💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...
Ph 2 paulozzi paone_kelly
1. Pharmacy
Track
Panel
Discussion:
Trends
in
Prescribing
Prac7ces
Presenters:
Len
Paulozzi,
MD,
MPH
Denise
Paone,
EdD
Tom
Kelly,
R.Ph.,
B.Sc
Moderator:
Andrew
Kolodny,
MD
2. Disclosures
• Len
Paulozzi
• Denise
Paone
has
no
financial
rela7onships
with
proprietary
en77es
that
produce
health
care
goods
and
services
• Thomas
Kelly
has
financial
rela7onships
with
proprietary
en77es
that
produce
health
care
products
and
services.
These
financial
rela7onships
are:
– President/C.E.O.
Medicine
To
Go
Pharmacies
• Retail
pharmacies
– President/C.E.O./Partner,
PPTP.net,
LLC
• Online
due
diligence
tool
for
preven7on
of
misuse,
abuse,
and
diversion
3. Learning
Objec7ves
1. Describe
current
trends
in
effec7ve
prescribing
habits.
2. Outline
best
prac7ces
for
u7lizing
data
and
PDMPs
as
effec7ve
tools
in
dispensing
controlled
substances.
3. Evaluate
opportuni7es
for
pharmacists
to
collaborate
with
prescribers
to
create
an
effec7ve
treatment
plan
for
their
pa7ents.
4. TM
Centers for Disease Control and Prevention
National Center for Injury Prevention and Control
Trends
in
Prescribing
of
Controlled
Substances,
United
States,
2007-‐2012
Len
Paulozzi,
MD,
MPH
Centers
for
Disease
Control
and
Preven7on
Na7onal
Prescrip7on
Drug
Summit
Atlanta,
GA
April
22,
2014
5. 5
Overview
Trends
in
mortality
Trends
in
prescribing
of
controlled
substances
Conclusions
6. Motor
vehicle
traffic,
poisoning,
and
drug
poisoning
death
rates,
United
States,
1980-‐-‐2010
0
5
10
15
20
25
1980
1985
1990
1995
2000
2005
2010
Deaths
per
100,000
popula?on
Motor
vehicle
traffic
Poisoning
Drug
poisoning
CDC/NCHS
Na7onal
Vital
Sta7s7cs
System
accessed
through
CDC
WONDER.
7. Drug
overdose
deaths
by
major
drug
type,
United
States,
1999-‐2010
CDC/NCHS
Na7onal
Vital
Sta7s7cs
System,
CDC
WONDER
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Number
of
Deaths
Year
Opioids
Heroin
Cocaine
Benzodiazepines
16,651
9. 9
Prescrip7on
Data
Source
Purchase
from
IMS
• Na7onal
Prescrip7on
Audit
(NPA)
2007-‐2012
• Data
from
38,000/57,000
pharmacies
• Includes
retail,
mail-‐order,
and
long-‐term
care
• Na7onal-‐level
counts
for
prescrip7ons
and
units
(e.g.,
pills)
es7mated
using
a
proprietary
method
• CDC
converted
to
popula7on-‐based
rates
• Non-‐Butrans
buprenorphine
excluded
from
opioid
rates
10. 10
Total
prescrip7on
rate,
United
States,
2007-‐2012
128,000
129,000
130,000
131,000
132,000
133,000
134,000
135,000
136,000
2007
2008
2009
2010
2011
2012
Prescrip?ons
per
10,000
Source:
IMS
Na7onal
Prescrip7on
Audit
(NPA)®
Extracted
July,
2013
Increase
from
13.1
to
13.5
prescrip7ons
per
person
from
2007
to
2012.
11. 11
Opioid
analgesic
prescrip7on
and
unit
rates,
United
States,
2007-‐2012
7,500
8,000
8,500
9,000
9,500
10,000
0
100,000
200,000
300,000
400,000
500,000
600,000
2007
2008
2009
2010
2011
2012
Prescrip?ons
per
10,000
Units
per
10,000
Unit
rate
Prescrip7on
rate
1%
drop
from
2010
Source:
IMS
Na7onal
Prescrip7on
Audit
(NPA)®
Extracted
July,
2013.
Excludes
buprenorphine
other
than
BuTrans
products.
Units
limited
to
solid
dosage
forms.
