1. Initiatives to Combat Prescription Drug Abuse in Kentucky: an Update on KASPER David R. Hopkins KASPER Program Manager Office of Inspector General Kentucky Cabinet for Health and Family Services The Different Faces of Substance Abuse January 28, 2014

2. Cabinet for Health and Family Services Contents Pill Mills KASPER Program Review House Bill 1 Preliminary Results and Evaluation

3. Pill Mills

4. Cabinet for Health and Family Services Jeff and Chris George Photos from Palm Beach Post

5. Cabinet for Health and Family Services Dr. Paul H. Volkman Story: Bill Estep, Lexington Herald-Leader, February 14, 2012. AP Photo released by U.S. Marshals Service (undated)

6. Cabinet for Health and Family Services Care More Pain Management Clinic Photo: Scott Utterback, Louisville Courier-Journal, January 25, 2012

7. Cabinet for Health and Family Services Care More Pain Management Clinic Photo: Scott Utterback, Louisville Courier-Journal, January 25, 2012

8. Cabinet for Health and Family Services Ernest William Singleton Photo: Lexington Community Corrections, January 2013

9. Cabinet for Health and Family Services Kitson Clothing Collection Story: WXIX Fox 19 Digital Media Staff, June 21, 2013

10. Cabinet for Health and Family Services Kitson Clothing Collection

11. KASPER Program Review

12. Status of Prescription Drug Monitoring Programs (PDMPs) Research is current as of February 1, 2012 AK AL AR CA CO ID ILIN IA MN MO MT NE NV ND OH OK OR TN UT WA AZ SD NM VA WY MI GA KS HI TX ME MS WI NY PA LA KY NC SC FL NH MA RI CT NJ DE MD DC VT WV Operational PDMPs Enacted PDMP legislation, but program not yet operational Legislation pending GU

13. 2011 KASPER Reports Requested Cabinet for Health and Family Services

14. KASPER Operation KASPER tracks most Schedule II – V substances dispensed in KY –Over 10 million controlled substance prescriptions reported to the system each year KASPER data is 1 to 3 days old –Dispensers have 1 business day to report Reports available to authorized individuals –Available via web typically within 15 seconds (97% of requests) –Available 24/7 from any PC with Web access

15. Annual KASPER Records Total / Per Person Cabinet for Health and Family Services 2.39 2.43 2.65 2.65 2.72 2.72 2.47 Number of Controlled Substance Prescriptions per Person

16. KASPER Reports Requested Cabinet for Health and Family Services

17. Top Prescribed Controlled Substances by Therapeutic Category by Doses - 2013 Hydrocodone 41.3% Lortab Lorcet Vicodin Alprazolam 11.2% Xanax Tramadol 6.8% Ultram Oxycodone 15.4% OxyContin Percodan Percocet Clonazepam 6.7% Klonopin Diazepam 4.3% Valium Amphetamine 3.1% Adderall Zolpidem 3.4% Ambien Testosterone 3.5% AndroGel Lorazepam 4.0% Ativan

18. 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. 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 Cabinet for Health and Family Services

19. House Bill 1 Preliminary Results and Evaluation

20. Cabinet for Health and Family Services Controlled Substance Dispensing – One Year Comparison DrugAugust 2011 through July 2012 August 2012 through July 2013 Change Hydrocodone 239,037,354 214,349,392 -10.3% Oxycodone 87,090,503 77,022,586 -11.6% Oxymorphone 1,753,231 1,138,817 - 35.0% Alprazolam 71,669,411 62,088,568 -13.4% Methylphenidate 10,659,840 11,454,025 + 7.5% Amphetamine 13,795,147 15,065,833 + 9.2% All Controlled Substances 739,263,679 676,303,581 -8.5% Figures shown in doses dispensed

