Presentation on theme: "Prescription Behavior Surveillance Using PDMP Data"— Presentation transcript:
1Prescription Behavior Surveillance Using PDMP Data Dagan Wright, PhD, MSPH (Oregon Health Authority)Denise Penone, PhD (New York City Department of Health)Special thanks and acknowledgement to Len Paulozzi who could not attend as all contributors
2Outline of the PDMP Talk What is PMP or PDMP?Why so important?What are general characteristics and data elements?What are questions that can be answered?Examples of dataExamples of outreach and evaluation
3What is PMP or PDMP?Tool utilized for reducing prescription drug misuse and diversionDrug Epidemic Warning SystemDrug Diversion & Fraud Investigative ToolPublic Health Surveillance tool to collect, monitor, and analyze dispensing dataAvoidance of Drug InteractionsPatient Care ToolIdentification & Prevention of “Doctor Shopping”*Data now can used to support states’ efforts in education, research, quality assurance (better healthcare), enforcement and abuse preventionNot meant to infringe on the legitimate prescribing of controlled substances*Doctor Shopping: Practice of obtaining multiple controlled substance prescriptions from multiple doctorsSource:
6Opioid analgesic overdose deaths increased 65% Opioid analgesic overdose deaths, NYC,2011 had the highest /Source: New York City Office of the Chief Medical Examiner &New York City Department of Health and Mental Hygiene6
7Oregon Drug Related Trends Counts and rates/100,00
8As I mentioned, we are developing SAS code to identify the drugs involved using the death certificate data. We did a quick and dirty run using Oregon data with our program to find the drugs listed on the death certificates in Oregon. For anyone familiar with ICD-10 coded data, you will notice that we cannot identify some of these drugs using the ICD-10 coded data as they are including in some of the “other specified” categories. Such as “other specified synthetic narcotics” and “other opioids”.This graph shows the data for 2010 & You can see it is following as we expected. The heroin & cocaine up, methadone, methadmephetemine down a very little. Heroin & cocaine have their own ICD-10 code, butMethamphetamine is with T43.6 Psychostimulants with abuse potentialIt is possible to look specifically at fentanyl which will be important as there is perhaps some new non-pharmetical fentanyl. An CDC epi-aid showed 16 deaths in RI involving these drugs.
12What are General Characteristics and Data Elements?
13PDMP: General Characteristics Typically require monthly or bi-weekly reportingSome States require weekly reporting i.e., Florida, OregonOklahoma, requires reporting at time of saleReactive vs. ProactiveReactive: Generate solicited reports only in response to a specific inquiryProactive: Generate unsolicited reports whenever suspicious or potentially at risk to the patient behavior is detectedDrug Schedules Monitored by states:24 collect Schedules II -V17 collect Schedules II –IV1 collect Schedule II only2 collect Schedules II & IIISource:Reactive: made by a prescriber, dispenser, or other party with appropriate authorityProactive: thus seen as a law enforcement toolMajority of states monitor classes 2 through 5
14PDMP: Information Collected Patient identificationName & AddressDOB & GenderPrescriber Information & Dispenser InformationDEA numberDrug InformationNational Drug Code (NDC) Info:NameTypeStrengthManufacturerQuantity & date dispensedSource:
15PDMP Attributes As a Surveillance System Simplicity: single data source, few data elements, drug code (NDC) is complicatedFlexibility: limited fieldsData quality: insurance and system error checksAcceptability: mandatorySee: Lee et al, eds., Principles and Practice of Public Health Surveillance, 3rd edition, 2010.
16PDMP Attributes As a Surveillance System Sensitivity: high, required by lawPredictive value positive: metrics untestedRepresentativeness: population-basedTimeliness: days to weeksStability: in most cases operating for yearsCost: support for many is inadequate for most PDMPsOther sources Oregon uses a provider licensing fee to support the PDMPSee: Lee et al, eds., Principles and Practice of Public Health Surveillance, 3rd edition, 2010.
