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New Developments in PDMPs:South Carolina, Wisconsin and Florida
Presenters:• Christie Frick, RPh, Director, Prescription Monitoring Program, South
Carolina Department of Health and Environmental Control• Chad Zadrazil, JD, Managing Director, Wisconsin Department of Safety and
Professional Services• Chris Delcher, PhD, Assistant Professor, University of Florida• Bruce Goldberger, PhD, Chief, Division of Forensic Medicine, University of
Florida College of Medicine
PDMP Track
Moderator: Karen H. Perry, Co-Founder and Executive Director, Narcotics Overdose Prevention and Education (NOPE) Task Force, and Member, Rx and Heroin Summit National Advisory Board
Disclosures
Chris Delcher, PhD; Christie Frick, RPh; Bruce Goldberger, PhD; Chad Zadrazil, JD; and Karen H. Perry have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.
Disclosures
• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest:
Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
Learning Objectives
1. Describe how two states improved integration of PDMP data into electronic health IT systems.
2. Identify challenges states may face when integrating PDMP data into electronic health IT systems.
3. Explain the operation and findings of Florida’s nascent drug surveillance systems.
4. Provide accurate and appropriate counsel as part of the treatment team.
New Developments in PDMPs: South Carolina, Wisconsin and
Florida
Christie Frick, RPh, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
Learning Objectives:
1. Describe how two states improved integration of PDMP data into electronic health IT systems.
2. Identify challenges states may face when integrating PDMP data into electronic health IT systems.
8
• In 2012 South Carolina joined the PMP InterConnect to facilitate interoperability and interstate data sharing between state PMPs.
• Currently sharing with 20 states. MI
AZ
NM
ND
KS
OH
SC
VAKY
SD
LA
IL
CT
DE
MS
ID
IN
WI
TN
MN
CO
AR
NJ
WV
NV
PMP InterConnect: A Nationwide PMP Data Sharing Platform
9
Pharmacists
Prescribers
Health Exchanges
MI
AZ
NM
ND
KS
OH
SC
VAKY
SD
LA
IL
CT
DE
MS
ID
IN
WI
TN
MN
CO
AR
NJ
WV
NV
PMP Gateway: A Health IT Connectivity Platform for PMP Data
South Carolina’s Integrations
• Palmetto Health System (Cerner EMR)• Lexington Medical Center (Epic EMR)
• Rx Care Plus Pharmacies (QS 1)• Kroger Pharmacy
Patient searches between October 1- December 31, 2015
Palmetto Health Emergency Departments (3 locations) 54,443Lexington Medical Center Emergency Department 1,543
So….what’s the big deal?
54,443 + 1,543 = 55,98655,986 x 3 mins = 167,958 mins = 2,799 hours
of time saved in the Emergency Room in 3 months!!
So…why isn’t everyone integrating?
•Get in line for a health system IT project•Cost (SC was fortunate enough to get a SAMHSA grant for funding)•Legal Agreements/Contracts•Authorizing Users – Must they be signed up separately with PMP (Need for Privacy Statement)
13
Agreements in Place
PMPs
State PMPs have MOUs in place with PMP InterConnect.
A contract is in place between Appriss/PMP Gateway and NABP/InterConnect.
Healthcare entity must have a contract in place with Appriss/PMP Gateway.
PMPs
PMPs
SC
In SC, PMP must also have a contract with each entity receiving funds.
Is it worth it?
