1. An Integrative and Intuitive Map to an Investigation Prescription Monitoring Programs:

2. Objectives Following this presentation, you will… Identify issues with overuse, misuse, and abuse of controlled substances Analyze the PDMP Integrate PDMP data with healthcare records Recognize the limitations of the PDMP

3. Why Do We Care? Opioids are the most widely misused or abused Rx and are involved in most Rx related overdoses In 2009, non medical users of psychotherapeutics (prescription opioid pain relievers, tranquilizers, sedatives, and stimulants) were similar to #s of 1 st time Marijuana users Office of National Drug Control Policy. (2011) Retrieved from https://www.whitehouse.gov/ondcp/ondcp-fact-sheets/prescription-drug- monitoring-programs

4. Why Do We Care? In 2010, 6 of the top 10 substances used by 12 th graders were pharmaceuticals In 17 states drug-induced deaths are now the leading cause of injury death https://www.whitehouse.gov/sites/default/files/ondcp/Fact_Sheets/pdmp_fact_sheet_4-8- 11.pdf

6. Why Do We Care? In 2013 ~ 2 Million Americans abused Rx pain meds Most common drugs in overdose deaths include: Hydrocodone (e.g. Vicodin) Oxycodone (e.g. OxyContin, Percocet) Oxymorphone (e.g. Opana) Methadone (especially when prescribed for pain) Between 1997 -2007 treatment admissions for overdose increased 4 fold.

7. Statistics 70% of people who abused prescription pain relievers got them from friends or relatives Data from the National Survey on Drug Use and Health show that nearly 1/3 of people aged 12 and over who used drugs for the first time in 2009, began using a prescription drug non-medically http://www.whitehouse.gov/ondcp/prescription-drug-abuse http://www.whitehouse.gov/ondcp/prescription-drug-abuse Each day, almost 7,000 people are treated in the ER for RX overdose

8. Nationwide… Approximately 15,000 people died every year from overdoses involving prescription pain killers, more than those who die from heroin and cocaine combined. Center for Disease Control and prevention (2013). Prescription Painkiller Overdoses in the U.S. Retrieved from http://www.cdc.gov/Features/VitalSigns/PainkillerOverdoses/inde x.html 15,000 died in 2008 – more than triple the 4,000 people killed by prescription drugs in 1999 Center for Disease Control and prevention (2013). Prescription Painkiller Overdoses in the U.S. Retrieved from http://www.cdc.gov/Features/VitalSigns/PainkillerOverdoses/inde x.html

10. Why Do We (as regulators) Care? Healthcare provider with active/untreated substance abuse disorder (SUD) puts patients at risk Reckless prescribing to persons with SUD or sell/provide the drugs to others puts the public at risk

11. Street Value Oxycodone 30mg = $30/each Percocet = $1 per mg OxyContin 80mg = $80/each Methadone = $5 - $10/each Hydrocodone (Vicodin) = $3 - $10/each

12. PDMP - What is it? Prescription Drug Monitoring Programs (PDMP) Controlled Substance Utilization Review and Evaluation System (CURES) Prescription Monitoring Program (PMP) Controlled Substance Prescription Monitoring Program (CSPMP) Controlled Substance Database Program (CSD) Michigan Automated Prescription System (MAPS) Kentucky All Schedule Prescription Electronic Reporting (KASPER)

13. Who Uses the PDMP? Statutory authority Originally developed for law enforcement to identify patterns of misuse, diversion, or excessive prescribing Prescribers Regulators Pharmacists Training Credentials Registration Tutorial

14. Identify how to access the PDMP

15. Authorized Recipients – Licensing/Regulatory Boards © 2015 Research is current as of December 2014. In order to ensure that the information contained herein is as current as possible, research is conducted using both nationwide legal database software and individual state legislative websites and direct communications with state PMP administrators. Please contact Heather Gray at (703) 836-6100, ext. 114 or hgray@namsdl.org with any additional updates or information that may be relevant to this document. This document is intended for educational purposes only and does not constitute legal advice or opinion. Headquarters Office: THE NATIONAL ALLIANCE FOR MODEL STATE DRUG LAWS, 420 Park Street, Charlottesville, VA 22902.

18. Morphine Equivalency Dosing (MED) System to equate different opiates and potencies into a standard morphine equivalent value Conversion chart created by Center for Disease Control (CDC) For each ACTIVE prescription then combined into one daily MED value “Press Pause” at 100 MED

19. Analyze the PDMP

20. How to use the PDMP? Must have a NEXUS to the case For the Respondent who is a patient (Respondent’s prescription profile) Unusual behavior/impaired/DUI For the Respondent who is a provider Prescribing concerns The PDMP is a TOOL used to address prescription drug diversion, misuse, and abuse. Doctor shopping Patterns of inappropriate prescribing

21. Analyzing the PDMP Red Flags for Patient Investigation Multiple pharmacies Multiple providers Escalating dosages Multiple address Similar birthdates Pattern of early refills Cash pay Volume and dose Street value? Multiple substances Oxycodone 30mg Back pain?

