PDMP Track: Prescriber Viewpoint: How Mandating Compliance is Working

1. PDMP Track
Prescriber Viewpoint: How
Mandating Compliance is Working
Presenters:
• Ryan A. Stanton, MD, FACEP, Emergency Room Physician, Baptist
Health Lexington
• John “Rett” Blake, III, MD, Medical Director, Specialists in Pain
Management
• Kelly S. Ramsey, MD, MPH, MA, FACP, Clinical Director of Special
Programs, Hudson River Health Care, Inc.
Moderator: John L. Eadie, Director, Prescription Drug Monitoring
Program (PDMP) Center of Excellence, and Member, Rx Summit
National Advisory Board

2. Disclosures
Ryan Stanton, MD, FACEP; John E. “Rett” Blake, III, MD;
Kelly S. Ramsey, MD, MPH, MA, FACP; and John L. Eadie
have disclosed no relevant, real or apparent personal or
professional financial relationships with proprietary
entities that produce health care goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following
to disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

4. Learning Objectives
1. Evaluate the impact on opioid prescribing by
state mandates that prescribers use the PDMP
prior to issuing opioid prescriptions to a new
patient and periodically thereafter.
2. Compare prescriber attitudes toward such
mandates before and after they were
implemented.
3. Advocate states adopt mandates that prescribers
use the PDMP prior to issuing opioid
prescriptions to a new patient and periodically
thereafter.

5. PDMP Track: Prescriber Viewpoint: How Mandating Compliance is Working
Dr. Ryan A. Stanton MD, FACEP
Public Relations Chairman ACEP/KACEP
Medical Director- Lexington Fire/EMS

6. Disclosure
• Ryan Stanton, MD FACEP,
has disclosed no relevant,
real or apparent personal
or professional financial
relationships with
proprietary entities that
produce health care goods
and services.

7. Objectives
• Review the “problem” in Kentucky
• Outlines the details of “Pill Mill” Legislation
• Look at the effects of the legislation
• Review key aspects of legislation from the ER
provider standpoint

8. Background

9. The 4-1-1
• Addiction is typically caught late in the disease process
• "Addiction is a brain disease"
• Substance abuse cost 467.7 billion annually(2005) to
governmental entities
• 1 out of 14 hospital stays are related to addiction(2004)
• Approx 30% of patient encounters(2009)
The DAWN Report(samhsa.gov)

10. The 4-1-1(USA)
• 8,400 new drug users every day
• 51% of new users under age 18
• Marijuana represents more than half of new drug
users
• 23.8% of people age 18-20 reported using an illicit
drug in the last month
• Estimated 22.5 million Americans over age 12
used an illicit drug in the last month(8.7%)(more
people addicted than Type I Diabetes Mellitus)
drugabuse.gov
The DAWN Report(samhsa.gov)

11. Kentucky Drug Overdoses

12. Drug Overdose Deaths

13. Opioids
• Over 16,000 deaths annually
• WV- 550% increase in 10 years(All OD deaths)
• KY- 282%(All OD deaths)
• USA- 160%(All OD deaths)
• Women- 400%(Rx opioid deaths)...6,600 in 2010
• Men- 265%(Rx opioid deaths)...10,000 in 2010
• Methadone made up 1/3rd of opiate deaths as of 2009
Drug Overdose Morbidity and Mortality, 2000-2010

14. Nation View

15. Kentucky Takes Action
• 2012 House Bill 1- “Pill Mill Bill”
• 2013 House Bill 217
• Physician ownership of pain clinics
• Limited prescriber dispensing
• Requires daily reporting of controlled substances to
KASPER
• Designated “institutional” accounts for KASPER
• Requires 7.5% of CME to be approved pain/addiction
related
• Mandates KASPER registration and use
American College of Emergency Physicians(ACEP)

16. Kentucky Takes Action
– KASPER Query Exemptions
• Emergency
• Within 14 days of surgery(3 days dental/oral)
• Patients in hospital/long term care
• Hospice/Cancer
• Single doses of anxiolytic prior to procedure

17. Kentucky Takes Action
– Results
• KASPER accounts up 340%
• KASPER queries increased from about 1 million
annually to about 5 million annually
• 2013 controlled substance prescriptions declined for
the first time since KASPER started in 1999
• 2013 2.47 prescriptions per person…about 2008 level
• Heroin numbers way up
• Decreased ER “doctor shopping” visits(subjective)