“I am working and one of the attendings came over and said ‘your new drug check’ just saved a man’s
life. Its a long story, but it was the highest narc score we had seen. He was here for a pseudo medical
problem that seemed legit and he likely would have gotten more meds from what he was saying. Since
NarcRx popped up right as soon as the doc looked at his chart, the doctor went back into the room and the whole story changed. He is now getting help with his
drug abuse. “
New Developments in PDMPs: South Carolina, Wisconsin and Florida
Experience in Wisconsin
March 30, 2016
Disclosure
Chad Zadrazil, JD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
Learning Objectives
1. Describe how two states improved integration of PDMP data into electronic health IT systems.
2. Identify challenges states may face when integrating PDMP data into electronic health IT systems.
18
PMPi
October 2013 Connection
PMP Gateway
September 2014 Connections
October 2015 Connection
EHR Integration in Wisconsin
19
20
MCIS PDMP Interface
FICTITIOUS DATA
21
MCIS PDMP Interface
FICTITIOUS DATA
Barrier to Integration
Legal Definition of “access”
Original Definition:To obtain access to PDMP information, pharmacists, pharmacist delegates, practitioners, and practitioner delegates shall create an account with the board on a form provided by the board.
Solution: Additions to “Access” Definition
• Create an account with a pharmacy or other entity at which pharmacists dispense or administer monitored prescription drugs in the course of professional practice with which the board has determined to have at least equivalent capability to maintain the confidentiality of PDMP information or that is connected to and lawfully obtains data from the state-designated entity under ch. 153, Stats.
• Create an account with a hospital or other entity at which practitioners prescribe, dispense, or administer monitored prescription drugs in the course of professional practice with which the board has determined to have at least equivalent capability to maintain the confidentiality of PDMP information or that is connected to and lawfully obtains data from the state-designated entity under ch. 153, Stats. Cite: Wisconsin Administrative Code CSB 4.09
Updated Definition of “Access”
Recognizes and authorizes:• Integration into pharmacy dispensing software• Integration into electronic medical records
and prescribing modules• Integration into the Wisconsin Statewide
Health Information Network (WISHIN), the HIE in WI
2016: A Year of WI PDMP Evolution
In addition to our current and future PDMP-HIT integration projects…
2016: A Year of WI PDMP Evolution• H.O.P.E. Agenda Bills (AB 364):
– Increases data submission frequency from 7 days to 1 day
– Requires prescribers to review PDMP data prior to issuing a prescription order for a controlled substance (some exceptions)
– Allows law enforcement agencies and prosecutorial units to request PDMP data without a court order
– Adds access for non-prescriber healthcare and substance abuse professionals
2016: A Year of WI PDMP Evolution• H.O.P.E. Agenda Bills (AB 365):
– Requires law enforcement agencies to report any of the following to the PDMP for dissemination to PDMP users:
• A suspected violation of the CSA involving a prescription drug
• A person who is undergoing or who immediately prior experienced an opioid-related overdose event
• A person who may have died as a result of using a narcotic drug
• A report of a stolen controlled substance prescription
Development of the WI ePDMP
• The primary emphasis of the design of the enhanced WI PDMP (“ePDMP”) is:• value-added clinical workflow integration• improved data quality capabilities• maximized public safety use
• Stakeholders and users are closely involved in every step of the process
Development of the WI ePDMP• Possible due to federal support and inter-agency
collaboration:
• 2014 Harold Rogers PDMP Enhancement Grant
• 2015 Harold Rogers PDMP Enhancement Grant
• 2015 CDC Prescription Drug Overdose Prevention Grant (in partnership with WI Department of Health Services)
Development of the WI ePDMP
• Iterative Design and Development Process• Modular, user-centered focus
• Continual user input and testing
• Feedback loop with stakeholders and subject matter experts
DRAFT
DRAFT
DRAFT
DRAF
T
FICT
ITIO
US
DATA
DRAF
T
FICT
ITIO
US
DATA
New Developments in PDMPs: South Carolina, Wisconsin and Florida
PDMP Track
Disclosure Statement• Bruce Goldberger, PhD, Professor, has disclosed no relevant,
real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
• Chris Delcher, PhD, Assistant Professor, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
Learning Objectives• Describe how two states improved integration of PDMP data
into electronic health IT systems.• Identify challenges states may face when integrating PDMP
data into electronic health IT systems.• Explain the operation and findings of Florida’s nascent drug
surveillance systems.• Provide accurate and appropriate counsel as part of the
treatment team.