22. New And Old OxyContin Pills 80-milligram tablets of the current OxyContin formula (left) and the previous OxyContin formula (right)

23. Old vs. New The pre-2010 OxyContin pill crushes into grains (left) while the newer formula is more difficult to break up (right).

24. Analyzing the PDMP Red Flags for Prescriber Investigation Multiple pharmacies Multiple providers Escalating dosages Early refills High dosages high volumes Family members of patient or provider Same med – Oxycontin 30mg “Pill mill”

25. Integrate PDMP data with healthcare records

26. Integrate PDMP Data with Healthcare Records Personal Characteristics of Patient Prescription not consistent with diagnostic evidence Doctor hopping Different names with same address Family members getting same drug UDS not consistent with prescriptions Excuses for lost/stolen prescriptions Early refills Ping ponging between drugs Request for specific meds/higher doses

27. Personal Characteristics of Patient Employment issues: “Documentation” errors Frequent absences ER/ICU (frequent and high drug usage) Nights/weekends/overtime DUI Legal issues What type of providers are they seeing? Are they impaired? Or do they have other medical issues?

28. Integrate PDMP Data with Healthcare Records Characteristics of Prescriber Investigation Replacement Rx Sloppy documentation/template High pain pt population (not consistent with specialty) High daily pt volume Communication with other providers? Response to PMP unexpected findings UDS and results

29. Personal Characteristics of Provider Characteristics of Prescriber Investigation Lack of Knowledge ? Or Misuse/Abuse and/or Sale? Pain agreement Consistent with national guidelines Cash visits Same drug over and over Law enforcement and DEA interest Consistent with genuine medical office (no sign out front, voice mail only)

30. Standard of Care Standard of Care # 1 Prescribing Long-Term Opioid Medications: Prior to prescribing long-term opioid medications for chronic non-malignant pain, it is standard of care for an NP to conduct an appropriate evaluation of the pain problem and identify the pain generator. This evaluation includes the NP taking a pain history, reviewing the patient’s medical records, conducting a targeted physical exam, taking a drug history including verification of current prescriptions, and considering concomitant medical/psychiatric problems that may impact pain management. Each patient’s treatment plan should be individualized, and include consideration of a multidisciplinary approach/collaboration with other medical experts, as appropriate

31. Standard of Care Deviation of Standard of Care #1 From on or about xxxxxx through xxxxx Respondent treated patient XX for Chronic pain with long-term opioid medications. The medical record fails to demonstrate that Respondent conducted an appropriate evaluation of the pain problem, which identified the pain generator. This medical record lacks evidence that Respondent took a pain history, reviewed the patient’s medical records, or conducted a targeted physical exam…

32. Standard of Care Standard of Care # 2 Periodic Urine Drug Screening Evaluation of the chronic pain patient should include periodic urine drug screen testing to detect the presence of the prescribed medications and presence of illegal or illicit substances.

33. Understand how to use the PDMP

34. How to use the PDMP Identify Nexus Remember it is just a tool in the investigation to find supporting evidence Identify concerning prescribing patterns Obtain a copy of original prescription with provider signature

35. Compare signatures Verify quantities Verify the medication was actually picked up Request medical records Request prescription profiles from pharmacy/insurance Compare PDMP to medical record

36. How to use the PDMP PMP During an Interview with prescriber “What is your practice when prescribing…” Step dosing, quantities, combinations If deviation, show PMP REMEMBER THE PMP IS JUST A TOOL

37. How to use the PDMP PMP During an Interview with Patient What medications have been prescribed to you and by who? How often? How many providers? What for? Show patient PMP if the story doesn’t fit REMEMBER THE PMP IS JUST A TOOL

38. Recognize the limitations of the PDMP

39. Who contributes and who does not Dispensing from office Federal facilities Methadone clinics Federal healthcare facilities (e.g. Department of Veterans Affairs, Department of Defense, and Indian Health Service) are not required and do not generally report to state PDMPs

40. Recognize the limitations of the PDMP Human error Illegible prescriber name ? Correct prescriber “Date filled” Up to a 2-week lag in data entry State Borders

42. Summary Putting the pieces together Identify issues with overuse, misuse, and abuse of controlled substances Analyze the PDMP Integrate PDMP data with healthcare records Recognize the limitations of the PDMP

43. Questions? Comments? Janeen Dahn PhD, FNP-C email: Jdahn@azbn.gov