Institute for Behavioral Health SCHNEIDER INSTITUTES FOR HEALTH POLICY Prescription Drug Monitoring Programs as a Key Tool in Addressing the Opioid Crisis Cindy Parks Thomas and Peter N. Kreiner Academy Health Annual Research Meeting June 27, 2017 Institute for Behavioral Health SCHNEIDER INSTITUTES FOR HEALTH POLICY
Overview • Background: Prescription Monitoring Programs – Data and uses • Prescription Behavior Surveillance System (PBSS) • Types of epidemiological studies conducted – Prescription Behavior Surveillance System (PBSS) data trends and comparison studies – Studies to assess PBSS data quality and consistency – Evaluations of PDMP law, policy, and practice – Studies using PDMP data linked with other health data Institute for Behavioral Health 2 SCHNEIDER INSTITUTES FOR HEALTH POLICY
Background: Prescription Drug Monitoring Programs • 49 states, all retail controlled substance prescriptions reported to state agency; 32 states require checks • Data – Prescription: date, medication, dose, quantity, days supply – Prescriber, pharmacy, location, patient age, gender, ID, CS prescription history • Uses – Prescribers and dispensers check for concurrent prescriptions or prescribers – Identify patterns and questionable activity – high prescribers, multiple prescribers, prescriptions pharmacies – Analytic: epidemiologic studies and surveillance – early warning or growth patterns by geographic area Institute for Behavioral Health 3 SCHNEIDER INSTITUTES FOR HEALTH POLICY
Background: Prescription Behavior Surveillance System (PBSS) • Funded by CDC and FDA • Longitudinal, multi-state database of de-identified PDMP data, to serve as: – Early warning public health surveillance tool – Policy and law evaluation tool • Currently houses data from 12 states: CA, DE, FL, ID, KY, LA, ME, OH, TX, VA, WA, WV • Data mostly from 2010 to present, updated quarterly • 43 descriptive measures and indicators of patient, prescriber, and pharmacy risk behaviors – compiled quarterly for each state Institute for Behavioral Health 4 SCHNEIDER INSTITUTES FOR HEALTH POLICY
Prescription Behavior Surveillance System (PBSS) metrics examples • Overall usage within drug classes and for selected individual drugs • Daily dosage • Overlapping prescriptions within each drug class, across the opioid and benzodiazepine classes, and across dosage forms of opioid analgesics (i.e., immediate vs. extended release) • Questionable activity within a class or classes • Payment sources • Pharmacy-based measures of possible inappropriate dispensing Each participating PDMP provides an initial set of legacy data, with subsequent quarterly updates, enabling an ongoing surveillance of prescription activity trends. Institute for Behavioral Health 5 SCHNEIDER INSTITUTES FOR HEALTH POLICY
PBSS-Related Projects and Studies I • PBSS data trends and comparisons – User-friendly state data briefs and multiple state issue briefs – Comparison of prescribing measures across states, 2013 (Paulozzi, Strickler, Kreiner, & Koris, 2015) – Comparison of prescribing measure and risk indicator trends across states – Examination of veterans’ prescriptions and risk indicators when using community providers vs. VHA providers (Becker et al., 2017) – Examination of prescription dosages by physician specialty in Ohio (Weiner et al., 2017) Institute for Behavioral Health 6 SCHNEIDER INSTITUTES FOR HEALTH POLICY
Hydrocodone SA Prescriptions per 1,000 State Residents By Quarter 250.00 Hydrocodone rescheduled 200.00 CA DE 150.00 FL ID KY LA 100.00 ME OH TX VA WV 50.00 0.00 Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec 2010 2010 2010 2010 2011 2011 2011 2011 2012 2012 2012 2012 2013 2013 2013 2013 2014 2014 2014 2014 2015 2015 2015 2015 2016 2016 2016 2016 7
PBSS-Related Projects and Studies II • Understanding and assessing PDMP data – Methods to assess data quality • Missing data, out-of-bounds values and their effects on surveillance measures – Documentation and assessment of methods to determine which prescriptions belong to the same patient (record linking) – Effects of different record-linking methods on descriptive measures and risk indicators Institute for Behavioral Health 8 SCHNEIDER INSTITUTES FOR HEALTH POLICY
PDMP Record-Linking Comparison: California Measure (2013) Exact match only Probabilistic match Percent change MPE count 718 3920 446.0% Average daily opioid 48.59 48.70 < 1 % dosage (MME) Percent with > 90 12.17 12.12 < 1% MME Percent overlapping 17.09 19.69 15.2% opioid days Percent overlapping opioid and 11.93 13.56 13.7% benzodiazepine days Percent overlapping LA and SA opioid 8.61 9.27 7.7% days Institute for Behavioral Health 9 SCHNEIDER INSTITUTES FOR HEALTH POLICY
PBSS-Related Projects and Studies III • Evaluations of PDMP law, policy, and practice – Evaluation of pilot electronic prescribing of controlled substances project, Berkshire Health System (Thomas et al., 2011, 2013) – Evaluation of Massachusetts PDMP unsolicited reporting (Thomas et al., 2014; Young, Kreiner, & Panas, 2017) – Effects of state mandatory prescriber use of PDMP laws on PDMP usage, prescribing measures, and risk indicators (Kreiner, 2017) Institute for Behavioral Health 10 SCHNEIDER INSTITUTES FOR HEALTH POLICY
Reports Requested by In-State Prescribers: Rate per 1,000 Residents Footnote: Indiana’s data is not available after Q1 of 2015. Institute for Behavioral Health 11 SCHNEIDER INSTITUTES FOR HEALTH POLICY
Overlapping (7 Days) Opioid Prescriptions: Rate per 1,000 Residents Footnote: Indiana’s data is not available after Q1 of 2015. Institute for Behavioral Health 12 SCHNEIDER INSTITUTES FOR HEALTH POLICY
PBSS-Related Projects and Studies IV • PDMP data linked with other health data – Changes in rates of heroin-related vs. prescription opioid- related death rates in Kentucky counties – Buprenorphine prescribing by waivered physicians (Thomas et al., under review) – Validation study of prescriber risk indicators (Kreiner et al., 2017) – Validation study of patient risk indicators • Patient behavior trajectory analysis – Effects of medical board sanctions on subsequent prescriber behavior and effects on their patients Institute for Behavioral Health 13 SCHNEIDER INSTITUTES FOR HEALTH POLICY
Prescription Opioid-related Death Rates per 100,000 Population by County, 2011-2012 and 2013-2014 Prescription opioid-related death rates 0 - 2.00 Prescription opioid-related death rates 2.01 - 2.63 0 - 1.57 2.64 - 3.27 1.58 - 2.29 3.28 - 3.97 2.30 - 2.94 3.98 - 7.24 2.95 - 4.39 4.40 - 7.86 14
Heroin-related Death Rates per 100,000 Population by County, 2011-2012 and 2013-2014 Heroin-related death rates 0 0.01 - 1.42 Heroin-related death rates 1.43 - 1.69 0 0.01 - 1.51 1.70 - 2.43 1.52 - 1.98 2.44 - 5.66 1.99 - 2.65 2.66 - 4.65 15
Kentucky: Opioid Prescriptions per Resident 2011-2012 Average, by County Opioid prescriptions per resident 0.84 - 1.05 1.05 - 1.15 1.15 - 1.25 1.25 - 1.43 1.43 - 1.85 16
Findings from Spatial Regressions • Prescription opioid- • Heroin-related death rates related death rates in in 2013-2014 associated 2013-2014 associated with: with: – Population density (p < .001) – Population mobility (p = .02) – Population density (p < .01) – Percent White (p = .02) – % Hispanic non-White (p = .03) – Spatial lag of heroin-related death – % White (p = .02) rate in 2011-2012 (p < .001) – Opioid prescription rate (p < – R 2 = .400 .001) – R 2 = .563 17
Buprenorphine prescribing patterns study Waivered physician prescribing will likely be critical to addressing insufficient MAT capacity • Approximately 2% of U.S. physicians are waivered • An estimated 33% of waivered physicians are not prescribing buprenorphine • Several small studies suggest that many prescribers treat relatively few patients Funded by ASPE, with RAND Corp. Institute for Behavioral Health 18 SCHNEIDER INSTITUTES FOR HEALTH POLICY
Using PBSS: What we wanted to learn • How many patients were buprenorphine prescribers actually treating? • What was treatment episode duration (long episodes could constrain the total number of patients treated)? • To what extent might patient limits be constraining treatment? Institute for Behavioral Health 19 SCHNEIDER INSTITUTES FOR HEALTH POLICY
ASPE study of waivered physicians ~10,600 prescribers + waiver status 3 states (CA, OH, ME) 223,000+ patients 4 4-year period (2010 – 2013) YEARS NOTES: • All prescribers who prescribed buprenorphine at any point during the study period • PDMP data representing 100% of prescriptions filled at retail pharmacies, excluding those indicated for pain Institute for Behavioral Health 20 SCHNEIDER INSTITUTES FOR HEALTH POLICY
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