1. Atlanta
Marrio+
Marquis
Atlanta,
Georgia
April
22,
2014

2. Disclosure
Statements
 Mike
Small
has
disclosed
no
relevant,
real
or
apparent
personal
or
professional
financial
rela3onships.
 Tina
Kim
has
disclosed
no
relevant,
real
or
apparent
personal
or
professional
financial
rela3onships.
 Roneet
Lev
has
disclosed
no
relevant,
real
or
apparent
personal
or
professional
financial
rela3onships.
 Patrick
Zarate
has
disclosed
no
relevant,
real
or
apparent
personal
or
professional
financial
rela3onships.

3. Learning
ObjecGves
1. Explain
how
using
PDMP
data
can
develop
a
Rx
drug
abuse
program
strategy
2. Outline
strategies
in
unifying
emergency
departments
under
uniform
controlled
substance
Rx
prescribing
protocols
3. Demonstrate
how
a
state
PDMP
can
partner
with
cri3cal
local
efforts
to
reduce
Rx
drug
overdose
deaths.

4. Tina
Kim,
Ph.D.
Los
Angeles
County
Department
of
Public
Health

5. In
Los
Angeles
County…
 Drug
overdose
is
the
2nd
leading
cause
of
injury-­‐related
death
 1
out
of
20
adults
and
1
out
5
teens
misuse
prescrip3on
drugs
 Rx
drug
abuse
cause:
500+
Deaths
1200
+
Treatment
Admissions
3000
+
HospitalizaGons
5000
+
Emergency
Department
Visits

6. PrescripGon
Drugs
Filled
in
LAC,
2012
(Scheduled
II-­‐IV)
OTHER,
4.2
HORMONES
3.2
MUSCLE
RELAXANTS
1.9
STIMULANTS
6.6
SEDATIVES
40.3
HYDROCODONE
67.0
OXYCODONE
10.9
CODEINE
10.6
MORPHINE3.9
FENTANYL
2.1
OTHER
5.6
OPIOIDS
43.9
(N
=
9,763,887)

7. ~27%
of
Prescribers
wrote
95%
of
prescripGons
(Scheduled
II-­‐IV)
37.0%
0.5%
36.4%
4.5%
20.0%
27.1%
6.6%
68.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Prescribers
PrescripGons
Very
Frequent
Prescribers
500-­‐17,019
Rx/Year
Frequent
Prescribers
50-­‐499
Rx/Year
Occasional
Prescribers
4-­‐49
Rx/Year
Rare
Prescribers
1-­‐3
Rx/Year
26.6%
95%

8. Doctor
Shopping
 Defined
as
paGents
who
received
prescripGon
opioids
from
at
least
4
prescribers
AND
at
least
4
pharmacies
in
2012

9. CURES/PDMP
Data
for
Opioid
PrescripGons
in
2002
 4,142,662
million
prescrip3ons
filled
 1,533,099
million
unique
pa3ents
 55,819
unique
prescribers
 4,621
unique
pharmacies
5,153 (0.3%) patients were identified as
doctor shoppers.

10. Gender
Difference
42.0%
41.9%
58.0%
58.1%
0%
10%
20%
30%
40%
50%
60%
70%
Doctor
Shoppers
Non-­‐Doctor
Shoppers
Male
Female

11. Age
Difference
0%
5%
10%
15%
20%
25%
30%
≤17
years
18-­‐24
years
25-­‐34
years
35-­‐44
years
45-­‐54
years
55-­‐64
years
≥65
years
Doctor
Shoppers
Non-­‐Doctor
Shoppers

12. Payment
Method
50%
15%
8%
3%
24%
52%
14%
8%
3%
24%
0%
10%
20%
30%
40%
50%
60%
Commercial
Insurance
Private
Pay
Medicare
Medicaid
Other/Unknown
Doctor
Shopper
Non-­‐Doctor
Shopper

13. Short-­‐acGng
vs
Long-­‐acGng
88.6%
11.4%
91.4%
8.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Short-­‐Ac3ng
Long-­‐Ac3ng
Doctor
Shopper
Non-­‐Doctor
Shopper

