Transcript Trends Analysis Using ArcGIS and Spatial Statistics

Initiatives to Combat Prescription
Drug Abuse in Kentucky:
an Update on KASPER
David R. Hopkins
KASPER Program Manager
Office of Inspector General
Kentucky Cabinet for Health and Family Services
The Different Faces of Substance Abuse
January 28, 2014
Contents
•
Pill Mills
•
KASPER Program Review
•
House Bill 1 Preliminary Results
and Evaluation
Cabinet for Health and Family Services
Pill Mills
Jeff and Chris George
Photos from Palm Beach Post
Cabinet for Health and Family Services
Dr. Paul H. Volkman
Story: Bill Estep, Lexington Herald-Leader, February 14, 2012. AP Photo released by U.S.
Marshals Service (undated)
Cabinet for Health and Family Services
Care More Pain Management Clinic
Photo: Scott Utterback, Louisville Courier-Journal, January 25, 2012
Cabinet for Health and Family Services
Care More Pain Management Clinic
Photo: Scott Utterback, Louisville Courier-Journal, January 25, 2012
Cabinet for Health and Family Services
Ernest William Singleton
Photo: Lexington Community Corrections, January 2013
Cabinet for Health and Family Services
Kitson Clothing Collection
Story: WXIX Fox 19 Digital Media Staff, June 21, 2013
Cabinet for Health and Family Services
Kitson Clothing Collection
Cabinet for Health and Family Services
KASPER Program Review
Status of Prescription Drug Monitoring Programs (PDMPs)
VT
ME
WA
MT
ND
OR
MN
ID
MI
WY
NE
NV
UT
CO
CA
AZ
KS
OK
NM
IA
IL
TX
IN
PA
OH
WV VA
NC
TN
SC
AR
LA
DC
KY
MO
MS
AK
NY
WI
SD
NH
MA
RI
CT
NJ
DE
MD
AL
GA
FL
Operational PDMPs
HI
Enacted PDMP legislation, but
program not yet operational
Legislation pending
GU
Research is current as of February 1, 2012
2011 KASPER Reports Requested
Cabinet for Health and Family Services
KASPER Operation
• KASPER tracks most Schedule II – V
substances dispensed in KY
– Over 10 million controlled substance
prescriptions reported to the system each year
• KASPER data is 1 to 3 days old
– Dispensers have 1 business day to report
• Reports available to authorized individuals
– Available via web typically within 15 seconds
(97% of requests)
– Available 24/7 from any PC with Web access
Cabinet for Health and Family Services
Annual KASPER Records Total / Per Person
2.39
2.43
2.65
2.65
2.72
2.72
Number of Controlled Substance Prescriptions per Person
Cabinet for Health and Family Services
2.47
KASPER Reports Requested
Cabinet for Health and Family Services
Top Prescribed Controlled Substances by
Therapeutic Category by Doses - 2013
Lorazepam 4.0%
Ativan
Testosterone
3.5%
AndroGel
Zolpidem 3.4%
Ambien
Diazepam 4.3%
Valium
Clonazepam 6.7%
Klonopin
Tramadol 6.8%
Ultram
Alprazolam 11.2%
Xanax
Cabinet for Health and Family Services
Oxycodone 15.4%
OxyContin
Percodan
Percocet
Amphetamine
3.1%
Adderall
Hydrocodone 41.3%
Lortab
Lorcet
Vicodin
KASPER Stakeholders
•
•
•
•
•
•
Licensing Boards – to investigate potential inappropriate
prescribing by a licensee.
Practitioners and Pharmacists – to review a current
patient’s controlled substance prescription history for medical
or pharmaceutical treatment.
Law Enforcement Officers, OIG employees,
Commonwealth’s attorneys, county attorneys - to review
an individual’s controlled substance prescription history as
part of a bona fide drug investigation or drug prosecution.
Medicaid – to screen members for potential abuse of
pharmacy benefits and to determine “lock-in”; to screen
providers for adherence to prescribing guidelines for Medicaid
patients.
A judge or probation or parole officer – to help ensure
adherence to drug diversion or probation program guidelines.
