1. Controlled Substance Monitoring Database Prescription Drug Abuse Prevention Conference September 19, 2014
Andrew Holt, PharmD.
Controlled Substance Monitoring Database

2. Disclosure Information- Andrew Holt, PharmD
I have no financial relationships to disclose
I will not discuss off label use and/or investigational use in my presentation

3. Opioid Prescription Rates by County, TN 2007
Source: Tennessee Department of Health internal files, Baumblatt, et al

4. Opioid Prescription Rates by County, TN 2008
Source: Tennessee Department of Health internal files, Baumblatt, et al

5. Opioid Prescription Rates by County, TN 2009
Source: Tennessee Department of Health internal files, Baumblatt et al

6. Opioid Prescription Rates by County, TN 2010
Source: Department of Health internal files, Baumblatt et al

7. Opioid Prescription Rates by County, TN 2011
Source: Tennessee Department of Health internal files, Baumblatt et al

8. C-II Controlled Substance Utilization by State
Rank State Rx per Capita
Delaware
Tennessee
District of Columbia
Massachusetts
Maine
Source: IMS Health

9. C-II Controlled Substance Growth by State 2013 vs. 2012
Rank State Change
Wyoming %
2 South Dakota 6.1%
3 Idaho 5.1%
4 Louisiana 5.0%
31 Tennessee 0.3%
Source: IMS Health

10. Oxycodone Utilization by State
Rank State Rx per Capita
1 Delaware
2 District of Columbia 0.32
3 Tennessee
4 Massachusetts 0.29
5 Pennsylvania
Source: IMS Health

11. Growth in Oxycodone Utilization by State
Rank State Change
Wyoming %
2 Mississippi 2.7%
3 South Dakota 2.5%
4 Idaho 2.3%
37 Tennessee -4.4%
Source: IMS Health

12. C-III Controlled Substance Utilization by State
Rank State Rx per Capita
Alabama
Tennessee
Mississippi 0.91
West Virginia 0.91
Kentucky 0.89
Source: IMS Health

13. C-III Controlled Substance Growth by State 2013 vs. 2012
Rank State Change 1 Vermont -0.2% 2 Arkansas -0.5% 3 South Dakota -0.9% 4 North Dakota -1.0% 31 Tennessee -5.0%
Source: IMS Health

14. Opioid Prescribing Analysis: Analysis of Specialty/Profession Type in Tennessee

15. Began collecting data in 2005
CSMD History
Law Enacted in 2002
Began collecting data in 2005
Became searchable by practitioners in 2006

16. Controlled Substance Monitoring Database Committee
Board of Medical Examiners
Board of Nursing
Board of Pharmacy
Board of Osteopathic Examination
Committee on Physician Assistants
Board of Veterinary Medical Examiners
Board of Optometry
Board of Podiatric Medical Examiners
Board of Dentistry

17. Most Commonly Prescribed CS in TN
Source: CSMD Annual Report to the 108th General Assembly, 2014

18. Prescription Safety Act of 2012
Mandatory PDMP registration
Mandatory PDMP usage
Shortened PDMP reporting window
Mandatory reporting of doctor shoppers to law enforcement by practitioners
Enabled interstate data sharing
Established delegate accounts-”extenders”
Increased administrative staffing

19. Prescriber CSMD Survey Results
71% changed a treatment plan after viewing a CSMD report
73% are more likely to discuss substance abuse issues or concerns with a patient
57% are more likely to refer a patient for substance abuse treatment
79% feel that the CSMD is useful for decreasing doctor shopping

20. Technological Innovations
Color-coded risk
icons on patient
report for:
Pharmacy Shopper
Doctor Shopper
High MME Dose
Automated username and password retrieval
Batch requests for high-volume clinics

21. CSMD Technology

22. CSMD Technology – Risk Indicators

23. Mandating CSMD Checking Resulted in More Queries in Tennessee
Mandated checking began April 1, 2013
Mandated registration began April 1, 2013
Source: Tennessee Department of Health Internal Files, February 2014

24. Number of High Utilization Patients* in PDMP 2012-2014

25. More PDMP Queries, Fewer High Utilization Patients

26. Statistics

27. Reducing Neonatal Abstinence Syndrome
Pink NAS reminder messaging on all females of childbearing age

28. NAS Messaging in CSMD
Pink cautionary statement on patient report for females of childbearing age
“Please remember that narcotic prescriptions for women of child bearing age could result in Neonatal Abstinence Syndrome (NAS) should pregnancy occur; please discuss with your patient methods to prevent unintended pregnancy.”

29. Future CSMD Activities
Integrate into clinical workflow
Enhanced analysis
$1.4 million CDC grant awarded in 2014
Increased interstate data sharing

30. Chronic Pain Management Guidelines Prescription Drug Abuse Prevention Conference September 19, 2014
Andrew Holt, PharmD.
Controlled Substance Monitoring Database

31. Public Chapter 430 Chronic Pain Guidelines written by January 1, 2014
All prescribers with DEA 2 hours CME every 2 years
Prescribe 30 days at a time Schedule II-IV

32. Process Began on January 28, 2013
Selected the Panel of Experts
Selected the Steering Committee
First Meeting Steering Committee Meeting July 1, 2013

33. Chronic Pain Guidelines Steering Committee
Worker’s Compensation Abbie Hudgens Office of General Counsel Andrea Huddleston, J.D. Controlled Substance Monitoring Database Andrew Holt, D.Ph. Department of Health Bruce Behringer, MPH David Reagan, M.D. Larry Arnold, M.D. Mitchell Mutter, M.D. Department of TennCare Vaughn Frigon, M.D.
Board of Medical Examiners
Dr. Michael Baron
TN Department of Mental Health
Rodney Bragg, M.A., M.Div.
Tennessee Medical Foundation
Dr. Roland Gray
Special Thanks To:
Ben E. Simpson, J.D.
Tracy Bacchus

