1. Inside Maine’s Medicine Cabinet

2. Inside Maine’s Medicine Cabinet: Analysis of the Maine Prescription Monitoring Program, 2010-2014 Christina Holt, MD, MSc 1, Kenneth McCall, PharmD 2, Stephanie Nichols, PharmD, BCPS, BCPP 3, Leslie Ochs, PhD, PharmD, BCPS 2, BCPS, Gary Cattabriga, BA 4, Chunhao Tu, PhD 2 1.Maine Medical Center, Department of Family Medicine, Portland, ME 2.College of Pharmacy, University of New England, Portland, ME 3.School of Pharmacy, Husson University, Bangor, ME 4.Center for Community & Public Health, University of New England, Portland, ME

3. Outline Prescribing Trends: Maine PMP, 2010-2014 Opioids – Buprenorphine Sedatives – Benzodiazepines Stimulants

4. Limitations The Maine VA System began reporting to the Maine PMP on 10/30/2014. Controlled prescriptions dispensed in other New England states are not included in the Maine PMP. Maine PMP prescription and recipient counts may include non-Maine residents. Methadone Clinics and Opioid Treatment Programs are exempt by federal regulations (42 CFR Part 2) from submitting data to the PMP. The administration of a drug in a clinic, emergency room, or other outpatient facility is not required to be reported to the PMP.

5. Number of Controlled Prescriptions (x1,000) : Maine PMP, 2006-2014 ‘Sedatives’ includes benzodiazepines and ‘z’ hypnotic drugs such as zolpidem.

6. Maine PMP 2014: The Big Picture 135.4 million dosage units (e.g., tablets, capsules, patches, etc.) of controlled prescription drugs were prescribed and dispensed in Maine in 2014. 52.2 million days-supply of controlled prescription drugs were prescribed and dispensed in Maine which is enough to medicate every man, woman and child around-the-clock for more than a month.

7. OPIOIDS

8. Number of Opioid Prescriptions (x1,000) : Maine PMP, 2006-2014 For comparative purposes, the Maine population estimated by the US Census Bureau: 2006 = 1,324,000; 2010 = 1,328,000; 2014 = 1,330,000

9. Number of Opioid Prescriptions (x1000) by Product: Maine PMP, 2010 & 2014 *Hydrocodone reclassified to DEA C-II in 2014, Tramadol reclassified to DEA C-IV in 2014, Propoxyphene withdrawn from US market in 2010 2010 2014

10. Trends in Number of Prescriptions of the Top 3 Opioids in Maine PMP, 2010-2014 *Hydrocodone reclassified from DEA C-III to C-II in 2014

11. Number of Opioid Prescriptions per Capita 1 by County: Maine PMP, 2014 COUNTYRXsRXs/CAPITA Androscoggin,ME108,0251.00 Aroostook,ME63,6050.91 Cumberland,ME*219,9510.77* Franklin,ME25,3210.83 Hancock,ME48,9500.89 Kennebec,ME132,9001.10 Knox,ME43,6501.10 Lincoln,ME35,6711.05 Oxford,ME58,2791.02 Penobscot,ME139,7250.91 Piscataquis,ME16,3520.95 Sagadahoc,ME30,9570.88 Somerset,ME55,4811.07 Waldo,ME37,8130.97 Washington,ME34,3911.07 York,ME171,1660.86 MAINE TOTAL1,222,2370.92 *This value is furthest from the rest, but not a significant outlier (P>0.05) 1. Maine County Population, 2010, US Census Bureau

12. Prescription Opioids: Key Findings In Maine, 1.22 million opioid prescriptions were dispensed for 291,000 individuals in 2014. Opioid prescribing peaked in 2010 at 1.31 million prescriptions annually. The peak was followed by a decline in opioid prescriptions from 2010 to 2013 and subsequently an increase in 2014. The recent increase may be related to the reclassification of Tramadal to DEA CIV in 2014 and the addition of Maine VA reporting in 2014. Hydrocodone containing products were the most common opioid prescribed in 2014. However, the recent reclassification of hydrocodone to DEA CII will likely affect future prescribing trends. While hydrocodone and oxycodone prescriptions consistently declined from 2010 to 2014, buprenorphine prescriptions have increased more than any other opioid in the same timeframe. Counties with the highest opioid prescriptions per capita include: Kennebec, Knox, Washington, and Somerset