17Model Act 2010 Revision Data Elements for PDMPs PrescriptionNumber, Date issued by prescriber,Date filled,New or refill, Number of refills,State-issued serial number (optional)DrugNDC code for drug,Quantity dispensed,Days’ supply dispensedComes from pmp model act 2010 revision document on Alliance website:
18Model Act 2010 Revision Data Elements for PDMPs PatientIdentification numberName, Address, Date of birth, SexSource of paymentName of person who receives prescription if other than patientPrescriberDispenserComes from pmp model act 2010 revision document on Alliance website:
19Descriptive Measures: Prescription Counts Specific compound, formulationDrug classOpioids, benzodiazepines, stimulants, etc.All extended-release formulations of opioidsClass within a schedule, e.g., Schedule II opioidsDaily dosage of an opioid prescription
21Descriptive Measures: Denominators Person, e.g., rx per 1,000 people (most common)Patient, e.g., rx per 1,000 patientsPrescriber, e.g., mean daily dose/prescriberPharmacy, e.g., rx/pharmacyTime period is specified: e.g., in 2012, in past quarter
22Descriptive Measures: “By” Variables Patient sex, age groupPatient/prescriber/pharmacy by county or zip codeMonth, year (prescribed or dispensed)Prescriber specialty (requires linkage based on prescriber number)Source of payment (where collected)Patient type, e.g., opioid-naive
23Risk Measures: Daily Dose for Opioids Converted to morphine milligram equivalents (MME)Usually categorized, e.g.,High, e.g., >100 MME/dayGoing beyond specific dosing guidelinese.g., more than 30 mg of methadone per day for an opioid-naïve personAlso quantified by measures of central tendency: mean, median , quartiles doseSAS coding to do MME conversions available from CDC
25Number of Patients Receiving Opioid Dosages > 100 MME/day, Tennessee, 2007‒2011 This graph shows the number of unique patients receiving a high dose of greater than 100 morphine milligram equivalents by year.The number of people who received greater than 100 morphine milligram equivalents on average per day for a year has increased from 2007 through 2011.Baumblatt J. Prescription Opioid Use and Opioid-Related Overdose Death TN, 2009–2010, CDC EIS Tuesday Morning Seminar, 1/8/2013
26Opioid Prescriptions Filled by Staten Islanders Are More Frequently High Dose Schedule II opioids + hydrocodone, New York State Prescription Drug Monitoring Program
27Number of people/1,000 residents receiving an opioid Oct 1, 2011 to March 31, 2012
28Number of people/1,000 residents receiving an opioid and benzodiazepine Oct 1, 2011 to March 31, 2012
29Number of people/10,000 residents using 4 or more prescribers and 4 or more pharmaciesOct 1, 2011 to March 31, 2012
30Rates of Unintentional Poisoning Mirrors Rates of Dispensed Prescriptions Neighborhoods with Highest Rates of Opioid Prescriptions Also Have the Highest Rates of Overdose Deaths,Of the five NYC neighborhoods with the highest rates of hydrocodone and/or oxycodone prescriptions filled,four were in Staten Island and overlapped with four of the five neighborhoods where the rate of unintentional opioid analgesic poisoning (overdose) deaths was highest during the yearsSource:
31Use of PMP Data by MA Dept. of Public Health “Shopping” as a portion of all prescriptionsOverdoses in ED DataSlide provided courtesy of Peter Kreiner, PMP Center of Excellence at Brandeis. Doctor shopping, the questionable activity, was defined as 4+ prescriber s and 4+ pharmacies for CSII in six months.
32Measures of “Shopping” or “Multiple Provider Episodes” Author (year)DrugNo. ofPrescribersPharmaciesRxOverlapTimePeriodHall (2008)Any CS5+NA1 yrPeirce (2012)4+6 moOhio DOH (2010)OpioidAvg of 5+Over 3 yrsGilson (2010, 2012)“Same medication”2+30 dKatz (2010)Any CSIICepeda (2012)3+1+ day18 moBJA criteriaCSII-IV3 mo.No standard. Not like 5 or more drinks per day.Sensitivity and specificity not determined, but measures have been associated with abuse or overdoseShorter time periods might be desirable if looking for short-term impact of an intervention.More specific measures might be chosen in response to limited resources for followup.
