1. Using the Maine PMP to Improve Prescribing Practices for Potentially Addictive Prescription Medications Susan Payne, MPH, PhD Research Professor Institute for Health Policy, Muskie School of Public Service, University of Southern Maine Patricia Lapera, MPH Prescription Monitoring Program Coordinator, Office of Substance Abuse, DHHS State of Maine

2. Objectives of the session  Provide an overview of the misuse and abuse of potentially addictive prescription medications in Maine  Describe the Maine Prescription Monitoring Program (PMP)  Describe how health care providers use the PMP to improve prescribing  Provide contact information on the PMP

3. Potentially addictive or “controlled” prescription medications  “Controlled” medications include pain relievers, stimulants, sedatives, tranquilizers, sleep aids, and hormone supplements (Oxycodone, Vicodin, Alprazolam).  They are commonly prescribed.  They have legitimate therapeutic uses and can be used safely with medical oversight.  They also have the potential to be addictive.

4. Maine has serious problems with the use of controlled medications Source: Office of the Chief Medical Examiner; Marcella Sorg, UMaine/Smith Pol. Center

5. Use of controlled medications is increasing in Maine  From 2005-2009, the number of prescriptions for controlled medications in Maine increased by 24%.  Use of Schedule II medications (with highest potential for addiction) grew faster than Schedule III or IV (with lower potential).  Use of pain relievers is growing fast; they are often used for non-medical reasons and are most commonly obtained by diversion.

6. Source: Epidemiologic Study 2005-2008, Dr. Susan Payne Prescriptions filled in Maine Age and Year, 2005-2008 6

7. Admissions to substance abuse treatment for opiate abuse Maine: 1999-2008 www.maine.gov/pmp 7

8. “Doctor shopping” & “pharmacy hopping”  Most patients get their controlled medications from only 1 or 2 prescribers.  However, some people use many prescribers or pharmacies, so that it is harder to monitor and control their medication use.  For example, in 2008, 1% of the people with prescriptions for controlled medications in Maine used 5 or more prescribers. Some individuals used 50 or more prescribers.

9. The Maine Prescription Monitoring Program (PMP)  What is the Maine PMP?  What are the PMP goals?  How does the PMP work?

10. What is the Maine PMP?  The Maine PMP provides information to prescribers and pharmacists to identify suspicious activity related to prescribing and dispensing controlled substances.  It is under the Maine Office of Substance Abuse (OSA).  It collects information from all pharmacies for all prescriptions filled in Maine for medications In US DEA Schedules II -IV. 10

11.  Prescribers and pharmacists can access the information, after appropriate registration processes are completed, through a secure, password-protected PMP website.  They can verify patients’ reports on their use of PMP-tracked medications and identify questionable activity.

12.  PMP legislation passed in Maine in 2003. -There are PMPs in more than 30 US states  Data collection began July 2004.  Data are submitted once per week from over 600 pharmacies  All information is saved in a centralized database, available online to data requesters/sub-account users.

13. 13 What are the goals of the PMP?  To improve patient care by giving health care providers comprehensive information  To curb misuse of prescription drugs  To ensure that those who do need prescription medications still receive them  To get those who are addicted into appropriate treatment  To help stop prescription drug overdoses and overdose deaths  To educate the public on the dangers of prescription drug misuse and abuse

14. How does the PMP work? Who has access to the data? Prescribers, other licensed providers and medical office assistants (new) Pharmacists Licensing boards Patients OSA staff members Law enforcement- through grand jury subpoena Office of MaineCare Services Office of the Chief Medical Examiner 14

15. Two useful PMP reports Requested reports  Health care professionals can register with the PMP to request online patient history or prescriber history reports for their patients.  Prescribers, dispensers, licensed providers and medical office assistants (new) can register.

16. Notification (threshold) reports  Sent automatically to prescribers and dispensers  Monthly patient threshold reports  Monthly buprenorphine/narcotics concurrent usage reports  Monthly acetaminophen threshold reports

17. Examples of how prescribers are using the PMP  Summary of results from a study of the PMP conducted by the Muskie School in 2010

18.  Prescribers and pharmacists can play a key role in monitoring medication use, reducing the chance of diversion and misuse, assuring patient safety, and improving quality of care.  To do this, they need information on their patients’ medication use.  We asked health care professionals registered with the PMP about when and how they use it to improve prescribing and patient care.

19. When do prescribers use the PMP?  With new patients  With unfamiliar or unknown patients (drop ins)  With patients with suspicious behavior (aggressive or belligerent, “lost prescription,” needs emergency refill)  With patients seeking pain relievers  With patients already prescribed pain relievers or Suboxone® (to avoid potential drug-drug interactions)

20. What do they do with the information if they see a potential problem?  Counsel the patient  Discuss the patient with other health care professionals  Modify the treatment plan  Contact the police

21. Examples of steps taken to improve prescribing  Conduct substance abuse (SA) screening and brief intervention  Refer patient to a pain specialist  Establish a controlled substances agreement (“narcotics contract”) with patient  Refer the patient to an substance abuse professional  Discharge patient from the practice

22. “Best practices” to institutionalize use of the PMP Standardize use: Access the PMP for all patients meeting certain criteria, such as having a prescription for a pain reliever or suboxone This de-stigmatizes the PMP use – patients don’t feel singled out. Pre-visit planning: Access the PMP prescribing history for patients before the visit and put it in the chart, so information is available to provider during the visit

23. “Best practices” Communication: Use the PMP information to initiate conversations about possible dependency, addiction, or clinically inappropriate medication usage New patients: Compare patient’s reported medication use to PMP information, to test veracity and begin honest conversation about medication use

24. Conclusions  There is a significant prescription drug misuse problem in Maine.  The PMP is a tool to prevent and detect prescription drug abuse.  The PMP can be used to effectively enhance patient care.  EVERYONE is at risk! www.maine.gov/pmp 24

25. Contact information  PMP registration: http://www.hidinc.com/mainepmp/rxsentry-data- requester-forms.html http://www.hidinc.com/mainepmp/rxsentry-data- requester-forms.html  Patricia Lapera: patricia.lapera@maine.gov or www.maine.gov/pmp or 207-287-3363patricia.lapera@maine.gov www.maine.gov/pmp  Susan Payne: spayne@usm.maine.edu orspayne@usm.maine.edu  207-780-5104