1%
increase
from
2010
14. 14
Other
major
opioids
prescrip7on
rate,
United
States,
2007-‐2012
0
100
200
300
400
500
600
2007
2008
2009
2010
2011
2012
Prescrip?ons
per
10,000
Morphine
Fentanyl
Methadone
Codeine
Oxymorphone
Source:
IMS
Na7onal
Prescrip7on
Audit
(NPA)®
Extracted
July,
2013
15. 15
Other
major
opioids
prescrip7on
rate,
United
States,
2007-‐2012
0
100
200
300
400
500
600
2007
2008
2009
2010
2011
2012
Prescrip?ons
per
10,000
Morphine
Fentanyl
Methadone
Codeine
Oxymorphone
Source:
IMS
Na7onal
Prescrip7on
Audit
(NPA)®
Extracted
July,
2013
Methadone
increased
sharply
to
2008,
when
DEA
compelled
restricted
use
of
the
largest
formula7on.
Rate
in
2012
same
as
rate
in
2007.
16. 16
Oxymorphone
prescrip7on
rate,
United
States,
2007-‐2012
0
10
20
30
40
50
60
2007
2008
2009
2010
2011
2012
Prescrip?ons
per
10,000
Source:
IMS
Vector
One® Na7onal
(VONA)
Extracted
July,
2013
Abuse-‐resistant
extended-‐release
formula7on
(Opana
ER)
came
on
market
February,
2012.
Rate
dropped
19%
from
2011
to
2012.
17. 17
Opioid
analgesic
prescrip7on
rate
by
payment,
United
States,
2007-‐2012
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
2007
2008
2009
2010
2011
2012
Prescrip?ons
per
10,000
Total
Cash
Cash
17%
of
all
opioid
rx
Source:
IMS
Na7onal
Prescrip7on
Audit
(NPA)®
Extracted
July,
2013
Excludes
buprenorphine
other
than
BuTrans
products
Cash
9%
of
all
opioid
rx
18. 18
Hydrocodone
and
oxycodone
prescrip7on
rate
paid
with
cash,
United
States,
2007-‐2012
0
100
200
300
400
500
600
700
800
900
2007
2008
2009
2010
2011
2012
Prescrip?ons
per
10,000
Hydrocodone
Oxycodone
48%
drop
from
20077
39%
drop
Source:
IMS
Na7onal
Prescrip7on
Audit
(NPA)®
Extracted
July,
2013
19. 19
Benzodiazepine
prescrip7on
and
unit
rates,
United
States,
2007-‐2012
200,000
205,000
210,000
215,000
220,000
225,000
230,000
235,000
240,000
2,500
2,700
2,900
3,100
3,300
3,500
3,700
3,900
4,100
4,300
2007
2008
2009
2010
2011
2012
Units
per
10,000
Prescrip?ons
per
10,000
Prescrip7on
rate
Unit
rate
Source:
IMS
Na7onal
Prescrip7on
Audit
(NPA)®
Extracted
July,
2013
21. 21
Carisoprodol
prescrip7on
rate,
United
States,
2007-‐2012
290
300
310
320
330
340
350
360
370
2007
2008
2009
2010
2011
2012
Prescrip?ons
per
10,000
Source:
IMS
Na7onal
Prescrip7on
Audit
(NPA)®
Extracted
July,
2013
DEA
places
carisoprodol
in
Schedule
IV,
Jan
2012;
11%
drop
22. Conclusions
Drug
overdose
epidemic
driven
by
overdoses
of
prescrip?on
opioids,
oPen
combined
with
benzodiazepines
and/or
muscle
relaxants
Opioid
overdose
rates
parallel
prescrip?on
rates
Steady
increase
in
opioid
prescribing
rate
since
1999
has
finally
leveled
off
Abuse-‐resistant
formula?on,
scheduling
change
appear
to
be
associated
with
largest
declines
in
certain
drugs
Overall
declines
alone
likely
too
small
to
reduce
prescrip?on
overdose
mortality
aPer
2010
23. Comments or questions:
Len Paulozzi, MD, MPH
lpaulozzi@cdc.gov
The
findings
and
conclusions
in
this
report
are
those
of
the
author
and
do
not
necessarily
represent
the
official
posi6on
of
the
Centers
for
Disease
Control
and
Preven6on/the
Agency
for
Toxic
Substances
and
Disease
Registry.
