Controlled Substance Prescribing Trends and Physician and Pharmacy Utilization Patterns: Epidemiological Analysis of the Maine Prescription Monitoring Program, Kenneth McCall, PharmD Chunhao Tu, PhD Matthew Lacroix, PharmD Kevin Wallace, MD Christina Holt, MD Jonathan Balk, PharmD Candidate

Outline Background Pharmacoepidemiological PMP Analysis – Methods – Prescription trends from – Physician and pharmacy utilization patterns Future Directions

BACKGROUND

4 Maine PMP Overview Established in 2004 Data from over 300 retail and mail-order pharmacies licensed to dispense in Maine Data submitted at least twice per month. Data available to health care professionals (e.g., pharmacists and prescribers) online (after registration – only 40% of prescribers and 15% of pharmacists) Quarterly threshold reports sent to prescribers

Non-heroin opiate admissions by state per 100,000 population aged 12 and older:

MAINE LEADS THE NATION IN ADMISSIONS FOR PRESCRIPTION OPIOID ABUSE

Non-heroin opiate admissions by state per 100,000 population aged 12 and older: Source: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS), Data received through

Non-heroin opiate admissions by state per 100,000 population aged 12 and older: Source: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS), Data received through

Non-heroin opiate admissions by state per 100,000 population aged 12 and older: Source: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS), Data received through

MAINE LEADS THE NATION IN ADMISSIONS FOR PRESCRIPTION OPIOID ABUSE

IN MAINE, THERE WERE MORE ADMISSIONS FOR PRESCRIPTION OPIOID ABUSE IN 2010 THAN FOR ALCOHOL

Poisoning deaths involving opioid analgesics, cocaine, and heroin: US,

Death rates for poisonings involving opioid analgesics: Comparison of state and US rates: 2006

IN MAINE, THERE ARE MORE DEATHS EACH YEAR FROM OPIOID POSIONING THAN FROM AUTOMODILE ACCIDENTS

Pharmacoepidemiological PMP Analysis

Methods Design – Retrospective dataset analysis. – The Maine PMP began in 2004 and collects Schedule II, III, and IV new and refill prescription information from licensed pharmacies. – Individuals who received one or more controlled substance prescriptions from a licensed pharmacy during state fiscal years 2006 to 2010 (July 1, 2005 to June 30, 2010; herein referred to by year only) are included in the study population. – Data was cleaned and coded prior to analysis.

Methods Analysis – The two-sided Welch’s two-sample t test was used to compare the difference between two groups for continuous variables. – The Chi-square test was applied to examine the statistical association between two categorical variables and equal proportions, and the Cochran-Mantel-Haenszel (CMH) test was used to examine the associations between classes for multiple categorical data groups. – The association between ordinal variables 13 was measured using gamma statistics (  ) with corresponding 95% confidence interval (CI) and significance testing for temporal trends was performed with the Cochran- Armitage test.

PRESCRIPTION TRENDS FROM

Unique Patients Per Year Maine PMP Number of Unique Patients Patients / YearTrend Line

Number of unique patients per year increased by 31,653 from , while the US census bureau estimates the Maine population only grew by around 5,000

Number of Prescriptions by Drug Enforcement Agency (DEA) Class, Maine PMP Data, % Increase, P < % Increase, P < 0.001

Prescriptions for controlled drugs increased by 22.4% in 5 years, whereas the estimated Maine population only increased by 0.4%.

Class II drugs, which have the highest potential for abuse, had the greatest rate of increase in prescriptions among DEA classes from 2006 to 2010.

Frequency of Prescriptions by Drug Category, Maine PMP Data, 2006 & 2010

Narcotics are the most frequently prescribed drug category and stimulants are the fastest growing drug category.