13. Buprenorphine

14. Number of Buprenorphine Prescriptions (x100) and Recipients (x10) per year: Maine PMP 2010-2014 From 2010 to 2014, the number of buprenorphine prescriptions, and recipients have increased by 65% and 48%, respectively. 317 buprenorphine prescribers in 2014 and 344 in 2015 (up only 9%) 214/344 (62%) wrote tx prescriptions 214/344 (62%) wrote tx prescriptions

15. Key Findings: Buprenorphine 156,088 buprenorphine prescriptions were dispensed for 13,050 individuals in Maine in 2014 The number of buprenorphine prescriptions and recipients has increased from 2010 to 2014 by 65% and 48% respectively, but the number of prescribers only increased 9% from 2014 – 2015. Buprenorphine prescribers are unequally distributed by county with some counties experiencing a decline in prescribers (Franklin, Hancock, Washington, York, Piscataquis, and Knox). Most physicians in Maine who prescribe buprenorphine are currently treating under 100 patients (mean = 41). However, the 2006 DATA amendment allows physicians to treat up to 100 patients after the first year of treating 30.

16. SEDATIVES

17. Number of Sedative Prescriptions (x1,000) : Maine PMP, 2006-2014 For comparative purposes, the Maine population estimated by the US Census Bureau: 2006 = 1,324,000; 2010 = 1,328,000; 2014 = 1,330,000

18. Number of Sedative Prescriptions (x1000) by Product: Maine PMP, 2014

19. Number of Benzodiazepine Prescriptions per Capita 1 by County: Maine PMP, 2014 COUNTYRXsRXs/CAPITA Androscoggin,ME*42,0640.39* Aroostook,ME33,2000.47 Cumberland,ME143,0410.50 Franklin,ME*11,6380.38* Hancock,ME26,1380.48 Kennebec,ME62,2190.51 Knox,ME22,1950.56 Lincoln,ME17,5270.51 Oxford,ME25,3560.44 Penobscot,ME73,7890.48 Piscataquis,ME8,1600.48 Sagadahoc,ME17,5810.50 Somerset,ME26,7500.52 Waldo,ME18,9540.49 Washington,ME18,7580.58 York,ME*104,3830.39* MAINE TOTAL651,7530.49 *These values are furthest from the rest, but are not significant outliers (P>0.05) 1. Maine County Population, 2010, US Census Bureau

20. Number of benzodiazepine prescriptions per year (x1,000) stratified by age and gender, Maine PMP 2011-2014 1 AGE & GENDER2011201220132014 2 0-19 years Female 12 6.7 11 5.8 10 5.3 20-59 years Female 450442 281 411 263 381 243 60+ years Female 234242 164 239 159 239 158 TOTAL*701697677631 1.For comparison, Maine Population according to 2010 US Census Data: Total population 1,328,361; 0-19 years 310,959; 20-59 years 716,662; 60+ years 300,740 Female 678,305; 0-19 years 151,075; 20-59 years 363,319; 60+ years 163,911 2.Data Extraction 12.19.2014 *including those categorized as unknown age

21. Number of individuals (x1,000) who received a benzodiazepine prescription stratified by age and gender, Maine PMP 2011-2014 1 AGE & GENDER2011201220132014 2 0-19 years Female 5.05.2 2.8 4.6 2.4 4.5 2.3 20-59 years Female 9997 61 91 58 91 57 60+ years Female 5557 37 58 37 62 39 TOTAL*160 154157 1.For comparison, Maine Population according to 2010 US Census Data: Total population 1,328,361; 0-19 years 310,959; 20-59 years 716,662; 60+ years 300,740 Female 678,305; 0-19 years 151,075; 20-59 years 363,319; 60+ years 163,911 2.Data Extraction 12.19.2014 *Including those categorized as unknown age.

