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Continuing Education Credit: TEXT: 501-406-0076 Event ID : 32055-30782

Continuing Education Credit: TEXT: 501-406-0076 Event ID : 32055-30782. Prescription Drug Monitoring Programs (PDMPs): How Effective Are They?. Corey J. Hayes, PharmD, PhD, MPH Assistant Professor Department of Psychiatry University of Arkansas for Medical Sciences College of Medicine.

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Continuing Education Credit: TEXT: 501-406-0076 Event ID : 32055-30782

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  1. Continuing Education Credit: TEXT: 501-406-0076 Event ID: 32055-30782

  2. Prescription Drug Monitoring Programs (PDMPs): How Effective Are They? Corey J. Hayes, PharmD, PhD, MPH Assistant Professor Department of Psychiatry University of Arkansas for Medical Sciences College of Medicine Jamie Turpin, PharmD PDMP Administrator Arkansas Department of Health

  3. Objectives: • Discuss the history of PDMPs and laws enacted regarding PDMPs. • Evaluate the current research regarding the effectiveness of PDMPs. • Discuss updates to the Arkansas PDMP.

  4. Objectives: • Discuss the history of PDMPs and laws enacted regarding PDMPs. • Evaluate the current research regarding the effectiveness of PDMPs. • Discuss updates to the Arkansas PDMP.

  5. What are PDMPs?

  6. From the beginning • 1918: New York (3 Years) • Heroin, cocaine, morphine, opium and codeine • 1939: California • oldest continuous operated PDMP • 1961: Illinois • first program housed in a Department of Health • 1967: Idaho • First program housed in a board of pharmacy

  7. First 50 years (‘39-’89) of PDMPs • Used as a tool for law enforcement • Only schedule II substances collected • Required sending prescription information to the state within 30 days • Required multi-copy state issued prescriptions • Triplicate—practitioner, pharmacy, PDMP • “Books” of these prescriptions were purchased by practitioners/facility

  8. Early PDMP Information Gathering Prescription Drug Monitoring Program Training and Technical Assistance Center

  9. Modernization of the PDMP • 1990: Oklahoma • first state for electronic submission • Lowered cost to operate • 1995: Nevada • First state to require schedule II – V • 2013: Arkansas • PDMP went live • 2016: Missouri • St. Louis County PDMP • Today: All States have PDMP minus Missouri • includes Puerto Rico, Guam, Military Health Systems

  10. Enactment of PDMPs Prescription Drug Monitoring Program Training and Technical Assistance Center

  11. PDMP Boom • Harold Rogers Prescription Drug Monitoring Programs Grant (2003) • Funds to Plan, Implement, Enhance PDMPs • Program Administered by Bureau of Justice Assistance • 2003-2012 33 States Enacted PDMP legislation

  12. Next Generation PDMPs • Movement Towards: • Interstate Data Sharing • Real Time Collection of Data • Integration into Health Information Exchange • Unsolicited Reports • PDMPs as Part of Standards of Care • Standardization of Programs • Increased Authorized Users of PDMPs

  13. Objectives: • Discuss the history of PDMPs and laws enacted regarding PDMPs. • Evaluate the current research regarding the effectiveness of PDMPs. • Discuss updates to the Arkansas PDMP.

  14. Are PDMPs effective? • Published June 1st, 2016 • Uses the National Ambulatory Medical Care Survey from 2001-2010 • Compared the prescribing of opioids and other pain medication before and after implementation • Controls were states without a program Bao et al. “Prescription Drug Monitoring Programs Are Associated with Sustained Reductions in Opioid Prescribing by Physicians.” Health Aff (Millwood). 2016 Jun 1; 35(6): 1045–1051.

  15. Are PDMPs effective? Bao et al. “Prescription Drug Monitoring Programs Are Associated with Sustained Reductions in Opioid Prescribing by Physicians.” Health Aff (Millwood). 2016 Jun 1; 35(6): 1045–1051.

  16. Are PDMPs effective? 2.2% 2.1% Bao et al. “Prescription Drug Monitoring Programs Are Associated with Sustained Reductions in Opioid Prescribing by Physicians.” Health Aff (Millwood). 2016 Jun 1; 35(6): 1045–1051.

  17. Are PDMPs effective? 4.3% Bao et al. “Prescription Drug Monitoring Programs Are Associated with Sustained Reductions in Opioid Prescribing by Physicians.” Health Aff (Millwood). 2016 Jun 1; 35(6): 1045–1051.