18. Kentucky Takes Action
– Early Lessons
• Engage stakeholders early
• Consider methods to decrease provider workload
– Delegates
– Institutional accounts
• Allow implementation time
• Make information and training easy and available
• Obtain feedback and adjust
• Make KASPER reports up to date and available
• Reports must be reviewed

19. ER MD Key Points
– Reports must be…
• Fast
• Accurate
• Timely
• Interstate
• Easy to obtain
– Delegates
– Institutional accounts
– Can’t take time away from the bedside
• Easy system

20. ER MD Key Points
– Also…
• Providers aren’t law
enforcement
• Must have administrative
support for refusal
– Patient satisfaction
– Pain as “vital sign”
• Strengthen healthcare abuse
laws
• Must bolster recovery resources
• Be ready for heroin

21. Summary
• Know your demons
– What are the substance abuse challenges of your community
• Understand what is fueling prescription abuse and
overdoses
• Healthcare’s apathy has led to legislative action
• Attacking Rx opioid abuse is multifaceted
– Healthcare
– Law Enforcement
– Recovery Resources
– Community Buy-In
– Legislation

22. Summary
• We must take steps to
curb a healthcare fueled
epidemic
• Providers MUST be part of
the solution conversation
• Solutions must not hinder
quality care/efficiency
• Attack the problems
– “Candyman” Docs
– “Strive for 5”
– Recovery Resources
– Foster EBM

23. National Drug Summit
Rett Blake, M.D.

24. Disclosure
• John E. “Rett” Blake, III, MD, has disclosed no
relevant, real or apparent personal or
professional financial relationships with
proprietary entities that produce health care
goods and services.

25. Top 5 USA
• Class II Drugs/per capita
a. Oxycodone
b. Morphine
c. Oxymorphone
• Class III
a. Hydrocodone
• Class IV
a. Codeine products
b. Tramadol
c. Benzodiazepine
d. Ambien

26. Top 10
• Unintended overdose deaths per capita
• NAS babies born dependent on opioids

27. Neonatal Abstinence Syndrome (NAS)

28. Corrective Action Plan
• Engage all Stakeholders
• Legislation
–Controlled Substance Monitoring Act 2002- CSMD began
collecting data in 2006
–Prescription Safety Act 2012
• Facilitation
• Implementation

29. Prescription Safety Act 2012
• Required Registration in CSMD
• Required querying the database for all opioid and benzodiazepine prescriptions over 7
days and annually thereafter with exceptions for hospice care and non-refillable post-
operative medications performed in a licensed facility
• Allows Providers to delegate two other licensed professionals to access CSMD on their
behalf
• Protected, but available to law enforcement only through an active case

30. Regulation/Legislation
• Requirement for registration and query of CSMD
• Required DOH to create the Chronic Pain Guidelines
finished in 2014.
• Expert Panel
• Symposia
• Pharmacy Conferences
• Law Enforcement

31. Number of Doctor Shopper Identified in CSMD by Quarter,
2010-2014*
Year
1st
Quarter
2nd
Quarter 3rd Quarter 4th Quarter Total
Change
(%)
2010 1,695 2,005 2,127 1,830 7,657 -
2011 1,950 2,413 2,515 2,352 9,230 20.5
2012 2,246 2,218 2,261 1,940 8,665 -6.1
2013 1,785 1,533 1,533 1,335 6,186 -28.6
2014 1,374 1,404 1,278 1,307 5,363 -13.3

32. *If patients in CSMD had same date of birth and same result of soundex first name and last name, we took the patients as same person.
Data used for above analysis were downloaded on Jan. 5, 2015. Data are subject to change due to database updating and the other
reasons. VA pharmacies were excluded from the analysis. Doctor and pharmacy shopper was defined as a person who got his/her
prescriptions from 5 or more different DEA prescribers and filled the prescriptions at 5 or more different DEA pharmacies within 3 months.
2010-2014 Number of “Doctor and Pharmacy
Shoppers" in CSMD *

33. 2010-2014 Morphine Milligram Equivalents Reported to
CSMD *
*Note: Morphine Milligram Equivalents (MME) were converted based on CDC MME conversion tables .
Above numbers were derived from CSMD data downloaded on January 5, 2015. 2014 data are subject to
change due to database updating. VA pharmacies were excluded from above analysis.