The
presenter
has
no
conflicts
of
interest
to
report.
Acknowledgements:
Jinnan Liu, PhD
Karin Mack, PhD
Chris Jones, PharmD, MPH
24. Prescrip?on
Monitoring
Program
(PMP)
in
New
York
City
Denise
Paone,
EdD
Director
of
Research
and
Surveillance
Bureau
of
Alcohol
and
Drug
Use
Preven7on,
Care,
and
Treatment
New
York
City
Department
of
Health
and
Mental
Hygiene
25. Disclosure
Statement
Denise
Paone
has
no
financial
rela7onships
with
proprietary
en77es
that
produce
health
care
goods
and
services
25
26. PMP:
Background
• Historically
,
seen
as
a
law
enforcement
tool:
– To
iden7fy
pa7ents
and
prescribers
engaged
in
possible
aberrant
behavior
– To
iden7fy
“doctor
shoppers”
– To
inves7gate
drug
diversion
&
fraud
• NYC
DOHMH
using
PMP
as
a
public
health
surveillance
tool:
– To
iden7fy
and
describe
palerns
of
opioid
analgesic
use
at
pa7ent
and
prescriber
levels
– To
iden7fy
pa7ents
at
risk
for
fatal
and
non-‐fatal
overdose
–
To
reduce
prescrip7on
drug
misuse
and
diversion
–
As
a
drug
epidemic
warning
system
• NYC
DOHMH
uses
PMP
as
a
pa7ent
care
tool:
– To
iden7fy
pa7ents
with
possible
substance
use
disorders
– To
avoid
risky
drug
Interac7ons
– To
iden7fy
and
reduce
pa7ent
visits
to
mul7ple
prescribers
• PMP
not
meant
to
infringe
on
the
legi7mate
prescribing
of
controlled
substances
Source: http://www.pmpalliance.org/content/prescription-monitoring-frequently-asked-questions-faq
27. PMP:
public
health
surveillance
tool
• Number
of
prescrip7ons,
pa7ents,
prescriber,
pharmacies
• Rate
of
opioid
analgesic
prescrip7ons
filled
overall
and
by
drug
type
• Median
day
supply
• Rate
of
pa7ents
filling
opioid
analgesic
prescrip7ons
• Rate
of
high
dose
opioid
analgesic
prescrip7ons
filled
28. PMP
surveillance
used
to
inform
public
health
ini?a?ves
• Opioid
prescribing
guidelines
• City
Health
Informa7on
(CHI)
–
primary
care
• Emergency
Department
guidelines
• Staten
Island
detailing
campaign
• Focused
on
prescribers
• Morphine
milligram
equivalent
calculator
• Media
campaign
• Public
Service
Announcement
on
“prescrip7on
painkiller
use”
29. Analy?c
methods
• Focus
on
schedule
II
prescrip7on
opioid
analgesics
(excluding
codeine-‐cII)
• Exclude
missing
pa7ent
or
prescriber
IDs,
veterinarians,
or
ins7tu7onal
licenses
• Report
rates
per
1,000
residents
and
adjust
to
2000
US
Standard
popula7on
31. Prescrip?on
variables
• Dura7on
of
ac7on
– Long-‐ac7ng
or
short-‐ac7ng
• Day
supply
• Morphine
Equivalent
Dose
(MED)
– Conversion
of
the
daily
dose
of
an
opioid
analgesic
prescrip7on
to
its
morphine
milligram
equivalent
– High
MED,
or
high
dose,
prescrip7ons
confer
increased
risks
of
overdose,
specifically
when
MED
≥
100.