14. Morphine
Equivalent
Dose
per
Day
86.7%
13.3%
89.9%
10.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
≤
100
MED
per
Day
>
100
MED
per
Day
Doctor
Shopper
Non-­‐Doctor
Shopper

15. Top
Opioid
Prescribed
64%
14%
6%
5%
4%
3%
67%
10%
11%
3%
2%
2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Hydrocodone
Oxycodone
Codeine
Morphine
Hydromorphone
Fentanyl
Doctor
Shopper
Non-­‐Doctor
Shopper

16. Opioid
PrescripGons
per
PaGent
Per
PaGent
Doctor
Shoppers
Non-­‐doctor
Shoppers
Number
of
Pills
1017.9
159.6
Number
of
PrescripGons
15.6
2.7
Days
of
Supply
239.8
40.2
Morphine
Equivalent
Doses
(MED)
946.2
157.3

17. Extreme
Cases
of
Opioid
PrescripGons
PaGent
with…
Value
Gender
Age
Highest
number
of
opioid
prescripGons
203
Male
44
Highest
number
of
prescribers
79
Male
Female
48
40
Highest
number
of
pharmacies
32
Male
33
Highest
number
of
opioid
pills
30,000
Unknown
13
Highest
opioid
dosage
per
day
(MED)
157,377
Unknown
13

18. Doctor
Shoppers
in
LAC…
 Doctor
Shoppers
are
more
common
among:
– Females
– Residents
aged
35-­‐64
years
 Compared
to
non-­‐doctor
shoppers,
doctor
shoppers
are
more
likely
to:
– Pay
for
their
opioids
with
private
pay
– Use
long-­‐ac3ng
opioids
– Use
higher
drug
dosages
(MED
>
100)
– Use
oxycodone,
morphine,
and
hydromorphone
– Obtain
a
significantly
greater
number
of
pills
and
prescrip3ons
and
longer
days
of
supply

19. To
Reduce
Doctor
Shopping/Over-­‐
Prescribing
in
LAC…

Promote
CURES/PDMP
enrollment
and
u3liza3on
 Send
out
Rx
for
Preven3on
ar3cles
to
physicians
 Con3nuing
Medical
Educa3on
Courses

Develop
standards
on
opioid
use
in
Eds
 LAC
Prescrip3on
Drug
Abuse
Medical
Task
Force
 Explore
policy
op3ons
to
become
an
authorized
user
of
iden3fied
CURES
data
 Send
out
e-­‐mail
alerts
who
are
over-­‐prescribing
or
have
a
high
number
of
doctor
shopping
pa3ents

21. Prescription
Drug Abuse
Roneet Lev, MD FACEP
Providers Need Drug Rehab
Before They Can Lead Our Nation
Into Recovery

22. PDA TF
and
PDA Medical Task Force

23. PDA Report Card

24. San Diego CURES Report

25. EMERGENCY
and
URGENT CARE
GUIDELINES

26. PAIN
AGREEMENT
– For
Chronic
Pain
=
3
months
of
short
ac3ng
or
anyone
requiring
long
ac3ng
opioids
– Only
1
provider
and
1
pharmacy
– No
ED
visit
– No
refills
– Do
not
drive
if
impaired
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'