Florida Medical Examiners Commission
• Temporal Coverage– Drug-related death data available since 2000
• Submission Source– District Medical Examiners
• Autopsy, toxicology results, decedent's drug use history, physical evidence, etc.
• Cause of death versus present in the body at the time of death• Accidental, natural, suicide, homicide and undetermined
• Specificity– Data collected in 2014 (# of drugs reported)
• Amphetamines (2), Benzodiazepines (13), Ethanol, Hallucinogenics (3), Inhalants (4), Opioids (12), Other (9)
Florida Prescription Drug Monitoring Program
• Implementation– September 2011
• Controlled substance schedules monitored– II, III, IV
• Voluntary registration• On-going updates
– Veteran’s Administration began reporting on October 1, 2014.
Period 1: 2003 - 2009
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
1.3
4.4 (+233.8%)
0.7
0.7 (0%)1.4
0.5 (-62.2%)1.3
1.6 (+26.2%)1.8
6.4 (+264.6%)
Alprazolam Fentanyl Heroin Morphine Oxycodone
Deat
h Ra
te (p
er 1
00,0
00 p
opul
ation
)
The original controlled-release formula-tion OxyContin® was approved in De-cember 1995 (launched in 1996).
Oxycodone is one of the most frequently abused prescription opioids (Cicero et al. 2005)
Percent change shown reported in (Goldberger et al., 2011)
Period 1 con’t: 2010
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
1.3
5.2
0.70.6
1.4
0.31.3
1.4
1.8
8.0
Alprazolam Fentanyl Heroin Morphine Oxycodone
Deat
h Ra
te (p
er 1
00,0
00 p
opul
ation
)
Oxycodone and alprazolam-caused death rate peaked in 2010Heroin death rate reached its lowest in 2010(Lee et al., 2014)
Period 2: “PILL Zone” (Interventions)
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
1.3
5.2
0.7
0.6
1.4
0.3
1.3
1.4
1.8
8.0
Alprazolam Fentanyl Heroin Morphine Oxycodone
Deat
h Ra
te (p
er 1
00,0
00 p
opul
ation
)
IndustryReformulated OxyContin® came on the market in August 2010 Legislative Actions1Jan 2010: Pain clinics must register2Oct 2010: Pain clinic regulation expanded3July 2011: Physician dispensing prohibited/strike forces activated4Sep 2011: Florida PDMP implemented5July 2012: Wholesale distributor regulations expandedLaw Enforcement (DEA Actions)Operation Pill Nation 6Feb 2010, 7Feb 2011, 8Aug 2012(Johnson et al., 2014)
PDMP Implementation
PILL: Public Health, Industry, Legislation, Law Enforcement
Period 3: 2010 – 2014 (Effects)
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
5.20535772985276
2.86025991568919 (-45.1%)
0.604903956374327
1.99564707650019 (+229.9%)
0.254696402683927
2.05094208365763 (+705.2%)1.39021786464977
3.5439072769084 (+154.9%)
8.04416138476736
2.36260485127227 (-70.6%)
Alprazolam Fentanyl Heroin Morphine Oxycodone
Deat
h Ra
te (p
er 1
00,0
00 p
opul
ation
)
Legislative and Regulatory Effect• Rx drug overdose deaths -23.2%, 2010-2012 (Johnson et al., 2014)• Rx opioid diversion declined, 2009-2012 (Surratt et al., 2014)• Oxycodone-caused mortality abruptly declined 25% month after PDMP
(Delcher et al., 2015)• Opioid prescriptions -1.4%, volume -2.5%, MME/transaction -5.6%,
2011-2012 (Rutkow et al, 2015)• ~1,029 lives saved from rx opioid overdose, 2010-2012
(Kennedy-Hendricks et al., 2016)Heroin• Connection b/w nonmedical use of prescription opioids and heroin use
(Compton et al., 2016)
PDMP Implementation
2003 - 2014
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
Alprazolam Fentanyl Heroin Morphine Oxycodone
Deat
h Ra
te (p
er 1
00,0
00 p
opul
ation
)
Surveillance Opportunities: Time
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 20150
20
40
60
80
100
120
140
160
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
Alprazolam (Deaths) Oxycodone (Deaths) Alprazolam (Rx)Oxycodone Long Acting (Rx) Oxycodone Short Acting (Rx)
Deat
hs, N
o.