32. USING
PMP
TO
DESCRIBE
PATTERNS
OF
OPIOID
ANALGESIC
PRESCRIPTION
USE
IN
NEW
YORK
CITY
33. Opioid
analgesic
(OA)
prescrip?ons
NYC,
2008–2012
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
2008 2009 2010 2011 2012
NumberofPrescriptions
YearSource: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2008–2012
Opioid analgesic prescriptions
Oxycodone
Hydrocodone
Note:
Schedule
II
opioid
analgesics
34. From
2008–2012
there
was
a
17%
increase
in
the
number
of
pa?ents
filling
OA
prescrip?ons
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
2008 2009 2010 2011 2012
Numberofprescriptions
Year
Patient
Prescriber
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2008-2012
35. 15%
of
prescribers
wrote
83%
of
opioid
analgesic
prescrip?ons
48%
2%
37%
15%
14%
49%
1%
34%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Prescribers Prescriptions
Prescribing frequency
Very Frequent
Prescribers
530-10,185 Rx/year
Frequent
Prescribers
50-529 Rx/year
Occasional
Prescribers
4-49 Rx/year
Rare Prescribers
1-3 Rx/year
Prescrip7ons
filled
by
NYC
residents,
2012
15%
83%
Percent
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2012 35
Note:
Schedule
II
opioid
analgesics
36. In
2012,
10%
of
prescribers
(n
=
5,384)
wrote
75%
of
prescrip?ons
(n
=1,623,157)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99
Percentofprescriptions
Percent of prescribers
Note: Schedule II opioid analgesics
Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2012
37. Two-‐thirds
of
pa?ents
filled
only
one
prescrip?on;
one-‐third
filled
78%
of
all
opioid
analgesic
prescrip?ons
63%
22%
14%
9%
5%
6%
8%
14%
10%
49%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Patients Prescriptions
Prescription Frequency
15 prescriptions
5 prescriptions
3 prescriptions
2 prescriptions
1 prescription
Prescrip7ons
filled
by
NYC
residents,
2012
Percent
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2012 37
37%
78%
Note:
Schedule
II
opioid
analgesics
38. Pa?ents
visi?ng
mul?ple
prescriber
and
mul?ple
pharmacies
are
rare
• In
2012,
1.2%
(9,137)
of
pa7ents
visited
4+
prescribers
and
4+
pharmacies
– Filled
7.9%
(170,282)
of
all
prescrip7ons
– Visited
15,042
unique
prescribers
– Visited
2,913
unique
pharmacies
Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2012
39. Two-‐thirds
of
opioid
analgesic
prescrip?ons
filled
were
paid
with
commercial
Insurance
67%
14%
8%
6%
4%
1%
Commercial
Insurance
Private
Pay
(Cash,
Charge,
Credit
Card)
Medicare
Other
Medicaid
Workers
Comp
Note:
Schedule
II
opioid
analgesics
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2012
40. Staten
Islanders
filled
OA
prescrip?ons
at
higher
rates
in
2012
0
50
100
150
200
250
300
350
400
450
500
NYC Bronx Brooklyn Manhattan Queens Staten Island
Age-adjustedrateofprescriptionsfilledper
1,000residents
Borough of Residence
Opioid Analgesics Oxycodone Hydrocodone
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2012
Note:
Schedule
II
opioid
analgesics
Rates are adjusted to 2000 US Census population
41. OA
prescrip?ons
filled
by
Staten
Islanders
have
longer
median
day
supply
0
5
10
15
20
25
30
NYC Bronx Brooklyn Manhattan Queens Staten Island
MedianSupply,Days
Borough of ResidenceSource: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2012
Note:
Schedule
II
opioid
analgesics
Median
day
supply
is
calculated
from
day
supply
of
each
prescrip7on
filled
in
the
year.
42. OA
prescrip?ons
filled
by
Staten
Islanders
are
more
frequently
high
dose
(>100
MED)
0
20
40
60
80
100
120
140
160
NYC Bronx Brooklyn Manhattan Queens Staten Island
Age-adjustedrateofhighdoseprescriptions
filledper1,000residents
Borough of Residence
2008 2009 2010 2011 2012
Note:
Schedule
II
opioid
analgesics
High
dose
is
any
opioid
analgesic
prescrip7on
with
a
calculated
morphine
equivalent
dose
(MED)
greater
than
100.
Among
pa7ents
receiving
opioid
prescrip7ons,
overdose
rates
increase
with
increasing
doses
of
prescribed
opioids.
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2008–2012
Rates are adjusted to 2000 US Census population
44. Neighborhoods
with
high
rates
of
OA
prescrip?ons
have
high
rates
of
uninten?onal
(overdose)
deaths
involving
opioid
analgesics
*Paone D, Bradley O’Brien D, Shah S, Heller D. Opioid analgesics in New York City: misuse, morbidity and mortality update. Epi Data
Brief. April 2011. Available at http://www.nyc.gov/html/doh/downloads/pdf/epi/epi-data-brief.pdf .