27. PDMP
Makes
You a
Better
Doctor
Generated by CamScanner

28. Sandiegosafeprescribing.org
6 FEBRUARY 2014
(858) 673-6100
Melissa N. Kagnoff, MD
Neurology
Cardiff by the Sea
(619) 582-2595
Brian W. Meyerhoff, MD
Internal Medicine
Escondido
(760) 745-1551
(760) 745-1551
Ryan B. Viets, MD
Diagnostic Radiology
La Mesa
(619) 460-2770
Escondido
(760) 745-1551
Emmet W. Lee, MD
Internal Medicine
Escondido
(760) 745-1551
www.SanDiegoSafePrescribing.org
The No. 1 cause of unintentional deaths in San Diego County is from drugs,
with almost one person a day dying in our county from this preventable cause.
The San Diego and Imperial County Prescription Drug Abuse Medical Task
Force is a coalition of medical leaders who have joined efforts to reduce deaths
andaddictionduetoprescriptiondrugs.Thetaskforceincludespainspecialists,
internal medicine physicians, emergency physicians, psychiatrists, dentists,
pharmacists, hospital administrators, health department administrators, and
our local DEA. The task force also includes broad health partners, including
Kaiser Permanente, Scripps Health, Sharp HealthCare, UC San Diego
Health System, Palomar Health, and the Community Clinics. The task force
encourages all medical practitioners to use the materials provided at www.
SanDiegoSafePrescribing.org to improve patient care.
SDCMS features m
physicians for their
accomplishments i
pages. If you would
be considered for o
“Featured Member
please email Editor
org. Thank you for
membership in SD
CMA!
Becomean
SDCMSFea
Member!
California: A T
for Physicians
ON JAN. 1, 2014, Californ
exchange,CoveredCaliforni
healthcoveragetomorethan
statewide.Withthatfiguree
theendofthe2014openenro
iscriticalthatphysiciansand
whattoexpect.Tothatend,
MedicalAssociation(CMA)h
sheet,“SurvivingtheSecond
California,”availablefreeto
members.Toreceivethistip
canemailMembership@SDC

31. DATA SUPPORTING ACTION – VENTURA COUNTY
PORTING ACTION – VENTURA COUNTY
data
suppor3ng
ac3on
–
Ventura
county
DATA SUPPORTING ACTION – VENTURA COUNTY
Selected Data Sources – mobilizing LOCAL action
• State PDMP: C.U.R.E.S. data ongoing
• State California Healthy Kids Survey bi-annual
• Local Medical Examiner/Coroner annual update
• Local Adolescent Treatment survey new/unique
• Local Jail Inmate survey new/unique

32. DATA SUPPORTING ACTION – VENTURA COUNTY
PORTING ACTION – VENTURA COUNTY
data
suppor3ng
ac3on
–
Ventura
county
VENTURA’S RX DRUG ABUSE WORKGROUP
Convened in early 2012, including
Alcohol and Drug Programs (ADP)
Public Health Department
Sheriff’s Department
County Office of Education
County Health Care Agency/Ambulatory Care
Subject Matter Experts by invitation
Focused on nature and scope of the LOCAL problems
KEY: Membership rank- can speak for their agencies

33. DATA SUPPORTING ACTION – VENTURA COUNTY
PORTING ACTION – VENTURA COUNTY
data
suppor3ng
ac3on
–
Ventura
county
DATA-INFORMED STRATEGIES
1. LOCAL MATTERS! – data speak to your needs,
and community direction
2. USE MULTIPLE INDICATORS – use PDMP and
other sources; see our “Ventura County
Responds” report
3. PARTNERSHIP MAKES THINGS POSSIBLE –
examples: custom survey administration in jails;
data sharing agreements, “mining” existing data

35. TARGETS FOR ACTION

36. Rx & HEROIN ABUSE: Ventura County RESPONDS
TARGET 1: PROFESSIONAL DEVELOPMENT
GOAL: Expand professional training and development
opportunities across all sectors.

37. Rx & HEROIN ABUSE: Ventura County RESPONDS
GOAL: Expand professional training and development
opportunities across all sectors.
ACTIONS
1.1 Prescriber Training
Problem: Low utilization of PDMP among prescribers locally.
Local Action: Training for Health Professionals (DDS, RN, MD)
Case Example: Elinore McCance-Katz, MD, PhD, Chief Medical
Officer, Substance Abuse and Mental Health Services
Administration (SAMHSA), presented one of the first in a projected
series of health care professional trainings, What Every Prescriber
Should Know About Addiction to Pain Medicines.