34. Chronic Pain Guideline Panel Members
Autry Parker, M.D. Brett Snodgrass, APN C. Allen Musil, M.D. Carla Saunders, APN Charles McBride, M.D. James Choo, M.D. Jason Carter, DPh Jeffrey Hazlewood, M.D. Jim Montag, PA-C John Culclasure, M.D. Katie Liveoak, D.Ph.
Michael O'Neil, D.Ph.
Paul Dassow, M.D.
Raymond McIntire, DPh
Rett Blake, M.D.
Stephen Loyd, M.D.
Ted Jones, PhD
Thomas Cable, M.D.
Tracy Jackson, M.D.
W. Clay Jackson, M.D.
William Turney, M.D.

35. Chapters of the TN Treatment Guidelines
Appendices
Pain Medicine Specialist
Risk Assessment Tools
Pregnant women
Use of Opioids in Worker's Compensation Medical Claims
Tapering protocol
Sample Informed consent
Sample Patient Agreement
Controlled Substance Monitoring Database
Medication Assisted Treatment Program
Morphine equivalents dose
Psychological Assessment Tools
Prescription Drug Disposal
Safety Net
Definitions
Table of Frequently Prescribed Pain Medications
Urine Drug Testing
Special Consideration: Women of Child Bearing Age
Introduction
Before initiating chronic opioid therapy (over 90 days)
Screening (including TN risk model), non-opioid therapies, referral to MH, others
Informed consent
Women's special considerations
Initiating chronic opioid therapy
Standard therapy, combination therapy
Special considerations
Methadone/buprenorphine
UDS - qualitative & quantitative
CSMD
Documentation in decision making
Follow up therapy
ED visits for OD
What constitutes a failure of standard therapy?
Referral to pain specialist
Taper / discontinuation of opioids
Documentation of decision making

36. Section I: Prior to Initiating Opioid Therapy
Non Opioid Treatment if Possible
All Newly Pregnant Women Should
Complete evaluation: History and Physical
Testing documented in medical record prior
Chronic Pain shall not be treated via telemedicine
Co-Morbid Mental Conditions
There shall be the establishment of a current diagnosis that justifies a need for opioid therapy

37. Section I: Prior to Initiating Opioid Therapy (cont.)
Risk for Abuse
Validated Risk Tools
CSMD
UDT
Goals for Treatment
Treatment plan for opioid and non-opioid treatment
Increase function, not to eliminate pain
Documentation in medical record

38. Section II: Initiating Opioids
Maximum four doses of short-acting opioids per day
Non pain medicine specialist should not prescribe methadone
Prescribers shall not prescribe buprenorphine in oral or sublingual for chronic pain
Avoid benzodiazepines
Document reasons for deviation from guidelines in record

39. Section II: Initiating Opioids (cont.)
Therapeutic trial
Lowest possible dose
Opioid Naïve
Informed Consent
Treatment Agreement female patient
Continually monitor for abuse, misuse, or diversions
CSMD and UDT

40. Section II: Initiating Opioids (cont.)
Women’s Health
Birth Control Plans
Informed Consent
Ask regarding pregnancy each visit
Before starting opioids – in women shall have pregnancy test

41. Section III: Treatment with Opioids
Single provider and pharmacy
Opioids used at lowest effective dose
Ongoing Therapy
Greater than 120 MEDD (Morphine Equivalent Dose) should refer to Pain Specialists
Greater than 120 MEDD shall refer
UDT twice/year
Continual assessment via 5A’s UDT, CSMD
Emergency Physician, Primary Provider Communication
Discontinue when risk greater than benefits

42. ABPM
Recognizes boards in the following certification as qualified to sit for Board Exam
Anesthesia
Psychiatry
Neurology
Neurosurgery
Physical Medicine and Rehabilitation
50 hours CME in Pain Medicine past two (2) years
Substantial, recent and comprehensive clinical practice experience

43. Pain Specialist
Board of Medical Specialties (ABMS) primary physician certification organization in US
ABMS certifies pain medicine fellowship programs in Anesthesia, Physical Medicine and Neurology
American Board of Pain Medicine (ABPM) is not ABMS and does not oversee fellowship training programs.
ABPM offers practice – related examinations to qualified candidates. Diplomates of ABPM have certification in Pain Medicine
AOA Certification

44. Pain Specialist (cont.)
Patients requiring less than 120 MEDD
Must have valid license by respective board and DEA
CME pertinent to pain management directed by regulatory board
Recommend (do not require) 3 year residency and be ABMS eligible or certified

45. Pain Specialist (cont.)
Patients requiring ≥ 120 MEDD
11 times more likely to have adverse event such as overdose death
Consultation with pain consultant who has additional in pain medicine is recommended
Pain Consultant up to 7/1/2016 shall have unencumbered license with no prior actions unless an exception is approved by the respective board
Two year experience
Minimum 25 CME hours in pain management every 12 months
Pain consultants after 7/1/2016 shall have ABPM diplomate status or ABMS Boards

46. Websites
Prescription for Success Pain Clinic Website Pain Clinic Guidelines Legislative Report CSMD%20Report%20to%20the%20General%20Assembly%20Post.PDF

47. Questions and Contact Information
Andrew Holt, PharmD Controlled Substance Monitoring Database Tennessee Department of Health