OA PRESCRIPTION RATES OA MORTALITY RATES
45. Opioid
prescribing
guidelines
• Less
oqen:
avoid
prescribing
opioids
for
chronic
non-‐cancer,
non-‐end-‐of-‐life
pain
e.g.,
low
back
pain,
arthri7s,
headache,
fibromyalgia
• Shorter
dura7on:
when
opioids
are
warranted
for
acute
pain,
3-‐day
supply
usually
sufficient
• Lower
doses:
if
dosing
reaches
100
Morphine
Milligram
Equivalents
(MME)
,
reassess
and
reconsider
other
approaches
to
pain
management
• Avoid
whenever
possible
prescribing
opioids
in
pa7ents
taking
benzodiazepines
Cita7on:
Paone
D,
Dowell
D,
Heller
D.
Preven7ng
misuse
of
prescrip7on
opioid
drugs.
City
Health
Informa7on.
2011;
30(4):
23-‐30
New
York
City
Opioid
Treatment
Guidelines,
Clinical
Advisors:
Nancy
Chang,
MD;
Marc
N.
Gourevitch,
MD,
MPH;
Mark
P.
Jarrel,
MD,
MBA;
Andrew
Kolodny,
MD;
Lewis
Nelson,
MD;
Russell
K.
Portenoy,
MD;
Jack
Resnick,
MD;
Stephen
Ross,
MD;
Joanna
L.
Starrels,
MD,
MS;
David
L.
Stevens,
MD;
Anne
Marie
S7lwell,
MD;
Theodore
Strange;
MD,
FACP;
Homer
Venters,
MD,
MS
45
46. New
York
City
Emergency
Department
Discharge
Opioid
Prescribing
Guidelines
Clinical
Advisory
Group:
Jason
Chu,
MD,
Brenna
Farmer,
MD,
Beth
Y.
Ginsburg,
MD,
Stephanie
H.
Hernandez,
MD,
James
F.
Kenny,
MD,
MBA,
FACEP,
Nima
Majlesi,
DO,
Ruben
Olmedo,
MD,
Dean
Olsen,
DO,
James
G.
Ryan,
MD,
Bonnie
Simmons,
DO,
Mark
Su,
MD,
Michael
Touger,
MD,
Sage
W.
Wiener,
MD.
Emergency
Department
guidelines
Released
January,
2013
Adopted
by
35
NYC
emergency
departments
46
47. Staten
Island
public
health
“detailing”
campaign
• 1-‐on-‐1
“detailing”
visits
from
Health
Department
representa7ves
• Deliver
key
prescribing
recommenda7ons,
clinical
tools,
pa7ent
educa7on
materials
• ~1,000
Staten
Island
physicians,
nurse
prac77oners,
physicians
assistants
• June–August
2013
• PMP
data
analyzed
to
evaluate
prescribing
palerns
pre-‐
and
post-‐
campaign
47
49. Morphine
Milligram
Equivalent
(MME)
calculator
• A
tool
to
calculate
total
MME
per
day
• Gives
alert
for
dosages
>100
MME
• Quick
and
easy
to
use
• Web-‐based
applica7on
– Search
for
“NYC
MME
Calculator”
hlp://www.nyc.gov/html/doh/html/mental/MME.html
• Smartphone
app
49
51. Media
campaigns
• Campaign
One:
– Goal:
Increase
awareness
of
risk
of
opioid
analgesic
overdose
– Ran
twice
(2012,
2013)
• Campaign
Two:
– Goal:
Reduce
s7gma
and
raise
awareness
of
opioid
analgesic
misuse
– 2
tes7monials
• Mom
lost
son
to
opioid
analgesic
overdose
• NYC
resident
in
recovery
– Ran
2013
and
2014
51
52.
53. Summary
• PMPs
can
be
used
as
a
public
health
surveillance
tool
to
understand
palerns
of
opioid
analgesic
prescrip7on
use
• New
Yorkers
filled
~2
million
opioid
analgesic
prescrip7ons
per
year
from
2008-‐2012
• From
2008-‐2012
Staten
Island
residents
filled
high
dose
prescrip7ons
(>100
MED)
at
highest
rates
• High
rates
of
opioid
analgesic
prescrip7on
use
mirror
high
rates
of
opioid
analgesic
overdose
mortality
54. Improving
Outcomes
while
Deterring
Misuse,
Abuse,
&
Diversion
Tom
Kelly,
R.Ph.,
B.Sc.
C.E.O./Partner:
Medicine
To
Go
Pharmacies,
PPTP.net
55. Disclosures
• Thomas
Kelly
has
financial
rela7onships
with
proprietary
en77es
that
produce
health
care
products
and
services.
These
financial
rela7onships
are:
• President/C.E.O.
Medicine
To
Go
Pharmacies
– Retail
pharmacies
• President/C.E.O./Partner,
PPTP.net,
LLC
– Online
due
diligence
tool
for
preven7on
of
misuse,
abuse,
and
diversion
56. Learning
Objec7ves
1. PMP's
and
PDMP's
are
valuable
clinical
tool
promo7ng
improved
outcomes.
2. There
is
a
difference
between
healthcare
and
enforcement.
57. How
Did
We
Get
Here?
• 1980
prehistoric
• 1996
Oxycon7n
launched
“less
poten7al
for
addic7on
and
abuse”,
chronic
pain
pa7ents
undertreated.
• Non
profits
funded
by
opiate
pharma
manuf.
(Am.
Pain
Founda7on)
• 8/31/2000
FDA
approves
NDA
for
Roxicodone
15mg
&
30mg
• Current
Trends:
– 6/3/2011
Fla:
HR
7095
an7-‐pill
mill
legisla7on
signed
by
Gov.
Rick
Scol
– DEA
suspends
permits
for
2
CVS
and
6
Walgreens
pharmacies
and
some
independent
pharmacies
in
Fla.
– DEA
suspends
permits:
3
Cardinal
Health
distribu7on
centers,
Walgreen’s,
Juniper,
Fl.,
AmerisourceBergen,
Orlando,
Fl.,
Harvard
Drug
Group,
Livonia,
Mi.
– McKesson
pays
$13
million
in
fines
for:
Fl.,
Tx.,
Md.,
Ut.,
Co.,
Ca.
58. The
Strange
Down
Stream
Trends
• Viola7ons
everywhere,
wholesale
distributors:
“But
how
much
can
we
sell?”
• Blind
speed
limits
• Contrac7on
in
opioid
analgesic
distribu7on
• Some
pa7ents
struggle
to
get
medica7ons,
really?
– 4.8%
of
worlds
popula7on
consumes
80%
opioid
analgesics
but
significant
hitches
in
supply
stream
• Wholesalers
using
numbers,
not
encouraging
or
establishing
the
use
of
sound
clinical
guidelines
– Place
pharmacist
on
review
team
59. Unfortunate
Reali7es
• Growing
popula7ons
trends
for
chronic
pain
pa7ents
– Advanced
trauma
care
leading
to
more
survivors
(fortunate
reality)
–
Diabetes
explosion
CDC
1980-‐2011
2.5
to
6.9%
-‐
genera7ng
more
neuropathies?
–
Arthri7s
rates
increasing
–
Obesity
increasing
• As
they
say
in
enforcement:
“Follow
the
money”
– 2008
recession
compounds
problem,
economic
relief
in
black
market
• 60%
of
diverted
medica7ons
sourced
from
friends
and
family,
Get
Rx
for
120,
use
40
divert
80.
Difficult
to
detect.
– Is
black
market
larger
than
legal
market?
• #120
oxycodone
15mg
@
$60
legal
via
insurance,
black
market
at
$1/mg
@$1,800
– Heroin
cheap,
easy
to
turn
• Prescrip7on
opioid
analgesics
&
heroin
more
valuable
than
cash
• We
cannot
enforce
our
way
out
• What
are
liabili7es
for
not
performing
due
diligence?
• Fewer
Fellowships
offered
in
pain
management,
family
prac7oners
and
GP’s
are
prescribing
– Only
a
couple
of
extra
pain
pa7ents
per
prescriber
add
up
• Not
my
pa7ents
60. Its
busy,
What
Can
I
Do?
(opportuni7es)
• Promote
and
u7lize
PMPs
as
a
tool
to
achieve
posi7ve
outcomes
(healthcare
term,
not
enforcement,
&
not
an
excuse
to
dispense!)
• Establish
PMP
review
in
workflow,
promote
states
to
allow
registered
technicians
and
nurses
to
access
data
bases
• Reduce
liability
with
due
diligence
• Verify
pa7ent
iden7ty
at
drop
off:
government
issued,
commercial
services
• Collaborate,
let
prescribers
know
around
the
clock
IR
meds
for
pain
control
not
illegal
but
frowned
upon,
decrease
#
doses
on
the
street,
use
sound
clinical
judgment
• Collaborate,
perform
random
medica7on
counts
for
pa7ents
exhibi7ng
adherent
behavior
for
your
prescribers
• Review,
review,
review
clinical
risks
with
pa7ents,
par7cularly
those
who
are
opiate
naive
• Counsel
all
regarding
secure
storage,
i.e.
dental
rxs,
loaded
gun
in
medicine
cabinet
analogy
• Ins7tute
a
treatment
agreements,
aka
narco7c
contract
61. But
What
Can
I
Do?
Con7nued…
(more
opportuni7es)
• Market
topically
compounded
analgesics-‐
far
lower
poten7al
for
abuse
• Partner
with
adver7zing
vendors
to
include
medica7on
guide
specific
for
commonly
abused
medica7on,
i.e.
LDM
Group,
CarePoints
(slide)
• Increase
sensi7za7on:
Use
social
media
&
poster
up,
“Who
Knew
Grandma
Kept
a
Stash”,
Partnership
for
a
Drug
Free
New
Jersey,
DEA’s
Na7onal
Prescrip7on
Drug
Take
Back
Day,
etc.
(slide)
• Partner
with
teaching
ins7tu7ons.
Sponsor
substance
abuse
CE
+
CME’s
for
health
care
providers,
including
pediatricians,
den7sts,
and
oral
surgeons
(slide)
• Get
involved,
collaborate,
join
work
groups,
encourage
community
based
ac7on,
no
one
group
can
defeat
this
scourge
alone
(slide)
– Form
local
coali7ons,
churches,
schools,
enforcement,
civic
groups,
etc.
• Sponsor
a
local
drop
off
box
for
unused
medica7ons
– www.americanmedicinechest.com/_media/permcollec7on1.pdf
62. Provide
Naloxone
Rescue
Kits
(opportunity)
• A
lille
work
results
in
most
significant
outcomes
alainable
• Develop
collabora7ve
prac7ce
agreements
• Trails
already
blazed,
follow
the
footsteps
– hlp://stopoverdose.org/index.htm
– hlp://harmreduc7on.org/
– hlp://prescribetoprevent.org/about-‐us/
63. Educa7on
Opportuni7es:
Pharmacy
Student
and
Technician
Training
• Establish
and
teach
clinical
guidelines
for
counseling
pa7ents
to
avoid
issues
associated
with
controlled
medica7ons.
• Encourage
training
in
detec7ng
evidence
of
misuse,
substance
abuse,
addic7on,
pseudo
addic7on,
and
diversion
in
pa7ent
popula7ons.
• Amplify
the
value
of
PMPs
as
a
clinical
tool.
• If
a
palern
of
abuse
is
detected,
provide
outline
on
how
to
assist
the
pa7ent
and
associated
healthcare
providers
move
forward
toward
posi7ve
outcomes.
i.e.
addic7on
services,
mental
health
services,
etc.
• Provide
protocols
on
when
and
how
to
engage
enforcement.
64. Big
Ideas-‐
Opportuni7es
to
do
beler?
• Develop
systems
for
ease
of
use
for
busy
prac7ces,
pharmacies
and
prescribers
alike.
Current
models
D+
– Allow
nurses
and
pharmacy
technicians
access?
• Reward
health
care
professionals
for
accessing
PMPs.
– Direct
compensa7on,
rebate
professional
license
fees,
tax
credits?
• Establish
and
encourage
realis7c
reimbursements
to
pharmacies
for
Medica7on
Therapy
Management
(MTM)
reviews
for
chronic
pain
pa7ents.
• Develop
Accountable
Care
Organiza7on
(ACO)
models
for
how
dispensing
pharmacies
can
partner
with
ACOs
&
manage
chronic
pain
pa7ents
to
improve
outcomes
and
subsequently
reduce
costs.