22. Proportion of Maine population who received a benzodiazepine prescription stratified by age, Maine PMP 2011-2014* * Maine PMP Recipient and Rx counts may include non-Maine residents For comparative purposes, the Maine population estimated by the US Census Bureau: 2010 = 1,328,000; 2014 = 1,330,000

23. Proportion of Maine population who received a benzodiazepine prescription stratified by age and gender, Maine PMP 2014* *Maine PMP Recipient and Rx counts may include non-Maine residents

24. Prescription Sedatives: Key Findings In Maine, 677,000 benzodiazepine and 179,000 “z drug” prescriptions were dispensed for greater than 155,000 individuals in 2013. Sedative prescriptions peaked in 2010 at 904,000 Benzodiazepine prescribing rates are highest among adults 60 years and older and especially highest among women in that age range Among adults age 60 years and older in Maine, approximately 1 in 5 received one or more benzodiazepine prescriptions in 2014. There may be an upward trend in the proportion of adults 60 years and older in Maine who are receiving benzodiazepine prescriptions (2011 – 18% vs 2014 – 21%) despite cautions regarding their use in older adults.

25. STIMULANTS

26. Number of Stimulant Prescriptions (x1,000) : Maine PMP, 2006-2014 For comparative purposes, the Maine population estimated by the US Census Bureau: 2006 = 1,324,000; 2010 = 1,328,000; 2014 = 1,330,000

27. Number of Stimulant Prescriptions (x1000) by Product: Maine PMP, 2014

28. Overall Trends in Stimulant Prescriptions: Maine PMP, 2010-2014

29. Number of Stimulant Prescriptions per Capita 1 by County: Maine PMP, 2014 COUNTYRXsRXs/CAPITA Androscoggin,ME 25,3590.24 Aroostook,ME 14,9070.21 Cumberland,ME* 122,1600.43* Franklin,ME 5,6470.19 Hancock,ME 12,2000.22 Kennebec,ME 40,8120.34 Knox,ME 9,9870.25 Lincoln,ME 6,1990.18 Oxford,ME 7,5290.13 Penobscot,ME* 68,1480.44* Piscataquis,ME 4,2690.25 Sagadahoc,ME 1,6840.05 Somerset,ME 4,8130.09 Waldo,ME 5,8720.15 Washington,ME 5,1000.16 York,ME 52,5010.26 MAINE TOTAL 387,1870.29 *These values are furthest from the rest, but are not significant outliers (P>0.05) 1. Maine County Population, 2010, US Census Bureau

30. Number of stimulant prescriptions (x1,000) per year stratified by age, Maine PMP 2010-2014 1 AGE20102011201220132014 RELATIVE INCREASE 0 – 29 222223232230237 6.8% 30 - 59 103112128133142 37.9% 60+ 1011131416 68.0% 1.For comparison, Maine Population according to 2010 US Census Data: Total population 1,328,361; 0-19 years 310,959; 20-59 years 716,662; 60+ years 300,740 Female 678,305; 0-19 years 151,075; 20-59 years 363,319; 60+ years 163,911 2.Data Extraction 2.3.2015

31. Number of individuals (x1,000) who received a stimulant prescription stratified by age, Maine PMP 2010-2014 1 1.For comparison, Maine Population according to 2010 US Census Data: Total population 1,328,361; 0-19 years 310,959; 20-59 years 716,662; 60+ years 300,740 Female 678,305; 0-19 years 151,075; 20-59 years 363,319; 60+ years 163,911 2.Data Extraction 2.3.2015 AGE20102011201220132014 RELATIVE INCREASE 0 - 29 30.632.533.132.534.6 13.1% 30 - 59 14.116.117.418.220.4 44.7% 60+ 1.72.02.22.32.7 57.1%

32. Prescription Stimulants: Key Findings In Maine, 395,000 stimulant prescriptions were dispensed for 57,800 individuals in 2014. Stimulants are the fastest growing category in the Maine PMP with a 91% increase in annual prescriptions from 2006 to 2014. All age categories experienced an increase in the number of stimulant prescriptions from 2010 to 2014 with the highest rate of increase among adults 30 years and older. Over 11,000 more people were prescribed stimulants in 2014 versus 2010 with the highest rate of increase among adults 30 years and older.

33. Acknowledgments: Office of Substance Abuse, PMP Program Coordinator: John Liposky Professors Brian Piper, PhD and Sarah Martin, PhD, Husson University School of Pharmacy. Funding from AAFP