1. Controlled Substance Prescribing Trends and Physician and Pharmacy Utilization Patterns: Epidemiological Analysis of the Maine Prescription Monitoring Program, 2006 - 2010 Kenneth McCall, PharmD Chunhao Tu, PhD Matthew Lacroix, PharmD Kevin Wallace, MD Christina Holt, MD Jonathan Balk, PharmD Candidate

2. Outline Background Pharmacoepidemiological PMP Analysis – Methods – Prescription trends from 2006-2010 – Physician and pharmacy utilization patterns Future Directions

3. BACKGROUND

4. www.maine.gov/pmp 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

5. Non-heroin opiate admissions by state per 100,000 population aged 12 and older: 1998-2008

6. MAINE LEADS THE NATION IN ADMISSIONS FOR PRESCRIPTION OPIOID ABUSE

7. Non-heroin opiate admissions by state per 100,000 population aged 12 and older: 1998-2008 Source: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS), Data received through 8.31.09.

8. Non-heroin opiate admissions by state per 100,000 population aged 12 and older: 1998-2008 Source: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS), Data received through 8.31.09.

9. Non-heroin opiate admissions by state per 100,000 population aged 12 and older: 1998-2008 Source: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS), Data received through 8.31.09.

10. MAINE LEADS THE NATION IN ADMISSIONS FOR PRESCRIPTION OPIOID ABUSE

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

13. Poisoning deaths involving opioid analgesics, cocaine, and heroin: US, 1999-2006

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

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

16. Pharmacoepidemiological PMP Analysis

17. 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.

18. 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.

19. PRESCRIPTION TRENDS FROM 2006-2010

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

21. Number of unique patients per year increased by 31,653 from 2006-2009, while the US census bureau estimates the Maine population only grew by around 5,000

22. Number of Prescriptions by Drug Enforcement Agency (DEA) Class, Maine PMP Data, 2006-2010 22.4% Increase, P < 0.001 28.6% Increase, P < 0.001

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

24. 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.

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

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

27. Narcotic Prescriptions, Maine PMP, 2006-2010 Fiscal Year# of RxsDays-Supply / Rx mean (SD) 20061,125,323 12.7% Increase P < 0.001 13.34 (12.50) 16.7% Increase P < 0.001 20071,177,11413.88 (12.66) 20081,250,58214.52 (12.82) 20091,271,66715.19 (13.48) 20101,268,24215.57 (13.45)

28. Hypnotic Prescriptions, Maine PMP, 2006-2010 Fiscal Year# of RxsDays-Supply / Rx mean (SD) 2006 707,793 27.8% Increase P < 0.001 26.11 (17.03) 9.8% Increase P < 0.001 2007 756,992 26.70 (17.37) 2008 830,105 27.34 (17.99) 2009 882,343 28.12 (19.32) 2010 904,72328.67 (19.60)

29. Stimulant Prescriptions, Maine PMP, 2006-2010 Fiscal Year# of RxsDays-Supply / Rx mean (SD) 2006 207,242 54.1% Increase P < 0.001 30.64 (11.02) 2.8% Increase P < 0.001 2007 228,209 30.75 (11.05) 2008 260,797 30.99 (11.59) 2009 287,547 31.51 (12.83) 2010 319,00131.20 (13.18)

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

31. Oxycodone Prescriptions, Maine PMP, 2006-2010 Fiscal Year# of RxsMean Dose Strength (mg) 2006150,504 48.1% Increase P < 0.001 14.45 7.7% Increase P < 0.001 2007183,87715.04 2008206,11314.97 2009194,61516.37 2010222,80415.56

32. Alprazolam Prescriptions, Maine PMP, 2006-2010 Fiscal Year# of RxsMean Dose Strength (mg) 2006135,774 14.1% Increase P < 0.001 0.601 11.1% Increase P < 0.001 2007140,4710.619 2008147,9160.631 2009150,7520.649 2010154,8420.668

33. Amphetamine/dextroamphetamine Prescriptions, Maine PMP, 2006-2010 Fiscal Year# of RxsMean Dose Strength (mg) 200673,983 59.2% Increase P < 0.001 17.61 5.1% Increase P < 0.001 200783,83118.02 200898,49118.15 2009107,09918.33 2010117,75818.51

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

35. 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

36. GRAMS of amphetamine/dextroamphetamine and oxycodone dispensed each year: Maine PMP Data, 2006-2010 53.1% Increase, P < 0.001 58.5% Increase, P < 0.001

37. 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.