Pres
crip
tions
, No.
PDMP Implementation
Surveillance Opportunities: Person
18-24 25-34 35-44 45-54 55-64 65 and older
050
100150200250300350400450
Stimulants
FemaleMale
# of
Rx
per 1
,000
pop
ulati
on
18-24 25-34 35-44 45-54 55-64 65 and older
0200400600800
1,0001,2001,4001,600
Benzodiazepines
# of
Rx
per 1
,000
pop
ulati
on
18-24 25-34 35-44 45-54 55-64 65 and older
0
200
400
600
800
1,000
1,200
1,400
Opioids
# of
Rx
per 1
,000
pop
ulati
on
Surveillance Opportunities: PlaceOPIOIDS
OPIOIDS Prescriptions per 1,000 Population, RY2014 OPIOIDS-Caused Deaths per 100,000 Population, CY2014 OPIOIDS-Related Deaths per 100,000 Population, CY2014
Rate (Quartile)5.180 - 13.15313.636 - 18.05018.076 - 24.61024.699 - 39.532
Rate (Quartile)0.899 - 6.3916.688 - 8.4788.839 - 11.51611.536 - 23.266
Rate (Quartile)283.080 - 705.693709.511 - 891.902913.402 - 1072.8581092.324 - 1451.318
OPIOIDS Prescriptions per 1,000 Population, RY2014 OPIOIDS-Caused Deaths per 100,000 Population, CY2014 OPIOIDS-Related Deaths per 100,000 Population, CY2014
Rate (Quartile)5.180 - 13.15313.636 - 18.05018.076 - 24.61024.699 - 39.532
Rate (Quartile)0.899 - 6.3916.688 - 8.4788.839 - 11.51611.536 - 23.266
Rate (Quartile)283.080 - 705.693709.511 - 891.902913.402 - 1072.8581092.324 - 1451.318
Surveillance Opportunities: PlaceOPIOIDS
Surveillance Opportunities con’t: PlaceBENZODIAZEPINES
BENZODIAZEPINES Prescriptions per 1,000 Population, RY2014 BENZODIAZEPINES-Caused Deaths per 100,000 Population, CY2014 BENZODIAZEPINES-Related Deaths per 100,000 Population, CY2014
Rate (Quartile)4.993 - 9.1519.173 - 13.49713.584 - 19.17319.304 - 51.238
Rate (Quartile)0.673 - 2.4322.488 - 4.0064.044 - 6.0536.391 - 32.939
Rate (Quartile)262.371 - 461.706463.866 - 518.818520.136 - 625.355626.343 - 795.535
BENZODIAZEPINES Prescriptions per 1,000 Population, RY2014 BENZODIAZEPINES-Caused Deaths per 100,000 Population, CY2014 BENZODIAZEPINES-Related Deaths per 100,000 Population, CY2014
Rate (Quartile)4.993 - 9.1519.173 - 13.49713.584 - 19.17319.304 - 51.238
Rate (Quartile)0.673 - 2.4322.488 - 4.0064.044 - 6.0536.391 - 32.939
Rate (Quartile)262.371 - 461.706463.866 - 518.818520.136 - 625.355626.343 - 795.535
Surveillance Opportunities con’t: PlaceBENZODIAZEPINES
US and State Rx Opioid Poisoning Mortality, 1999-2014
US Rate
Source: National Center for Health Statistics, CDC WONDER Online Database, released 2015.
