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

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Presentation on theme: "Controlled Substance Monitoring Database Prescription Drug Abuse Prevention Conference September 19, 2014 Andrew Holt, PharmD. Controlled Substance Monitoring."— Presentation transcript:

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 1 Delaware Tennessee District of Columbia Massachusetts Maine Source: IMS Health

9 C-II Controlled Substance Growth by State 2013 vs Rank State Change 1 Wyoming 7.1% 2South Dakota6.1% 3Idaho5.1% 4Louisiana5.0% 31Tennessee0.3% Source: IMS Health

10 Oxycodone Utilization by State RankState Rx per Capita 1Delaware0.36 2District of Columbia0.32 3Tennessee0.31 4Massachusetts0.29 5Pennsylvania0.29 Source: IMS Health

11 Growth in Oxycodone Utilization by State Rank State Change 1 Wyoming 5.1% 2Mississippi2.7% 3South Dakota2.5% 4Idaho2.3% 37Tennessee-4.4% Source: IMS Health

12 C-III Controlled Substance Utilization by State Rank State Rx per Capita 1 Alabama Tennessee Mississippi West Virginia Kentucky0.89 Source: IMS Health

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

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

15 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 Source: Tennessee Department of Health Internal Files, February 2014 Mandated checking began April 1, 2013 Mandated registration began April 1, 2013

24 Number of High Utilization Patients* in PDMP

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 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 UDS - qualitative & quantitative CSMD ED visits for OD What constitutes a failure of standard therapy? Referral to pain specialist Taper / discontinuation of opioids Documentation of decision making 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

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 a.Must have valid license by respective board and DEA b.CME pertinent to pain management directed by regulatory board c.Recommend (do not require) 3 year residency and be ABMS eligible or certified

45 Pain Specialist (cont.) Patients requiring ≥ 120 MEDD a.11 times more likely to have adverse event such as overdose death b.Consultation with pain consultant who has additional in pain medicine is recommended 1.Pain Consultant up to 7/1/2016 shall have unencumbered license with no prior actions unless an exception is approved by the respective board 2.Two year experience 3.Minimum 25 CME hours in pain management every 12 months 4.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 Andrew Holt, PharmD Controlled Substance Monitoring Database Tennessee Department of Health Questions and Contact Information


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