38. Rx & HEROIN ABUSE: Ventura County RESPONDS
GOAL: Expand professional training and development
opportunities across all sectors.
ACTIONS
1.1 Prescriber Training (cont’d.)
Problem: Limited opportunities for facilitated enrollment in CURES
Local Action: C.M.E. events, Grand Rounds, physician registration
Case Example: Medical Director for Behavioral Health hosting
medical education with emphasis on importance of CURES, and
‘value added’ opportunity for real-time registration by attendees

39. Rx & HEROIN ABUSE: Ventura County RESPONDS
GOAL: Expand professional training and development
opportunities across all sectors.
“Health care professionals who prescribe...are in a key
position to balance the benefits of prescribing opioid
analgesics to treat pain against the risks of serious
adverse outcomes including addiction, unintentional
overdose, and death. Opioid misuse and abuse, resulting
in injury and death, has emerged as a major public health
problem. Appropriate prescribing practices and patient
education are important steps to help address this public
health problem.”
– FDA Blueprint for Prescriber Education, 2013
In Ventura County, we believe LOCAL ACTION matters…

40. Rx & HEROIN ABUSE: Ventura County RESPONDS
GOAL: Expand professional training and development
opportunities across all sectors.
TARGET 2: ENFORCEMENT & SECURITY
GOAL: Support law enforcement, monitoring and
security to enhance public safety by deterring
drug misuse, abuse and diversion.

41. Rx & HEROIN ABUSE: Ventura County RESPONDS
ACTIONS
2.1 Safe and Secure Rx Disposal
Safe and confidential Rx disposal bins
now actively used and supported by law
enforcement in all 10 cities across the
county.
Board Supervisors raised local standard
by unanimously declaring Every Day is
Take Back Day in Ventura County.

42. Rx & HEROIN ABUSE: Ventura County RESPONDS
Ventura County Board of Supervisors
declaration: Every Day is Take Back Day

43. Rx & HEROIN ABUSE: Ventura County RESPONDS
2.3 Ventura County Interagency Pharmaceutical Crimes Unit
Problem: Illegal prescribing of Rx opioids at the local level
Local Action: Established Pharmaceutical Crimes Task Force, Ventura
County Sheriff’s Office (VCSO), the Ventura County Pharmaceutical
Crimes Unit includes members of law enforcement from VCSO, Simi
Valley PD, DA’s Office, others.
Case Example: The main mission of the task force is combating the
transfer of legal medication to the illegal market.
* Fifty-four arrests were made in the first six months
* 120,000 pharmaceutical pills seized
* CURES records important to several recent MD investigations
* 49 search warrants to date, with $1.5 million in assets seized, 12 guns

44. TARGETS FOR ACTION
PDMP value begins with prescriber policies, and grows
local and even regional inter-agency cooperation.
“The Ventura County Interagency Pharmaceutical Crimes
Unit, in conjunction with LA County Health Authority Law
Enforcement Task Force (HALT) and the California Medical
Board, concluded five month investigation into a “pill mill”.
Detectives learned of this criminally operating medical clinic
through a tip from a local Simi Valley pharmacist. The had
previously contacted every pharmacy in Ventura County
during the Summer of 2013 and made them aware of the
task force.”
One Case: Doctor Shopping, MDs at clinic investigated,
3,000+ scripts written in name of 1 doc, 5 arrests

45. Rx & HEROIN ABUSE: Ventura County RESPONDS
GOAL: Expand professional training and development
opportunities across all sectors.
GOAL: Support law enforcement, monitoring and
security to enhance public safety by deterring
drug misuse, abuse and diversion.
TARGET 3: EDUCATION & AWARENESS
GOAL: Increase outreach and education for
parents, patients and the public to raise
awareness of prescription drug and heroin
abuse problems and solutions.

46. Rx & HEROIN ABUSE: Ventura County RESPONDS
GOAL: Expand professional training and development
opportunities across all sectors.
3.2 Drug Disposal Campaign
A multimedia campaign on the
importance of safe and secure drug
disposal was directed to the public
from a variety of angles, including a
billboard on CA Highway 33,
newspaper and radio ads, medicine
chest reminder magnets, clinic
posters and brochures. Concurrent
outreach
to real estate professionals warned
of the risks of medicine chest thefts
during open houses.