2000 2005 2010 2015 2000 2005 2010 2015 2000 2005 2010 2015 2000 2005 2010 2015
0
10
20
30
0
10
20
30
0
10
20
30
Florida1.5
5.8
Kentucky1.2
11.5
Nevada
5.6
9.6
New Mexico
8.7
14.5
Oklahoma2.6
12.2
Oregon1.2
5.1
South Carolina1.0
9.3
Utah
6.0
16.0
Vermont4.0
7.0
Washington2.7
5.5
West Virginia1.5
24.7
Wisconsin1.1
6.9
Year
Age Adjusted Rate (per 100,000 population)
ReferencesCicero, T. J., Inciardi, J. A., & Muñoz, A. (2005). Trends in abuse of Oxycontin and other opioid analgesics in the United States: 2002-2004. The Journal of Pain: Official Journal of the American Pain Society, 6(10), 662–672.
Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016). Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. The New England Journal of Medicine, 374(2), 154–163.
Delcher, C., Wagenaar, A. C., Goldberger, B. A., Cook, R. L., & Maldonado-Molina, M. M. (2015). Abrupt decline in oxycodone-caused mortality after implementation of Florida’s Prescription Drug Monitoring Program. Drug and Alcohol Dependence.
Goldberger, B., Thogmartin, J., Johnson, H., Paulozzi, L., Rudd, R., & Ibrahimova, A. (2011). Drug Overdose Deaths — Florida, 2003–2009. Morbidity and Mortality Weekly (MMWR), 60, 869–872.
Johnson, H., Paulozzi, L., Porucznik, C., Mack, K., Herter, B., & Hal Johnson Consulting and Division of Disease Control and Health Promotion, Florida Department of Health. (2014). Decline in drug overdose deaths after state policy changes - Florida, 2010-2012. MMWR. Morbidity and Mortality Weekly Report, 63(26), 569–574.
Kennedy-Hendricks, A., Richey, M., McGinty, E. E., Stuart, E. A., Barry, C. L., & Webster, D. W. (2016). Opioid Overdose Deaths and Florida’s Crackdown on Pill Mills. American Journal of Public Health, 106(2), 291–297.
Lee, D., Delcher, C., Maldonado-Molina, M. M., Bazydlo, L. A. L., Thogmartin, J. R., & Goldberger, B. A. (2014). Trends in licit and illicit drug-related deaths in Florida from 2001 to 2012. Forensic Science International.
Rutkow, L., Chang, H.-Y., Daubresse, M., Webster, D. W., Stuart, E. A., & Alexander, G. C. (2015). Effect of Florida’s Prescription Drug Monitoring Program and Pill Mill Laws on Opioid Prescribing and Use. JAMA Internal Medicine, 175(10), 1642–1649.
Surratt, H. L., O’Grady, C., Kurtz, S. P., Stivers, Y., Cicero, T. J., Dart, R. C., & Chen, M. (2014). Reductions in prescription opioid diversion following recent legislative interventions in Florida. Pharmacoepidemiology and Drug Safety, 23(3), 314–320.
Acknowledgements
• Florida Medical Examiners Commission (FDLE)• Florida Prescription Drug Monitoring Program
(FDOH)• Prescription Behavioral Surveillance System
(CDC) • BJA Grant #: 2013-PM-BX-0010
New Developments in PDMPs:South Carolina, Wisconsin and Florida
Presenters:• Christie Frick, RPh, Director, Prescription Monitoring Program, South
Carolina Department of Health and Environmental Control• Chad Zadrazil, JD, Managing Director, Wisconsin Department of Safety and
Professional Services• Chris Delcher, PhD, Assistant Professor, University of Florida• Bruce Goldberger, PhD, Chief, Division of Forensic Medicine, University of
Florida College of Medicine
PDMP Track
Moderator: Karen H. Perry, Co-Founder and Executive Director, Narcotics Overdose Prevention and Education (NOPE) Task Force, and Member, Rx and Heroin Summit National Advisory Board