  18. Are PDMPs effective? • 40% national random sample of Medicare beneficiaries from 2006 to 2012 • Evaluated laws individually and together: • Prescription Limits • Tamper-Resistant Products • Patient Identification • Doctor-Shopping Restriction • Physician Examination • Pharmacist Verification • PDMP Implementation • Pain Clinic Regulation Meara et al. “State Legal Restrictions and Prescription-Opioid Use among Disabled Adults.” N Engl J Med 2016; 375:44-53 DOI: 10.1056/NEJMsa1514387

  19. Are PDMPs effective? Meara et al. “State Legal Restrictions and Prescription-Opioid Use among Disabled Adults.” N Engl J Med 2016; 375:44-53 DOI: 10.1056/NEJMsa1514387

  20. Are PDMPs effective? Meara et al Although, these were not significant after adjustment for multiple comparisons Meara et al. “State Legal Restrictions and Prescription-Opioid Use among Disabled Adults.” N Engl J Med 2016; 375:44-53 DOI: 10.1056/NEJMsa1514387

  21. Are PDMPs effective? • Uses multiple public sources from 1999-2013 • Uses regression models to predict rates of opioid-related overdose deaths for states that had implemented a program and for those that had not Patrick et al. “Implementation of Prescription Drug Monitoring Programs Associated with Reductions in Opioid-Related Death Rates.” Health Aff (Millwood). 2016 Jul 1;35(7):1324-32. doi: 10.1377/hlthaff.2015.1496.

  22. Are PDMPs effective? Patrick et al Patrick et al. “Implementation of Prescription Drug Monitoring Programs Associated with Reductions in Opioid-Related Death Rates.” Health Aff (Millwood). 2016 Jul 1;35(7):1324-32. doi: 10.1377/hlthaff.2015.1496.

  23. Strong Evidence for Improved Clinical Decision-Making, Less Diversion, and Doctor shopping • Green TC, Mann MR, Bowman SE, et al. How does use of a prescription monitoring program change medical practice? Pain Med. 2012;13(10):1314–1323. http://www.ncbi.nlm.nih.gov/pubmed/22845339. • Weiner SG, Griggs CA, Mitchell PM, et al. Clinician impression versus prescription drug monitoring program criteria in the assessment of drug-seeking behavior in the emergency department. Ann Emerg Med. 2013;62(4):281–289. http://www.ncbi.nlm.nih.gov/pubmed/23849618. • BaehrenDF, Marco CA, Droz DE, Sinha S, Callan EM, Akpunonu P. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010;56(1):19–23.e3. http://linkinghub.elsevier.com/retrieve/pii/S0196064409018125. • Surratt HL, O’Grady C, Kurtz SP, et al. Reductions in prescription opioid diversion following recent legislative interventions in Florida. Pharmacoepidemiol Drug Saf. 2014;23(3):314–320. http://www.ncbi.nlm.nih.gov/pubmed/24677496. • BonifasT. Doctor shopping in Virginia for illicit use of pain medication is on the decline. 2014. http://www.dhp.virginia.gov/About/News/PMPRelease06092014.pdf. • ViriginiaPrescription Monitoring Program: 2010 statistics. 2010; http://www.dhp.virginia.gov/dhp_programs/pmp/docs/ProgramStats/2010PMPStatsDec2010.pdf. Accessed September 18, 2018. • Scott R, Armstrong JH, Poston R. Prescription Drug Monitoring Program annual report. 2013; http://www.floridahealth.gov/statistics-and-data/e-forcse/news-reports/_documents/2012-2013pdmp-annual-report.pdf. • PradelV, Frauger E, Thirion X, et al. Impact of a prescription monitoring program on doctor-shopping for high dosage buprenorphine. Pharmacoepidemiol Drug Saf. 2009;18(1):36–43. http://www.ncbi.nlm.nih.gov/pubmed/19040199.

  24. Does mandating their use improve effectiveness? • A 2009-2012 study found that the median registration rate for prescribers across the country was 35% • The rate at which prescribers actually use the database is much lower • Only 26 states require or recommend prescribers access the state’s PDMP database • with the majority only recommending it be accessed. • Arizona recommends prescribers in the state access the database prior to prescribing certain controlled substances • Only 30% of prescribers are signed up to use it Prescription Drug Monitoring Program Training and Technical Assistance Center

  25. Does mandating their use improve effectiveness? • Decline in opioid prescriptions from urgent dental care settings in New York after the implementation of their PDMP mandate • Reduction in opioid prescribing with their enactment among Medicaid enrollees Rasubala L, Pernapati L, Velasquez X, Burk J, Ren Y-F. Impact of a mandatory prescription drug monitoring program on prescription of opioid analgesics by dentists. PLoS One. 2015;10(8):e0135957. Wen H, Schackman BR, Aden B, Bao Y. States with prescription drug monitoring mandates saw a reduction in opioids prescribed to Medicaid enrollees. Health Aff (Millwood). 2017;36(4):733–741.

  26. Are mandates effective? • 2011-2014 Medicaid State Drug Utilization Files • Linear models comparing opioid prescriptions for states exposed to mandates and those not exposed but with a PDMP

  27. Wen et al: States with prescription drug monitoring mandates saw a reduction in opioids prescribed to Medicaid enrollees Wen H, Schackman BR, Aden B, Bao Y. States with prescription drug monitoring mandates saw a reduction in opioids prescribed to Medicaid enrollees. Health Aff (Millwood). 2017;36(4):733–741.