47. Rx & HEROIN ABUSE: Ventura County RESPONDS
GOAL: Expand professional training and development
opportunities across all sectors.
3.4 Ventura County’s Rx Drug Abuse Summit
More than 240 local treatment and prevention professionals,
healthcare experts, law enforcement, policymakers and other
key stakeholders learned about CURES and local strategies.

48. Rx & HEROIN ABUSE: Ventura County RESPONDS
TARGET 4: SAFE SCHOOLS
GOAL: Collaborate with schools, PTAs and Ventura
County Office of Education (VCOE) to increase
communication channels and prevention
opportunities for teachers, parents, students
and school personnel.

49. Rx & HEROIN ABUSE: Ventura County RESPONDS
4.2 Teacher Education
Teachers are vital for educating
students about substance abuse.
A “Working Together” insert was
developed especially for
teachers as a companion to the
“What You Need to Know About
Rx Abuse and Heroin” brochure.
The materials help teachers
deliver concise prevention
messaging to students at the
most teachable moments.

50. Rx & HEROIN ABUSE: Ventura County RESPONDS
4.4 Systematic School-based Data Collection
The data collected from youth through surveys administered in schools
provides invaluable information for effective collaborative prevention
efforts. The Rx Workgroup will continue support of systematic school-
based data collection and reporting, like the California Healthy Kids
Survey, to gauge the prevalence of prescription drug misuse and heroin
abuse among students in Ventura County.
LIFETIME USE BY VENTURA COUNTY STUDENTS:
• 14% of 9th graders and 20% of 11th graders reported misusing
Rx painkillers
• 4% of 9th graders and 5% of 11th graders reported using heroin
— California Healthy Kids Survey, Ventura County 2011–2012

51. Rx & HEROIN ABUSE: Ventura County RESPONDS
TARGET 5: PREVENTION POLICY & RESEARCH
GOAL: Expand Advance continued research and
data analysis to develop key policy actions
addressing Rx and heroin abuse.

52. Rx & HEROIN ABUSE: Ventura County RESPONDS
5.1 Tracking Local Data
To better understand the prevalence and impacts of prescription
drug and heroin abuse in Ventura County, relevant multiagency
data from 2008 through 2012 were collected and analyzed. By
developing an established baseline, the Rx Workgroup was able
to create a tracking tool for ongoing monitoring, analysis and
shared reporting of abuse trends over time.
CURES data, in combination with local data, are now being
used to: plan educational interventions, measure progress
and plan new Targets for Action.

53. Rx & HEROIN ABUSE: Ventura County RESPONDS
5.2 Special Local Research
HIGHLIGHTS
• 32% of respondents reported heroin use in their lifetime.
• Of those who reported lifetime heroin use, 45% indicated
beginning with Rx opioids, then moving to heroin.
• Transition from prescription-type opioids to heroin was
highest among the respondents in younger age groups.
• Of respondents who ever misused Rx opioids, 61%
bought or received them from a friend or family member.

54. Rx & HEROIN ABUSE: Ventura County RESPONDS
5.4 Legislative Analysis
Active legislative analysis and reporting help inform and shape
some Target Actions.
EXAMPLE: Rx Workgroup carefully followed the recent
introduction, amendments and approval of CA Senate Bill
809 establishing CURES database funding and expansion.
Improvement of CURES will, in turn, advance Workgroup’s goal
to improve data links between physicians, pharmacists and law
enforcement, ultimately benefitting public safety.

55. Rx & HEROIN ABUSE: Ventura County RESPONDS
5.5 Future Policy Actions
New policies and projects being studied and considered by the
Rx Workgroup include:
- Enhanced E.R. and ambulatory care opioid prescription
policies to patients and the public;
- Pharmaceutical product stewardship;
- Overdose education and prevention programs; and
- Drug-impaired driving.