21. Cabinet for Health and Family Services Hydrocodone

22. Cabinet for Health and Family Services Oxycodone

23. Cabinet for Health and Family Services Alprazolam

24. Cabinet for Health and Family Services Methadone

25. Cabinet for Health and Family Services Oxymorphone

26. Cabinet for Health and Family Services Tramadol

27. Cabinet for Health and Family Services Buprenorphine

28. Cabinet for Health and Family Services Controlled Substance Prescribing 2013

29. Cabinet for Health and Family Services Controlled Substance Usage 2013

30. Cabinet for Health and Family Services House Bill 1 Impact Study Comprehensive assessment of HB1’s impact on patients, prescribers, and other stakeholders Overall goals: –Evaluate the impact of HB1 on reducing prescription drug abuse and diversion in Kentucky –Identify unintended consequences associated with implementation of HB1 that impact patients, providers and citizens of the Commonwealth –Develop recommendations to improve effectiveness of HB1 and mitigate identified unintended consequences Final study report planned for July 2014

32. Kentucky Pharmacists Non-KY Pharmacists

33. Kentucky

34. Stakeholder interviews were conducted to inform the development of a KASPER registrant survey instrument –Board of Pharmacy –Board of Nursing –Board of Medical Licensure –Board of Dentistry –Kentucky Coalition of Nurse Practitioners and Nurse Midwives –Kentucky Dental Association –Kentucky Pharmacists Association –Kentucky Medical Association –Operation UNITE –National Association Drug Diversion Investigators (NADDI) –Medicaid, Office of Inspector General –Kentucky Sheriff’s Association –Kentucky Narcotic Officers Association

35. Initiatives to Combat Prescription Drug Abuse in Kentucky: an Update on KASPER Van Ingram Executive Director Office of Drug Control Policy Kentucky Justice and Public Safety Cabinet The Different Faces of Substance Abuse January 28, 2014

36. Contents Legislative Update 2013 National Survey on Drug Use and Health HB1 Provider Training Kentucky Overdose Data Justice & Public Safety Cabinet

37. Legislative Update

38. HB 1 – Pain Management Facilities Physician ownership requirement on all pain management facilities (PMF) Exception for those health facilities operating as a PMF on April 24, 2012 No sanctions or convictions imposed on facility or employees Justice & Public Safety Cabinet

39. PMF Oversight KBML responsible for licensure standards for physician-owned pain management facilities. OIG, Division of Health Care is responsible for licensure standards for existing pain management facilities that qualify for the physician-ownership exemption of HB 1. Justice & Public Safety Cabinet

40. Non-Physician Owned PMFs Justice & Public Safety Cabinet 29 non-physician owned PMFs were identified April 24, 2012 (HB1 passage date) 8 closed prior July 20, 2012 (HB1 effective date) 12 closed after the HB1 effective date 2 illegal or non-physician owned PMFs discovered after HB 1 effective date 4 PMFs were sent cease and desist letters 7 PMFs are being reviewed for compliance and certification by the Cabinet for Health and Family Services

41. KASPER Reporting KRS 218A.202 Controlled substance administration or dispensing must be reported within one day effective July 1, 2013 Justice & Public Safety Cabinet

42. KASPER Accounts – KRS 218A.202 KASPER registration is mandatory for Kentucky practitioners or pharmacists authorized to prescribe or dispense controlled substances to humans. Justice & Public Safety Cabinet

43. 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 Justice & Public Safety Cabinet

44. KASPER Regulations – Licensure Boards 201 KAR 5:130 –Kentucky Board of Optometric Examiners KASPER requirements 201 KAR 8:532 –Kentucky Board of Dentistry KASPER requirements 201 KAR 9:230, 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. Justice & Public Safety Cabinet

45. KASPER Institutional Accounts - KRS 218A.202 Hospitals and long term care facilities can establish “facility” KASPER accounts –eKASPER institutional master account established by Chief Medical Officer or designated employee –If no CMO, a designated physician employee may create master account –79 institutional master accounts currently established Justice & Public Safety Cabinet