34. Number of Prescriptions of Controlled
Substances Dispensed and Reported to
CSMD, 2010-2014
15,500,000
16,000,000
16,500,000
17,000,000
17,500,000
18,000,000
18,500,000
19,000,000
2010 2011 2012 2013 2014
NumberofPrescriptions
Year

35. • Risk assessment-objective tool
• Dose, frequency, previous pain practices, different
pharmacies
• Vitally important tool for opioid prescription
monitoring
Clinical Perspective

36. Implementation -Enhancement
• Delegates who can check CSMD for provider
• Morphine Equivalents
• Practitioner vs. Peer
• Self Look-up and Extender Look-up Capabilities
• Clinical Risk indicators; patients at risk for overdose diversion, or doctor
shopping
a. MEDD
b. Number of Doctors and Providers
c. Number of Pharmacies
d. Child bearing age reminder

37. Trends off Legislative Report
• MME
• Interstate Sharing
• Doctor Shopping
Projected Enhancement
1. Increase emergency department ease to access
2. Automate law enforcement request

38. PDMP Track: Prescriber Viewpoint:
How Mandating Compliance Is Working:
New York State
Kelly S. Ramsey, MD, MPH, MA, FACP, Clinical Director of Special
Programs, Hudson River Health Care, Inc.

39. Disclosures:
• Kelly S. Ramsey, MD, MPH, MA, FACP, has
disclosed no relevant, real or apparent personal
or professional financial relationships with
proprietary entities that produce health care
goods and services.

40. Learning Objectives:
1. Evaluate the impact on opioid prescribing by
state mandates that prescribers use the PDMP
prior to issuing opioid prescriptions to a new
patient and periodically thereafter.
2. Compare prescriber attitudes towards such
mandates before and after implementation.
3. Advocate that states adopt mandates that
prescribers use the PDMP prior to issuing opioid
prescriptions to a new patient and periodically
thereafter.

41. Age-adjusted drug poisoning death rates: United States, 1999-2012
NOTE: Drug-poisoning deaths may involve both opioid analgesics and heroin.
SOURCE: CDC/NCHS, National Vital Statistics Systems, Mortality File

42. Scope of the Problem: New York City
• Drug overdose is a leading cause of accidental death in
New York City, with a majority involving either heroin or
prescription painkillers. Overdose deaths related to
prescription painkillers increased 233% between 2000
and 2012. Heroin-related overdose deaths increased
84% between 2010 and 2012 in New York City, after four
years on the decline.
• Source: http://www.nyc.gov/html/doh/html/pr2014/pr003-14.shtml

43. Scope of the Problem: New York State
• Deaths and Death Rates: 2012, New York State,
exclusive of New York City:
• Total Deaths due to Accidental Poisonings: 1,036
• Crude Death Rate (per 100,000) due to Accidental
Poisonings: 9.2
• Adjusted Death Rate (adjusted for age and sex) due
to Accidental Poisonings: 9.3
• Source: https://www.health.ny.gov/statistics/vital_statistics/2012/table33b.htm

44. • New York State:
• I-STOP/PMP - Internet System for Tracking Over-Prescribing -
Prescription Monitoring Program
• Prescription Monitoring Program Registry
• Effective August 27, 2013, most prescribers are required to consult the
Prescription Monitoring Program (PMP) Registry when writing prescriptions for
Schedule II, III, and IV controlled substances. The PMP Registry provides
practitioners with direct, secure access to view dispensed controlled substance
prescription histories for their patients. The PMP is available 24 hours a day/7
days a week via an application on the Health Commerce System (HCS) at
https://commerce.health.state.ny.us. Patient reports will include all controlled
substances that were dispensed in New York State and reported by the
pharmacy/dispenser for the past six months. This information will allow
practitioners to better evaluate their patients' treatment with controlled substances
and determine whether there may be abuse or non-medical use. The same law
allows pharmacists to consult the PMP registry before dispensing a controlled
substance. Pharmacists are not required to consult the registry.
• Source: https://www.health.ny.gov/professionals/narcotic/prescription_monitoring/

45. Unfortunately, I-STOP Lacks Teeth: From
I-STOP's FAQ:
• Q: What are the penalties if I willfully do not consult the PMP
Registry when I prescribe a Schedule II,III, or IV?
• A: There are no specific penalties attached to failing to comply
with
• I-STOP. However, a violation of the provisions of this law is the
same penalty as for any violation of the Public Health Law.
• Source:
https://www.health.ny.gov/professionals/narcotic/prescription_monitoring/docs/p
mp_registry_faq.pdf