Narcotic Prescriptions, Maine PMP, Fiscal Year# of RxsDays-Supply / Rx mean (SD) 20061,125, % Increase P < (12.50) 16.7% Increase P < ,177, (12.66) 20081,250, (12.82) 20091,271, (13.48) 20101,268, (13.45)

Hypnotic Prescriptions, Maine PMP, Fiscal Year# of RxsDays-Supply / Rx mean (SD) , % Increase P < (17.03) 9.8% Increase P < , (17.37) , (17.99) , (19.32) , (19.60)

Stimulant Prescriptions, Maine PMP, Fiscal Year# of RxsDays-Supply / Rx mean (SD) , % Increase P < (11.02) 2.8% Increase P < , (11.05) , (11.59) , (12.83) , (13.18)

The mean days-supply per prescription has significantly increased for all controlled drug categories; narcotics, hypnotics, and stimulants.

Oxycodone Prescriptions, Maine PMP, Fiscal Year# of RxsMean Dose Strength (mg) , % Increase P < % Increase P < , , , ,

Alprazolam Prescriptions, Maine PMP, Fiscal Year# of RxsMean Dose Strength (mg) , % Increase P < % Increase P < , , , ,

Amphetamine/dextroamphetamine Prescriptions, Maine PMP, Fiscal Year# of RxsMean Dose Strength (mg) , % Increase P < % Increase P < , , , ,

The mean dose per tablet of oxycodone, alprazolam, and amphetamine/dextroamphetamine has significantly increased.

Percent increase in Controlled Substance Rxs, CII Rxs, Days- supply per Rx (narcotics), and Strength per dose (oxycodone): Indexed to 2006 Levels Maine PMP Data

GRAMS of amphetamine/dextroamphetamine and oxycodone dispensed each year: Maine PMP Data, % Increase, P < % Increase, P < 0.001

In 2010, more than 300,000 grams of oxycodone and nearly 100,00 grams of amphetamine were dispensed to patients in Maine. Compared to 2006, this represents a significant 58.5% and 53.1% increase, respectively.

PHYSICIAN AND PHARMACY UTILIZATION PATTERNS

Distribution of individuals (number/%) receiving controlled prescriptions by number of prescribers and number of pharmacies in 2010 Number of Prescribers Used Number of Pharmacies Used 1234>5>5Total 1 246, , , , , , , , , , , , , , , , , , , >5>5 5, , , , , , Total341, , , , , ,

Most individuals (82.7%) obtained their prescriptions for controlled drugs from one or two prescribers in 2010.

Distribution of individuals (number/%) receiving controlled prescriptions by number of prescribers and number of pharmacies in 2010 Number of Prescribers Used Number of Pharmacies Used 1234>5>5Total 1 246, , , , , , , , , , , , , , , , , , , >5>5 5, , , , , , Total341, , , , , ,

Most individuals (93.6%) received their prescribed controlled drugs from one or two pharmacies in 2010.

Distribution of individuals (number/%) receiving controlled prescriptions by number of prescribers and number of pharmacies in 2010 Number of Prescribers Used Number of Pharmacies Used 1234>5>5Total 1 246, , , , , , , , , , , , , , , , , , , >5>5 5, , , , , , Total341, , , , , ,

The vast majority of individuals who used only one prescriber also used a single pharmacy (92.5%).

Distribution of individuals (number/%) receiving controlled prescriptions by number of prescribers and number of pharmacies in 2010 Number of Prescribers Used Number of Pharmacies Used 1234>5>5Total 1 246, , , , , , , , , , , , , , , , , , , >5>5 5, , , , , , Total341, , , , , , ([  = 0.711; 95% CI = (0.709, 0.714)])

The greater the number of prescribers, the more likely the prescription recipient used a greater number of pharmacies ([  = 0.711; 95% CI = (0.709, 0.714)]).

Number and percent of Schedule II, III, or IV prescription recipients who used five or more physicians, five or more pharmacies, either or both in DEA Class>5 Prescribers >5 Pharmacies >5 Prescribers OR >5 Pharmacies >5 Prescribers AND >5 Pharmacies II 4, % 1, % 5, % % III 3, % % 3, % % IV2, % % 2, % % A significantly greater percentage of individuals taking Schedule II drugs used five or more prescribers and/or five or more pharmacies than those taking only Schedule III or IV drugs (P<0.001).

Future Directions Geographic analysis Data linkages with state mortality data Pediatric and Geriatric prescribing trends Prescribing trends among prescribers who are registered with PMP versus prescribers who are not registered

QUESTIONS?