33Patient vs. Provider Metrics? Top 1% of prescribers based on number of prescriptions might account for 33% of the morphine equivalents (MME) in your state.(1)Top 1% of patients might account for 40% of MME.(2)1. Swedlow 2011; 2. Edlund 2010
3415% of prescribers write 82% of opioid analgesic prescriptions Prescriptions filled by NYC residents, 201015%82%Percent-more prescription data from PDMP PH and PS go after this a little differently-X axis shows prescriber on left and rx on right. Y axis percent.-point: 15% of prescribers write 82% of opioid analgesic rx.-we can then use data to better understand high volume prescribers.Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program,
35Distribution of CS II-IV prescriptions to prescribers, Oregon, 1/12 to 9/12 % of Prescribers% of CS PrescriptionsOregon Health Authority. Prescription Drug Dispensing in Oregon, October 1, 2011 – March 31, 2012
37Patient vs. Provider Metrics? 100 patients in the PMP for every prescriberIt takes roughly 100 times more effort to address the same fraction of problematic prescriptions.For interventions, provider case-finding is preferred based on efficiency.
381st Evaluation of Oregon PDMP soon followed by NIH study – survey use 65% say it is very helpful to monitor patients’ prescriptions for controlled substances64% report it is very helpful to control “doctor shopping”78% have spoken with patient about controlled substance use after using system59% reduced or eliminated prescriptions for a patient after using system49% contacted other providers or pharmaciesSource: Oregon Prescription Drug Monitoring Program Evaluation
39NYC Opioid Treatment Guidelines Avoid prescribing opioids for chronic non-cancer, non-end-of-life painE.g. low back pain, arthritis, headache, fibromyalgiaWhen opioids are warranted for acute pain, 3-day supply usually sufficientAvoid whenever possible prescribing opioids in patients taking benzodiazepinesIf dosing reaches 100 MED, reassess and reconsider other approaches to pain managementClinical experts in primary care, rheumatology, psychiatry, emergency medicine, and pain management, including Theodore Strange and Mark Jarrett from Staten Island University Hospital and Anne Marie Stilwell from Interventional Pain Management of Staten Island, helped us develop these guidelines.
40References CitedCepeda, M., D. Fife, et al. (2012). "Assessing opioid shopping behavior." Drug Safety.Edlund, M. J., B. C. Martin, et al. (2010). "Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP study." Drug Alcohol Depend 112(1-2):Forrester, M. B. (2011). "Ingestions of hydrocodone, carisoprodol, and alprazolam in combination reported to Texas poison centers." Journal of Addictive Diseases 30:Hall, A. J., J. E. Logan, et al. (2008). "Patterns of abuse among unintentional pharmaceutical overdose fatalities." JAMA 300:Katz, N., L. Panas, et al. (2010). "Usefulness of prescription monitoring programs for surveillance---analysis of Schedule II opioid prescription data in Massachusetts, " Pharmacoepidemiol Drug Safety 19:Ohio Department of Health. (2010). "Epidemic of prescription drug overdoses in Ohio." Retrieved September 1, 2010, fromPeirce, G., M. Smith, et al. (2012). "Doctor and pharmacy shopping for controlled substances." Med Care.Swedlow, A., J. Ireland, et al. (2011). Prescribing patterns of schedule II opioids in California Workers' Compensation, California Workers' Compensation Institute.White, A. G., H. G. Birnbaum, et al. (2009). "Analytic models to identify patients at risk for prescription opioid abuse." Am J Manag Care 15(12):Wilsey, B. L., S. M. Fishman, et al. (2010). "Profiling multiple provider prescribing of opioids, benzodiazepines, stimulants, and anorectics." Drug Alcohol Depend 112: