Oklahoma PMP

1. Oklahoma PMP Prescription Drug Abuse

2. Definition • The term “doctor shopping” has traditionally referred to a patient obtaining controlled substances from multiple health care practitioners without the prescribers’ knowledge of the other prescriptions.

3. National Restrictions • Almost all states have a “general” fraud statute that adopts verbatim or with slight alteration the provision in the Uniform Narcotic Drug Act of 1932 or the Uniform Controlled Substances Act of 1970. These statutes prohibit obtaining drugs, including through “doctor shopping,” by any or all of the following means: fraud, deceit, misrepresentation, subterfuge, or concealment of material fact.

4. Applicable Laws

5. How PMP’s Can Help • Doctors say they often rely on their own instant judgments in the office and have little reliable means of double-checking the patients' information • It puts doctors in the uncomfortable position of playing private eye. • Unfortunately, with the widespread misuse of controlled substances and diversion risks, we're often taken advantage of • Doctor shoppers often visit facilities where medical professionals don't know them

6. Types of Doctor Shoppers • Patients who have pain but cannot not find a doctor who will adequately treat it • Patients who are addicted • Patients who divert prescription drugs for profit and/or to feed their addiction

7. What Every Pharmacists Should Know It's a relatively insignificant source of diverted prescription drugs, as compared with theft from drug stores, warehouses, acquisition over the Internet, theft from people's homes

8. Fraud and Forgery • Stolen Script Pads • Reproduced Script Pads • Early Fills • Cash Fills vs. Insurance • Pill Mills • Script Mills • Scripts Called In

9. Oklahoma Shoppers

10. Impact • In general, the number of doctor shoppers represent a very small number of total patients • A study in West Virginia found that doctor shoppers are at a much higher risk of death from overdose and abuse • Doctor shoppers divert care from legitimate patients especially in emergency rooms • In Oklahoma, a single doctor shopper visited 108 doctors and 93 pharmacies in less than a year • Prescribing more doses than needed increases opportunity

11. PMP’s and What They Do • A statewide electronic database that gathers information from dispensers of controlled substances • Pharmacies • Doctors • Veterinarians • A tool used to guard against the diversion of controlled drugs • A diagnostic tool used by practitioners to evaluate patients • A research tool to identify trends and help identify solutions

12. Controlled Drugs in Oklahoma

13. Trends

14. #1 Hydrocodone

15. The Rise of z-Sedatives • According to the National Institutes of Health, approximately 30 percent of all Americans complain of sleep disruption, while 10 percent display symptoms congruent with chronic insomnia. One of the most common treatments for insomnia is prescription sleep medications that help people fall asleep and remain asleep. Historically barbiturates were initially popular for treating insomnia, but their long "hangover" effect made them easily replaced with the introduction of the benzodiazepines. Triazolam (Halcion), diazepam (Valium), and oxazepam (Serax) rapidly became the treatment of choice for insomnia. Recently a new class of nonbenzodiazepines---the "z-sedatives"--has overtaken the older benzodiazepines as the most commonly prescribed sleep medications. The three most popular z-drugs are zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). The Food and Drug Administration (FDA) also recently approved the production of zolpidem tartrate, a generic form of Ambien. Many dentists prescribe these medications for patients who have difficulty sleeping the night prior to an appointment or as a procedural sedative. With 43 million prescriptions for sleep medications filled in 2005, generating $2.7 billion for pharmaceutical companies, it is important that dentists be aware of these drugs' mechanism of action and potential drug interactions. • http://www.ncbi.nlm.nih.gov/pubmed/18069595

16. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1993866/

17. Opiates and Benzos • Some combinations of drugs can be dangerous and even deadly. Mixing benzodiazepines and opiates can be extremely dangerous. Both benzos and opiates are central nervous system depressants. When taking both a benzodiazepine, such as lorazepam, and an opiate like morphine, the drugs can lead to excessive depression of the nervous system, causing respiratory depression and ultimately death. • http://www.desmoinesaddictiontreatment.com/rehab-guide/dangers-of-using-benzodiazepines-with-opiates/

18. Opiate/Benzo Research • According to the evidence, there is a positive association between the risk of death and the use of benzodiazepines in combination with methadone. Though limited, there is an indication that opioids, including buprenorphine, have the potential for increased risk in combination with benzodiazepines. Clinical mechanisms are hypothesized. • - See more at: http://www.thementalelf.net/mental-health-conditions/anxiety-disorders/is-it-safe-to-prescribe-benzodiazepines-and-opioids-together/#sthash.L92Va1MB.dpuf

19. Real Conversations from Drug Seekers • “UserX had this happen to him when he never did benzos (oxy+diazapam). the high was no where near as good as pure OC. now he cant do opiates without wanting benzos, its like the high is incomplete. but now hes a benzo addict...” • “My doctor has me on 8 MG of Xanax daily. (QID) 2 MG. Xanax bars) then for my spinal infection Percocet 10/325 6 times a day. Im also on Zoloft 200 MG's a day... im only 27 years old and i feel like i am 50 years old. Im going to ask to be switched to Valium again because of the rebound anxiety i get with Alprazolam.. i also live in the state of CALIFORNIA i possess my Prop 215 Card for Medicinal Cannabis(i feel Cannabis is the best medicine for anxiety and severe pain HANDS DOWN!!!! im allowed to exceed the limit on my card. i can possess 6 pounds of buds, and grow up to 90 plants. I love California”

20. When Overprescribing Becomes Criminal • DrX • 8th in Schedule II Prescribing • 1st in Scehdule III Prescribing • 1st in Scheudle IV Prescribing • At one point was writing nearly 3% of all opiates dispensed in Oklahoma • 10+ Overdose Deaths • Multiple Counts of Murder • Previous felony convictions involving controlled drugs • Motivation?

21. Morphine Equivalent • More than 100mg of morphine equivalent per day increases the risk of death by overdose by 9 times. • Direct correlation between mortality and morphine equivalent • Opiate Naïve Patients

22. Making a Difference • Nationally Recognized as the Leaders in Innovation and Leadership Among State PMP’s • Real Time Reporting by Dispensers (Within 5 Minutes) • Practitioner Use up 167% • Pharmacy Use up 1,085% • Law Enforcement/Regulatory Use up 60% • For the 1st Time in the Last Two Years Accidental Overdose Deaths have Declined • Full Time PMP Trainer Hired • De-Identified PMP Data Being Provided to ODMHS Nov. 1, 2013

23. Leadership and Innovation • Question and Listen • Challenge and Communicate • Risk Experimentation • Reflect • Consider Dynamics Inside and Outside the Organization • Be Authentic • Be Outcome Driven • Dare to Imagine

24. New Laws • Interstate Data Sharing (November 1, 2014) • Access by Federal Medical Professionals without being Registrants • Enumerated Delegate Accounts • Mandatory PMP Queries New Processes • Recommended prescribing guidelines • Prescriber dispensing education

25. Vision We cannot solve a problem by using the same kind of thinking we used when we created them. [A. Einstein]