  28. ARIMA Model of Diagnoses for Opioid Abuse and Dependence and Prescriptions for Suboxone

  29. Conclusions • Clear evidence that PDMPs reduce: • Doctor Shopping • Diversion • Clear evidence that PDMPs improve clinical decision-making • Less clear evidence on the overall impact of PDMPs on prescribing

  30. Objectives: • Discuss the history of PDMPs and laws enacted regarding PDMPs. • Evaluate the current research regarding the effectiveness of PDMPs. • Discuss updates to the Arkansas PDMP.

  31. PDMP users • By the end of January 2019, the Arkansas PDMP surpassed 20,000 users. • Top three users are • MD/DO • Pharmacists • Prescriber Delegates • We also share data with other states through the PMP interconnect/RxCheck

  32. Interstate Data Sharing • Number of States: 36 • Puerto Rico • Military Health Systems

  33. AR PDMP over the years • 2015 • Access added to delegates and CLEPDDI • Allows PDMP to provide reports on prescribers/dispensers to professional boards once metrics for the report has been determined by the boards • 2017 • Access added to Medicaid • Verify prescriber/dispenser accounts for insurances • Allows de-identified data for research • Mandatory Use Law/Quarterly Reports • 2019 • Access added to Office of Medicaid Inspector General • Added sharing of data with Military Health Systems

  34. Prescriber Comparison Reports • Quarterly reports sent to all prescribers with a PDMP account and prescribed an opioid within the set time frame • Report that compares prescribing habits within a prescribers specialty (self-identified)

  35. Patient/Clinical Alerts • Alerts are sent out to prescribers/pharmacies notifying when a patient has reached the set thresholds • 2 Thresholds for Patient Alerts • Prescriber/Pharmacy Threshold • 5 prescribers/5 pharmacies within a 90 day period • Drug Combination • Opioid and Benzodiazepine within the same day supply

  36. Doctor Shopping “Doctor shopping” is when a patient goes to multiple providers to get the same prescription or type of prescription. The PDMP identifies patients who get multiple prescriptions from multiple prescribers and fill them at multiple pharmacies.

  37. MyRx Report • Self-report for prescriber • Able to see all controlled Rx’s filled under their DEA # • Forgeries • Pharmacy errors

  38. Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Event ID: 32055-30782

  39. JL Patient Case • JL is a 56 y/o farmer who injured his back 10 years ago, and has had intermittent, severe lower back pain since that time with exacerbations that have limited his ability to work and hold steady employment. His loss of income has led to marital disharmony and eventual marital dissolution. He is a Marine veteran, having served in the 1st Iraq War (Operation Desert Storm), and was a survivor of the Khobar Tower bombing. He reports “losing it” whenever he hears a loud noise such as a door slam, and wakes up in a cold sweet with his heart racing. He has been seen at the local rural health clinic by Dr. Smart who referred him to physical therapy which he was unable to do due to lack of transport, and who prescribed him Oxycontin 30mg BID and Norco 10/325 every 4 hours for breakthrough pain. For the last 8 months, he has been taking six tablets of Norco daily. He also has chronic obstructive lung disease, and is on Spiriva and Serevent, although he continues to smoke 1.5 packs of cigarettes per day. Dr. Smart prescribed him lorazepam 1mg BID for anxiety which he feels when he is due for his oxycodone, which takes the edge off, but doesn’t eliminate the craving. He reports he uses lorazepam more than BID, often using it at nighttime to help him get to sleep. He has used methamphetamine, but feels “he doesn’t have a problem with it”. He reports since his back injury and being placed on Oxycontin, that he has gained 35 lbs, has less energy and less libido, and doesn’t sleep well with frequent waking gasping for air. He presents to you today because “he wants to get off this stuff. • What to do for JL? What to taper first? What to do with the Ativan? What if JL were against tapering? http://www.partnershiphp.org/Providers/HealthServices/Documents/Managing%20Pain%20Safely/TAPERING%20TOOLKIT_FINAL.pdf

  40. What about tapering Fentanyl Patches? • A patient has been using 100 μg/hour fentanyl patches, changed every 72 hours. He also takes oxycodone 10 mg IR q12 h prn. He is not certain this has been helping his pain very much, and it is quite expensive. He would like to taper off this regimen. • Option A: Reduce by 50% every 6 days: • 50 μg/hour × 6 days (new patch on third day) • 25 μg/hour × 6 days (new patch on third day) • 12 μg/hour × 6 days (new patch on third day) • Discontinue • Option B: Reduce by 25 μg/hour (25%) every 15 days • 75 μg/hour every 3 days × 15 days (1 box of 5 patches) • 50 μg/hour every 3 days × 15 days (1 box of 5 patches) • 25 μg/hour every 3 days × 15 days (1 box of 5 patches) • 12 μg/hour every 3 days × 15 days (1 box of 5 patches) • Some recommend tapering the SA first, but here I might start with the patches leaving the IR http://mhc.cpnp.org/doi/full/10.9740/mhc.2015.05.102?code=cpnp-site

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