46. KASPER Prescriber Reports – KRS 218A.202 CS prescribers can obtain a KASPER report on themselves: –To review and assess the individual prescribing patterns –To determine the accuracy and completeness of information contained in KASPER –To identify fraudulent prescriptions Justice & Public Safety Cabinet

47. Providing Reports to Patients – KRS 218A.202 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 Justice & Public Safety Cabinet

48. Federal Actions - Hydrocodone Hydrocodone combination products to be rescheduled from CIII to CII –Approved by FDA –Pending recommendation to HHS and approval by HHS and DEA FDA approved CII pure hydrocodone product –Zohydro tm ER manufactured by Zogenix, Inc. –Available 1Q 2014 –Not abuse-resistant formulation Justice & Public Safety Cabinet

49. National Survey on Drug Use and Health January 8, 2013

50. NATIONAL TRENDS States with Rates between 5.33 and 6.37 1 Oregon 6.37 5.25-7.71 2 Colorado 6.00 4.96-7.24 3 Washington 5.75 4.76-6.92 4 Idaho 5.73 4.74-6.91 5 Indiana 5.68 4.68-6.89 6 Arizona 5.66 4.60-6.94 7 Nevada 5.62 4.57-6.89 8 Delaware 5.61 4.61-6.82 9 Arkansas 5.55 4.60-6.68 10 New Mexico 5.45 4.47-6.64 Justice & Public Safety Cabinet

51. States with Rates between 4.80 and 5.32 11 Alaska 5.32 4.41-6.42 12 Oklahoma 5.19 4.26-6.30 13Rhode Island 5.18 4.26-6.27 14 Vermont 5.13 4.24-6.19 15 Michigan 5.11 4.57-5.72 16 Ohio 5.00 4.49-5.56 17 Tennessee 5.00 4.14-6.02 18 Louisiana 4.87 4.09-5.80 19 Montana 4.84 4.02-5.80 20 Missouri 4.83 4.03-5.78 NATIONAL TRENDS Justice & Public Safety Cabinet

52. States with Rates between 4.46 and 4.79 21 West Virginia 4.79 3.97-5.75 22 California 4.68 4.13-5.30 23District of Columbia 4.68 3.79-5.76 24 Wyoming 4.68 3.85-5.68 25 South Carolina 4.62 3.81-5.59 26 Virginia 4.60 3.79-5.58 27 Minnesota 4.57 3.79-5.49 28 New Hampshire 4.57 3.77-5.53 29 Kansas 4.56 3.77-5.50 30 Wisconsin 4.51 3.68-5.52 31 Kentucky 4.48 3.70-5.41 NATIONAL TRENDS Justice & Public Safety Cabinet

53. Among persons aged 18 to 25, the rates of past year nonmedical use of pain relievers declined in 14 states: Florida, Kentucky, Louisiana, Maine, Massachusetts, Michigan, New Hampshire, New York, Ohio, Oklahoma, Rhode Island, Texas, Utah, and West Virginia. NATIONAL TRENDS Justice & Public Safety Cabinet

54. HB1 Provider Training

55.  ODCP, OPERATION UNITE and KENTUCKY COALITION OF NURSE PRACTITIONERS/NURSE MIDWIVES HAVE SPONSORED 4 TRAININGS HB 1 TRAININGS Justice & Public Safety Cabinet

56. Overview of HB1 and Regulations C. Lloyd Vest, JD How to Recognize Drug Abuse and Dependence in Patients Gregory Jones, MD How to Discuss Drug Issues with a Patient Gregory Jones, MD An Update on KASPER - Post House Bill 1 David Hopkins Opioid Therapy: Risks vs. Rewards Gregory Jones, MD HB 1 TRAININGS Justice & Public Safety Cabinet