46. Provider Response to New York's I-STOP
• The Benefits of the Enhanced Prescription Monitoring Program
(PMP)
• The Prescription Monitoring Program (PMP) registry will provide
practitioners with confidential reports from data provided by
pharmacies across the state. Accessed through the secure, online
New York Health Commerce System, results will be available in real-
time. The registry is a tool to help enhance understanding of a
patient’s controlled substance utilization, guide management, and
improve quality of care. For questions related to the Prescription
Monitoring Program, the NYS Department of Health Bureau of
Narcotic Enforcement has a toll-free number that you can call: 1-
866-811-7957.
• Source: http://www.nyacp.org/i4a/pages/index.cfm?pageid=3700

47. One Organization's Response to the Problems with
Prescription Opioid Abuse: HRHC, Inc.
• HRHC, Inc., a network of FQHC community health centers,
primarily in NYS's Hudson Valley
• Pre-2011:
• Provider awareness was low regarding the risks of opioid prescribing
and the possibility of diversion/misuse/abuse.
• Oversight of patients with contracts and monitoring was inconsistent.
Interpretation of urine drug screenings (UDS) was often inaccurate.
• 2011-2013:
• Focused pain management education and training, including
interpretation of UDS, done with more problematic prescribing sites.
• Collaboration with Mount Sinai Hospital Pain Management Department
via teleconferencing for pain management educational purposes.
• Creation of a pain management packet, including an opioid consent, an
enforceable contract, and use of an opioid risk tool (ORT). Routinization
of UDS. Peer pain management chart reviews instituted.
Encouragement of use of (then) NYS PMP (pre-I-STOP).

48. One Organization's Response to the Problems with
Prescription Opioid Abuse: HRHC, Inc. (continued)
• 2013-2014:
• Buprenorphine program started with mandatory behavioral health component.
Mandatory use of NYS PMP (I-STOP) for all controlled substance prescriptions
written: with, ultimately (!), positive provider response. Acceptance by NYS DOH
as an opioid overdose prevention site.
• Agency wide decreased opioid prescribing and increased referrals for
interventional pain management and substance abuse treatment.
• 2015 (thus far):
• Adoption of new pain management policies by HRHC, including an opioid ceiling
dose (120 MEQ) and mandatory yearly behavioral health assessment.
• The Future...
• Consider expansion of buprenorphine program.
• Dissemination of opioid overdose prevention (distribution of naloxone kits)
program to additional sites.
• Ongoing education of providers and clinical support staff (social workers, case
managers, nurses, administrators) regarding prescription opioid abuse,
substance abuse, drug history screening, and handling difficult situations and
challenging patients.

49. Conclusions:
• Increasing rates of prescription opioid abuse and heroin abuse are national
problems.
• Strategies to address these problems and prevent opioid abuse need to be multi-
pronged efforts, including: PDMPs, prescription drug “take back” events, safe
opioid prescribing education, expansion of opioid agonist treatment
(buprenorphine), expanding access to naloxone (opioid overdose prevention
programs), supervised injection facilities, and expanded syringe access programs
(ESAP).*
• Mandatory PDMPs, such as in NYS, which requires checking the PDMP
BEFORE ALL controlled substance prescriptions are written (with rare exception),
help decrease prescription opioid misuse, abuse, diversion, and “doctor
shopping”. An inappropriate finding on a PDMP printout offers a unique
opportunity to have a conversation with a patient about their risk for opioid
dependence, overdose, and death.
• A consideration to make implementation of the PDMP more efficacious would be
implementing repercussions if it is not utilized as mandated.
• Source: Harm Reduction Coalition, NY

50. Thanks!
Contact Info: kramsey@hrhcare.org

51. PDMP Track
Prescriber Viewpoint: How
Mandating Compliance is Working
Presenters:
• Ryan A. Stanton, MD, FACEP, Emergency Room Physician, Baptist
Health Lexington
• John “Rett” Blake, III, MD, Medical Director, Specialists in Pain
Management
• Kelly S. Ramsey, MD, MPH, MA, FACP, Clinical Director of Special
Programs, Hudson River Health Care, Inc.
Moderator: John L. Eadie, Director, Prescription Drug Monitoring
Program (PDMP) Center of Excellence, and Member, Rx Summit
National Advisory Board