Medical Examiners engaged in a death investigation
Cabinet for Health and Family Services
House Bill 1 Preliminary Results
and Evaluation
Controlled Substance Dispensing – One Year Comparison
Drug
August 2011
through
July 2012
August 2012
through
July 2013
239,037,354
214,349,392
-10.3%
87,090,503
77,022,586
-11.6%
1,753,231
1,138,817
- 35.0%
Alprazolam
71,669,411
62,088,568
-13.4%
Methylphenidate
10,659,840
11,454,025
+ 7.5%
Amphetamine
13,795,147
15,065,833
+ 9.2%
All Controlled
Substances
739,263,679
676,303,581
-8.5%
Hydrocodone
Oxycodone
Oxymorphone
Figures shown in doses dispensed
Cabinet for Health and Family Services
Change
Hydrocodone
Cabinet for Health and Family Services
Oxycodone
Cabinet for Health and Family Services
Alprazolam
Cabinet for Health and Family Services
Methadone
Cabinet for Health and Family Services
Oxymorphone
Cabinet for Health and Family Services
Tramadol
Cabinet for Health and Family Services
Buprenorphine
Cabinet for Health and Family Services
Controlled Substance Prescribing 2013
Cabinet for Health and Family Services
Controlled Substance Usage 2013
Cabinet for Health and Family Services
House Bill 1 Impact Study
• Comprehensive assessment of HB1’s impact on
patients, prescribers, and other stakeholders
• Overall goals:
– Evaluate the impact of HB1 on reducing prescription
drug abuse and diversion in Kentucky
– Identify unintended consequences associated with
implementation of HB1 that impact patients, providers
and citizens of the Commonwealth
– Develop recommendations to improve effectiveness of
HB1 and mitigate identified unintended consequences
• Final study report planned for July 2014
Cabinet for Health and Family Services
KASPER Prescriber Accounts, 2009-2013
16,000
14,000
Kentucky Prescribers
12,000
Registrants
10,000
8,000
6,000
Non-KY
Prescribers
4,000
2,000
0
Jul
2009
Oct
2009
Jan
2010
Apr
2010
Jul
2010
Oct
2010
Jan
2011
Apr
2011
Jul
2011
Oct
2011
Jan
2012
Apr
2012
Jul
2012
Oct
2012
Jan
2013
Apr
2013
Jul
2013
KASPER Pharmacist Accounts, 2009-2013
4,500
4,000
Kentucky Pharmacists
3,500
Registrants
3,000
2,500
2,000
1,500
1,000
500
Non-KY Pharmacists
0
Jul
2009
Oct
2009
Jan
2010
Apr
2010
Jul
2010
Oct
2010
Jan
2011
Apr
2011
Jul
2011
Oct
2011
Jan
2012
Apr
2012
Jul
2012
Oct
2012
Jan
2013
Apr
2013
Jul
2013
KASPER Law Enforcement Accounts, 2009-2013
1,600
1,400
Kentucky
Registrants
1,200
1,000
800
600
400
200
Non-KY
0
Jul
2009
Oct
2009
Jan
2010
Apr
2010
Jul
2010
Oct
2010
Jan
2011
Apr
2011
Jul
2011
Oct
2011
Jan
2012
Apr
2012
Jul
2012
Oct
2012
Jan
2013
Apr
2013
Jul
2013
• Stakeholder interviews were conducted to inform the
development of a KASPER registrant survey instrument
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–
–
–
–
–
–
–
–
–
–
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Board of Pharmacy
Board of Nursing
Board of Medical Licensure
Board of Dentistry
Kentucky Coalition of Nurse Practitioners and Nurse Midwives
Kentucky Dental Association
Kentucky Pharmacists Association
Kentucky Medical Association
Operation UNITE
National Association Drug Diversion Investigators (NADDI)
Medicaid, Office of Inspector General
Kentucky Sheriff’s Association
Kentucky Narcotic Officers Association
Initiatives to Combat Prescription
Drug Abuse in Kentucky:
an Update on KASPER
Van Ingram
Executive Director
Office of Drug Control Policy
Kentucky Justice and Public Safety Cabinet
The Different Faces of Substance Abuse
January 28, 2014
Contents
•
Legislative Update
•
2013 National Survey on Drug Use
and Health
•
HB1 Provider Training
•
Kentucky Overdose Data
Justice & Public Safety Cabinet
Legislative Update
HB 1 – Pain Management Facilities
• Physician ownership requirement on all
pain management facilities (PMF)
• Exception for those health facilities
operating as a PMF on April 24, 2012
• No sanctions or convictions imposed on
facility or employees
Justice & Public Safety Cabinet
PMF Oversight
• KBML responsible for licensure
standards for physician-owned pain
management facilities.
• OIG, Division of Health Care is
responsible for licensure standards for
existing pain management facilities that
qualify for the physician-ownership
exemption of HB 1.
Justice & Public Safety Cabinet
Non-Physician Owned PMFs
• 29 non-physician owned PMFs were identified April
24, 2012 (HB1 passage date)
• 8 closed prior July 20, 2012 (HB1 effective date)
• 12 closed after the HB1 effective date
• 2 illegal or non-physician owned PMFs discovered
after HB 1 effective date
• 4 PMFs were sent cease and desist letters
• 7 PMFs are being reviewed for compliance and
certification by the Cabinet for Health and Family
Services
Justice & Public Safety Cabinet
KASPER Reporting KRS 218A.202
• Controlled substance administration or
dispensing must be reported within one
day effective July 1, 2013
Justice & Public Safety Cabinet
KASPER Accounts – KRS 218A.202
• KASPER registration is mandatory for
Kentucky practitioners or pharmacists
authorized to prescribe or dispense
controlled substances to humans.