38. PHYSICIAN AND PHARMACY UTILIZATION PATTERNS

39. 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 1 246,386 56.79 16,224 3.74 2,874 0.66 655 0.15 312 0.07 266,451 61.42 2 61,498 14.17 24,732 5.70 4,349 1.00 1,049 0.24 492 0.11 92,120 21.23 3 20,790 4.79 12,030 2.77 4,187 0.97 1,171 0.27 584 0.13 38,762 8.93 4 7,802 1.80 5,723 1.32 2,736 0.63 1,000 0.23 569 0.13 17,830 4.11 >5>5 5,359 1.24 5,450 1.26 3,643 0.84 2,064 0.48 2,172 0.50 18,688 4.31 Total341,835 78.79 64,159 14.79 17,789 4.10 5,939 1.37 4,129 0.95 433,851 100.00

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

41. 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 1 246,386 56.79 16,224 3.74 2,874 0.66 655 0.15 312 0.07 266,451 61.42 2 61,498 14.17 24,732 5.70 4,349 1.00 1,049 0.24 492 0.11 92,120 21.23 3 20,790 4.79 12,030 2.77 4,187 0.97 1,171 0.27 584 0.13 38,762 8.93 4 7,802 1.80 5,723 1.32 2,736 0.63 1,000 0.23 569 0.13 17,830 4.11 >5>5 5,359 1.24 5,450 1.26 3,643 0.84 2,064 0.48 2,172 0.50 18,688 4.31 Total341,835 78.79 64,159 14.79 17,789 4.10 5,939 1.37 4,129 0.95 433,851 100.00

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

43. 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 1 246,386 56.79 16,224 3.74 2,874 0.66 655 0.15 312 0.07 266,451 61.42 2 61,498 14.17 24,732 5.70 4,349 1.00 1,049 0.24 492 0.11 92,120 21.23 3 20,790 4.79 12,030 2.77 4,187 0.97 1,171 0.27 584 0.13 38,762 8.93 4 7,802 1.80 5,723 1.32 2,736 0.63 1,000 0.23 569 0.13 17,830 4.11 >5>5 5,359 1.24 5,450 1.26 3,643 0.84 2,064 0.48 2,172 0.50 18,688 4.31 Total341,835 78.79 64,159 14.79 17,789 4.10 5,939 1.37 4,129 0.95 433,851 100.00

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

45. 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 1 246,386 56.79 16,224 3.74 2,874 0.66 655 0.15 312 0.07 266,451 61.42 2 61,498 14.17 24,732 5.70 4,349 1.00 1,049 0.24 492 0.11 92,120 21.23 3 20,790 4.79 12,030 2.77 4,187 0.97 1,171 0.27 584 0.13 38,762 8.93 4 7,802 1.80 5,723 1.32 2,736 0.63 1,000 0.23 569 0.13 17,830 4.11 >5>5 5,359 1.24 5,450 1.26 3,643 0.84 2,064 0.48 2,172 0.50 18,688 4.31 Total341,835 78.79 64,159 14.79 17,789 4.10 5,939 1.37 4,129 0.95 433,851 100.00 ([  = 0.711; 95% CI = (0.709, 0.714)])

46. 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)]).

47. 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 2010. DEA Class>5 Prescribers >5 Pharmacies >5 Prescribers OR >5 Pharmacies >5 Prescribers AND >5 Pharmacies II 4,534 3.00% 1,808 1.19% 5,744 3.81% 598 0.40% III 3,429 1.53% 649 0.29% 3,766 1.69% 312 0.14% IV2,011 0.98% 554 0.27% 2,382 1.16% 183 0.09% 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).

48. 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

49. QUESTIONS?