57. MOREHEAD 119 TRAINEES 83 PRESCRIBERS PAINTSVILLE 147 TRAINEES 55 PRESCRIBERS BOWLING GREEN 239 TRAINEES 170 PRESCRIBERS MANCHESTER 110 TRAINEES 80 PRESCRIBERS HB 1 TRAININGS Justice & Public Safety Cabinet

58.  615 TOTAL TRAINEES  388 PRESCRIBERS  AVAILABLE ONLINE  MEETS LICENSING BOARDS REQUIREMENTS HB 1 TRAININGS Justice & Public Safety Cabinet

59. HB 1 TRAININGS Justice & Public Safety Cabinet

60. The Good, Bad, and Ugly of Addiction Justice & Public Safety Cabinet

61. Kentucky Overdose Data

62.  1004 OVERDOSE FATALATIES IN 2012  19 FEWER THAN 2011. THE FIRST DECLINE IN OVER A DEACDE 888 UNINTENTIONAL 59 SUICIDES 57 UNDETERMINED 2012 OVERDOSE DATA Justice & Public Safety Cabinet

63.  LARGEST INCREASE CAMPBELL COUNTY. FROM 25 IN 2011 TO 54 IN 2012  LARGEST DECREASE, FLOYD COUNTY WITH 23 FEWER DEATHS IN 2012 THAN 2011  MOST PER 100,000 LESLIE COUNTY WITH RATE OF 85 PER 100,000 2012 OVERDOSE DATA Justice & Public Safety Cabinet

64.  DEATHS ATTRIBUTABLE TO HEROIN ROSE 550%  ALPROZOLAM MOST DETECTED SUBSTANCE AT 41.44% OF ALL MEDICAL EXAMINER CASES 2012 OVERDOSE DATA Justice & Public Safety Cabinet

65.  YOUNGEST OD DEATH AGE 16  OLDEST 72  AVERAGE AGE 40  MALE 58%  FEMALE 42% 2012 OVERDOSE DATA Justice & Public Safety Cabinet

66. FIRST 3 QUARTERS OF 2013  639 TOTAL OVERDOSE DEATHS REPORTED DURING three quarters OF 2013  170 OR 26% HAVE HEROIN IN THE TOXICOLOGY REPORT  OVERWHELMING MAJORITY POLY DRUG Cabinet for Health and Family Services

67. 2013  JEFFERSON 94  FAYETTE 26  KENTON 26  BOONE 20  CAMPBELL 8  FRANKLIN 5  17 COUNTIES 1 or 2  97 COUNTIES NONE Cabinet for Health and Family Services

68. HEROIN Cabinet for Health and Family Services

69. HEROIN Cabinet for Health and Family Services

70. HOW DID WE GET HERE?  LONG HISTORY OF OPIOD/PAINKILLER ABUSE  INCREASING NUMBERS OF IV DRUG USAGE  ABUSE DETERRANT FORMULATIONS  CRACKDOWN ON ROUGUE PAIN CLINICS  GREATER AWARENESS FROM PRESCRIBERS  ESTABLISHED DRUG CARTELS RECOGNIZING DEMAND Cabinet for Health and Family Services

71. HOW DID WE GET HERE? PRICE AVAILABILITY PERCEPTION OF RISK PUBLIC ATTITUDES Cabinet for Health and Family Services

72. HOW DO WE ADDRESS IT?  PUBLIC EDUCATION  INCREASED ACCESS TO TREATMENT  ENHANCED PENALTIES FOR MAJOR TRAFFICKERS  GREATER ACCESS TO NALOXONE Cabinet for Health and Family Services

73. Van Ingram Kentucky Justice and Public Safety Cabinet 125 Holmes Street Frankfort, KY 40601 502-564-8291 Van.Ingram@ky.gov David Hopkins Kentucky Cabinet for Health and Family Services 275 East Main Street, 5ED Frankfort, KY 40621 502-564-2815 ext. 3333 Dave.Hopkins@ky.gov