Justice & Public Safety Cabinet
KASPER Prescriber Usage - KRS 218A.172
•
Query KASPER for previous 12 months of
data:
–
Prior to initial prescribing or dispensing of a
Schedule II controlled substance, or a Schedule
III controlled substance containing hydrocodone
– No less than every three months
– Review data before issuing a new prescription or
refills for a Schedule II controlled substance or a
Schedule III controlled substance containing
hydrocodone
• Additional rules/exceptions included in licensure
board regulations
Justice & Public Safety Cabinet
KASPER Regulations – Licensure Boards
• 201 KAR 5:130
– Kentucky Board of Optometric Examiners KASPER
requirements
• 201 KAR 8:532
– Kentucky Board of Dentistry KASPER requirements
• 201 KAR 9:230, 201 KAR 9:260
– Kentucky Board of Medical Licensure KASPER
requirements
• 201 KAR 20:057
– Kentucky Board of Nursing KASPER requirements
• 201 KAR 25:090
– Kentucky Board of Podiatry KASPER requirements.
Justice & Public Safety Cabinet
KASPER Institutional Accounts - KRS 218A.202
• Hospitals and long term care facilities
can establish “facility” KASPER
accounts
– eKASPER institutional master account
established by Chief Medical Officer or
designated employee
– If no CMO, a designated physician
employee may create master account
– 79 institutional master accounts currently
established
Justice & Public Safety Cabinet
KASPER Prescriber Reports – KRS 218A.202
• CS prescribers can obtain a KASPER
report on themselves:
– To review and assess the individual
prescribing patterns
– To determine the accuracy and
completeness of information contained in
KASPER
– To identify fraudulent prescriptions
Justice & Public Safety Cabinet
Providing Reports to Patients – KRS 218A.202
• KASPER reports can be shared with the
patient or person authorized to act on
the patient’s behalf
• KASPER reports can be placed in the
patient’s medical record, with the report
then being deemed a medical record
subject to disclosure on the same terms
and conditions as an ordinary medical
record
Justice & Public Safety Cabinet
Federal Actions - Hydrocodone
•
Hydrocodone combination products to be
rescheduled from CIII to CII
– Approved by FDA
– Pending recommendation to HHS and approval
by HHS and DEA
• FDA approved CII pure hydrocodone product
– Zohydrotm ER manufactured by Zogenix, Inc.
– Available 1Q 2014
– Not abuse-resistant formulation
Justice & Public Safety Cabinet
National Survey on
Drug Use and Health
January 8, 2013
NATIONAL TRENDS
States with Rates between 5.33 and 6.37
1 Oregon 6.37 5.25-7.71
2 Colorado 6.00 4.96-7.24
3 Washington 5.75 4.76-6.92
4 Idaho 5.73 4.74-6.91
5 Indiana 5.68 4.68-6.89
6 Arizona 5.66 4.60-6.94
7 Nevada 5.62 4.57-6.89
8 Delaware 5.61 4.61-6.82
9 Arkansas 5.55 4.60-6.68
10 New Mexico 5.45 4.47-6.64
Justice & Public Safety Cabinet
NATIONAL TRENDS
States with Rates between 4.80 and 5.32
11 Alaska 5.32 4.41-6.42
12 Oklahoma 5.19 4.26-6.30
13Rhode Island 5.18 4.26-6.27
14 Vermont 5.13 4.24-6.19
15 Michigan 5.11 4.57-5.72
16 Ohio 5.00 4.49-5.56
17 Tennessee 5.00 4.14-6.02
18 Louisiana 4.87 4.09-5.80
19 Montana 4.84 4.02-5.80
20 Missouri 4.83 4.03-5.78
Justice & Public Safety Cabinet
NATIONAL TRENDS
States with Rates between 4.46 and 4.79
21 West Virginia 4.79 3.97-5.75
22 California 4.68 4.13-5.30
23District of Columbia 4.68 3.79-5.76
24 Wyoming 4.68 3.85-5.68
25 South Carolina 4.62 3.81-5.59
26 Virginia 4.60 3.79-5.58
27 Minnesota 4.57 3.79-5.49
28 New Hampshire 4.57 3.77-5.53
29 Kansas 4.56 3.77-5.50
30 Wisconsin 4.51 3.68-5.52
31 Kentucky 4.48 3.70-5.41
Justice & Public Safety Cabinet
NATIONAL TRENDS
Among persons aged 18 to 25, the rates
of past year nonmedical use of pain relievers
declined in 14 states:
Florida, Kentucky, Louisiana, Maine,
Massachusetts, Michigan, New Hampshire,
New York, Ohio, Oklahoma, Rhode Island,
Texas, Utah, and West Virginia.
