of C-II medications to a 48 hour supply Require 7.5% of CME in addiction, pain management or KASPER Increase public awareness Increase resources and funding for substance abuse prevention and treatment 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 data to identify potentially inappropriate or illegal controlled substance prescribing or dispensing

Kentucky Overdose Deaths

Kentucky Overdose Deaths

Controlled Substances and Overdose Deaths Approximately 60% of Kentucky resident drug overdose decedents in 2018 received a controlled substance within one year of their date of death.

Photo courtesy of www.legacy.com, August 14, 2019 Richard Brown 1972 - 2019 Photo courtesy of www.legacy.com, August 14, 2019

KASPER Program Information

Kentucky All Schedule Prescription Electronic Reporting

KASPER KASPER is Kentucky’s Prescription Drug Monitoring Program (PDMP). KASPER tracks Schedule II – V controlled substance prescriptions dispensed within the state as reported by pharmacies and other dispensers, and provides a tool to help address the misuse, abuse and diversion of controlled pharmaceutical substances.

Controlled Substance Schedules Schedule I – Illegal Drugs e.g. heroin, marijuana, ecstasy Schedule II – Most addictive legal drugs; high abuse potential e.g. fentanyl (Actiq, Duragesic), oxycodone (OxyContin, Percocet), methylphenidate (Ritalin), hydrocodone (Vicodin, Norco) Schedule III – Less abuse potential than I or II e.g. testosterone (Androgel), buprenorphine/naloxone (Suboxone) Schedule IV – Less abuse potential than III e.g. benzodiazepines (Xanax, Valium) Schedule V – least abuse potential e.g. codeine containing cough mixtures

KASPER Operation Over 11 million controlled substance prescriptions reported to the system each year Over 12.5 million report/data requests processed in 2018 KASPER data updated within 1 to 2 days Dispensers have 1 business day to report Reports available to authorized individuals Available via web typically within 30 - 60 seconds Available 24/7 from any PC with web access

KASPER Data KASPER tracks: Retail pharmacies dispensing into KY (in-state, mail order, Internet) Hospital emergency departments dispensing controlled substances to an ED patient Practitioners administering or dispensing a controlled substance in the office Dispensing from Department for Veterans Affairs pharmacies (except gabapentin)

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

Buprenorphine/Naloxone 3.4% Top Prescribed Controlled Substances by Therapeutic Category based on Number of Doses - 2018 Buprenorphine/Naloxone 3.4% Suboxone Lorazepam 2.9% Ativan Pregabalin 2.7% Lyrica Amphetamine 4.1% Adderall Gabapentin 29.0% Neurontin Clonazepam 5.0% Klonopin Alprazolam 6.8% Xanax Tramadol 7.3% Ultram Oxycodone 13.2% OxyContin, Percocet Hydrocodone/APAP 25.6% Lortab, Vicodin, Norco

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; for the birth mother of an infant being treated for neonatal abstinence syndrome or prenatal drug exposure. 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

Controlled Substance Records Reported to KASPER - Total/Per Person 2.65 2.72 2.72 2.47 2.43 2.41 2.37 2.43 2.53 Number of Controlled Substance Prescriptions per Person

KASPER Report Requests Report/Data Requests in Thousands 7354 6871

What does a KASPER Report Show? A KASPER report includes: The patient name and date of birth The drug name, dosage, days supply, date prescription written, date prescription filled The prescriber name and city The dispenser name and city Morphine milligram equivalent data Per opioid prescription Total for all active opioid prescriptions

How KASPER is Used

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

KASPER Regulations – Licensure Boards 201 KAR 5:130 Kentucky Board of Optometric Examiners KASPER requirements 201 KAR 8:540 Kentucky Board of Dentistry KASPER requirements 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.

General KASPER Query Exceptions In an emergency situation (disaster or mass casualties) Within 14 days of surgery or within three days of oral surgery Patients in hospitals and long term care facilities Patients in Hospice care or being treated for cancer pain Single doses of anxiety medicine prior to a procedure Prescribing a substitute medication within 7 days of initial prescription Schedule V controlled substances

Providing Reports to Patients 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

KASPER Prescriber Report Card Program Enhancements KASPER Prescriber Report Card Launched February 2017 Provides a quarterly and annual summary of a practitioner’s prescribing practices and how they compare with other practitioners in their specialty area

Program Enhancements Drug Conviction data from Administrative Office of the Courts Class A misdemeanor and felony drug conviction information from the AOC CourtNet system 6.1% (973,245) of YTD 2019 KASPER queries included a request for drug conviction information 1.1% (11,112) of those requests returned drug conviction information for the patient

Non-fatal drug overdose warning flag to be added in 4Q 2019 Program Enhancements Non-fatal drug overdose warning flag to be added in 4Q 2019 Based on patient overdose information reported by Emergency Departments to the Kentucky Health Information Exchange (KHIE) KASPER will be linked to KHIE to notify practitioners if the patient experienced a non-fatal drug overdose in the ED Practitioners and pharmacists can view the patient information in KHIE

OIG Overdose Death Notification Project Letters to practitioners who prescribed one or more opioid prescriptions that were active at the time of their patient’s death. Tips on managing pain and prescribing opioids Patient Information Treatment Resource Locator: findhelpnowky.org

House Bill 1 Controlled Substance Dispensing Comparison Drug July 2011 through June 2012 July 2018 through June 2019 Percent Change Opioid Analgesics 5,762,843 3,770,735 -35% Opioid Analgesic Average Daily MED 45 39 -13% Benzodiazepines and Other Sedatives 2,666,208 1,683,861 -37% Stimulants 1,171,718 1,455,651 +24% Gabapentin Not Scheduled 1,759,496   Buprenorphine/ Naloxone 331,190 1,053,251 +218% All Controlled Substances 11,992,912 11,194,891 -7% All figures based on dispensed controlled substance prescription data reported to KASPER

Opioid Analgesics vs. Medication Assisted Treatment Source: Kentucky All Schedule Prescription Electronic Reporting System

QUESTIONS? KASPER Web Site: https://chfs.ky.gov/agencies/os/oig/dai/deppb/Pages/kasper.aspx