Justice & Public Safety Cabinet
HB1 Provider Training
HB 1 TRAININGS
 ODCP, OPERATION UNITE and
KENTUCKY COALITION OF NURSE
PRACTITIONERS/NURSE MIDWIVES
HAVE SPONSORED 4 TRAININGS
Justice & Public Safety Cabinet
HB 1 TRAININGS
Overview of HB1 and Regulations
C. Lloyd Vest, JD
How to Recognize Drug Abuse and Dependence in Patients
Gregory Jones, MD
How to Discuss Drug Issues with a Patient
Gregory Jones, MD
An Update on KASPER - Post House Bill 1
David Hopkins
Opioid Therapy: Risks vs. Rewards
Gregory Jones, MD
Justice & Public Safety Cabinet
HB 1 TRAININGS
MOREHEAD
119 TRAINEES
83 PRESCRIBERS
PAINTSVILLE
147 TRAINEES
55 PRESCRIBERS
BOWLING GREEN
239 TRAINEES
170 PRESCRIBERS
MANCHESTER
110 TRAINEES
80 PRESCRIBERS
Justice & Public Safety Cabinet
HB 1 TRAININGS




615 TOTAL TRAINEES
388 PRESCRIBERS
AVAILABLE ONLINE
MEETS LICENSING BOARDS
REQUIREMENTS
Justice & Public Safety Cabinet
HB 1 TRAININGS
Justice & Public Safety Cabinet
The Good, Bad, and Ugly of Addiction
Justice & Public Safety Cabinet
Kentucky Overdose Data
2012 OVERDOSE DATA
 1004 OVERDOSE FATALATIES IN
2012
 19 FEWER THAN 2011. THE FIRST
DECLINE IN OVER A DEACDE
• 888 UNINTENTIONAL
• 59 SUICIDES
• 57 UNDETERMINED
Justice & Public Safety Cabinet
2012 OVERDOSE DATA
 LARGEST INCREASE CAMPBELL
COUNTY. FROM 25 IN 2011 TO 54 IN
2012
 LARGEST DECREASE, FLOYD
COUNTY WITH 23 FEWER DEATHS
IN 2012 THAN 2011
 MOST PER 100,000 LESLIE COUNTY
WITH RATE OF 85 PER 100,000
Justice & Public Safety Cabinet
2012 OVERDOSE DATA
 DEATHS ATTRIBUTABLE TO
HEROIN ROSE 550%
 ALPROZOLAM MOST DETECTED
SUBSTANCE AT 41.44% OF ALL
MEDICAL EXAMINER CASES
Justice & Public Safety Cabinet
2012 OVERDOSE DATA





YOUNGEST OD DEATH AGE 16
OLDEST 72
AVERAGE AGE 40
MALE 58%
FEMALE 42%
Justice & Public Safety Cabinet
FIRST 3 QUARTERS OF 2013
 639 TOTAL OVERDOSE DEATHS
REPORTED DURING three quarters OF
2013
 170 OR 26% HAVE HEROIN IN THE
TOXICOLOGY REPORT
 OVERWHELMING MAJORITY POLY DRUG
Cabinet for Health and Family Services
2013
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JEFFERSON 94
FAYETTE 26
KENTON 26
BOONE 20
CAMPBELL 8
FRANKLIN 5
17 COUNTIES 1 or 2
97 COUNTIES NONE
Cabinet for Health and Family Services
HEROIN
Cabinet for Health and Family Services
HEROIN
Cabinet for Health and Family Services
HOW DID WE GET HERE?
 LONG HISTORY OF OPIOD/PAINKILLER
ABUSE
 INCREASING NUMBERS OF IV DRUG
USAGE
 ABUSE DETERRANT FORMULATIONS
 CRACKDOWN ON ROUGUE PAIN CLINICS
 GREATER AWARENESS FROM
PRESCRIBERS
 ESTABLISHED DRUG CARTELS
RECOGNIZING DEMAND
Cabinet for Health and Family Services
HOW DID WE GET HERE?
PRICE
AVAILABILITY
PERCEPTION OF RISK
PUBLIC ATTITUDES
Cabinet for Health and Family Services
HOW DO WE ADDRESS IT?
 PUBLIC EDUCATION
 INCREASED ACCESS TO
TREATMENT
 ENHANCED PENALTIES FOR MAJOR
TRAFFICKERS
 GREATER ACCESS TO NALOXONE
Cabinet for Health and Family Services
Van Ingram
Kentucky Justice and Public Safety Cabinet
125 Holmes Street
Frankfort, KY 40601
502-564-8291
[email protected]
David Hopkins
Kentucky Cabinet for Health and Family Services
275 East Main Street, 5ED
Frankfort, KY 40621
502-564-2815 ext. 3333
[email protected]