KASPER and Kentucky’s Response to the Opioid Crisis

1. KASPER and Kentucky’s Response to the Opioid Crisis David R. Hopkins KASPER Business Analyst Office of Inspector General Mental Health and Addiction Treatment Symposium October 24, 2019

2. Disclosure • David R. Hopkins • No relevant financial relationships • No conflicts of interest

3. Contents • Controlled Substance Abuse and the Opioid Crisis • KASPER Program Information • How KASPER is Used

4. Controlled Substance Abuseand theOpioid Crisis

5. Misuse, Abuse, Diversion (SAMHSA) • Misuse: • incorrect use of a controlled substance medication by a patient (wrong time, wrong dose, wrong reason) • Abuse: • maladapted pattern of controlled substance use leading to significant impairment or distress • Diversion: • controlled substance medication leaving the legal distribution channels (manufacture, transport, pharmacy, patient)

6. Commonwealth of KentuckyRESPONSE TO THE OPIOID EPIDEMIC

8. Prelude to House Bill 1 • Opioid abuse a national epidemic • KY controlled substance abuse increasing • KY opioid overdose deaths increasing • “Pill mills” proliferating • Governor, Office of Drug Control Policy, Attorney General and legislators viewed medical community as contributors to the problem • Low provider utilization of PDMP (KASPER)

9. 2012 Extraordinary Session HB12013 Regular Session HB217

10. Strategies • PRESCRIPTION MONITORING • PRESCRIBING REGULATIONS • ROGUE PAIN CLINICS • DRUG DISPOSAL • PRESCRIBER AND PUBLIC EDUCATION

11. Kentucky’s Prescription Drug Abuse StrategyOffice of Drug Control Policy • Require physician ownership of pain management facilities • Limit prescriber dispensing of C-II medications to a 48 hour supply • Require 7.5% of CME in addiction, pain management or KASPER • Increase public awareness • Increase resources and funding for substance abuse prevention and treatment • Increase drug disposal opportunities • Enhance use of Prescription Drug Monitoring Program • Require daily reporting to KASPER • Mandate KASPER registration and usage • Pharmacists must register • Controlled substance prescribers must register and query under certain circumstances • Utilize KASPER data to identify potentially inappropriate or illegal controlled substance prescribing or dispensing

12. Kentucky Overdose Deaths

13. Kentucky Overdose Deaths

14. Controlled Substances and Overdose Deaths Approximately 60% of Kentucky resident drug overdose decedents in 2018 received a controlled substance within one year of their date of death.

15. Richard Brown 1972 - 2019 Photo courtesy of www.legacy.com, August 14, 2019

16. KASPER Program Information

17. KentuckyAllSchedulePrescriptionElectronicReporting

18. KASPER KASPER is Kentucky’s Prescription Drug Monitoring Program (PDMP). KASPER tracks Schedule II – V controlled substance prescriptions dispensed within the state as reported by pharmacies and other dispensers, and provides a tool to help address the misuse, abuse and diversion of controlled pharmaceutical substances.

19. Controlled Substance Schedules • Schedule I – Illegal Drugs • e.g. heroin, marijuana, ecstasy • Schedule II – Most addictive legal drugs; high abuse potential • e.g. fentanyl (Actiq, Duragesic), oxycodone (OxyContin, Percocet), methylphenidate (Ritalin), hydrocodone (Vicodin, Norco) • Schedule III – Less abuse potential than I or II • e.g. testosterone (Androgel), buprenorphine/naloxone (Suboxone) • Schedule IV – Less abuse potential than III • e.g. benzodiazepines (Xanax, Valium) • Schedule V – least abuse potential • e.g. codeine containing cough mixtures

20. KASPER Operation • Over 11 million controlled substance prescriptions reported to the system each year • Over 12.5 million report/data requests processed in 2018 • KASPER data updated within 1 to 2 days • Dispensers have 1 business day to report • Reports available to authorized individuals • Available via web typically within 30 - 60 seconds • Available 24/7 from any PC with web access

21. KASPER Data • KASPER tracks: • Retail pharmacies dispensing into KY (in-state, mail order, Internet) • Hospital emergency departments dispensing controlled substances to an ED patient • Practitioners administering or dispensing a controlled substance in the office • Dispensing from Department for Veterans Affairs pharmacies (except gabapentin)

22. KASPER Data • KASPER does not track: • Methadone administered at a federally regulated methadone clinic • Controlled substances dispensed for administration to a patient in a hospital, long-term care facility, jail, correctional facility or juvenile detention facility • Pseudoephedrine (tracked separately via NPLEx) • Dispensing by military pharmacies • Schedule I or other illegal drugs

23. Top Prescribed Controlled Substances by Therapeutic Category based on Number of Doses - 2018 Buprenorphine/Naloxone 3.4% Suboxone Pregabalin 2.7% Lyrica Lorazepam 2.9% Ativan Amphetamine 4.1% Adderall Gabapentin 29.0% Neurontin Clonazepam 5.0% Klonopin Alprazolam 6.8% Xanax Tramadol 7.3% Ultram Oxycodone 13.2% OxyContin, Percocet Hydrocodone/APAP 25.6% Lortab, Vicodin, Norco

24. 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; for the birth mother of an infant being treated for neonatal abstinence syndrome or prenatal drug exposure. • 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

25. Controlled Substance RecordsReported to KASPER - Total/Per Person 2.65 2.72 2.72 2.47 2.43 2.41 2.37 2.43 2.53 Number of Controlled Substance Prescriptions per Person

26. KASPER Report Requests Report/Data Requests in Thousands 7354 6871

27. What does a KASPER Report Show? • A KASPER report includes: • The patient name and date of birth • The drug name, dosage, days supply, date prescription written, date prescription filled • The prescriber name and city • The dispenser name and city • Morphine milligram equivalent data • Per opioid prescription • Total for all active opioid prescriptions

29. How KASPER is Used

30. 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

31. KASPER Regulations – Licensure Boards • 201 KAR 5:130 • Kentucky Board of Optometric Examiners KASPER requirements • 201 KAR 8:540 • Kentucky Board of Dentistry KASPER requirements • 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.

32. General KASPER Query Exceptions • In an emergency situation (disaster or mass casualties) • Within 14 days of surgery or within three days of oral surgery • Patients in hospitals and long term care facilities • Patients in Hospice care or being treated for cancer pain • Single doses of anxiety medicine prior to a procedure • Prescribing a substitute medication within 7 days of initial prescription • Schedule V controlled substances

33. Providing Reports to Patients • 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

34. Program Enhancements • KASPER Prescriber Report Card • Launched February 2017 • Provides a quarterly and annual summary of a practitioner’s prescribing practices and how they compare with other practitioners in their specialty area

37. Program Enhancements • Drug Conviction data from Administrative Office of the Courts • Class A misdemeanor and felony drug conviction information from the AOC CourtNet system • 6.1% (973,245) of YTD 2019 KASPER queries included a request for drug conviction information • 1.1% (11,112) of those requests returned drug conviction information for the patient

39. Program Enhancements • Non-fatal drug overdose warning flag to be added in 4Q 2019 • Based on patient overdose information reported by Emergency Departments to the Kentucky Health Information Exchange (KHIE) • KASPER will be linked to KHIE to notify practitioners if the patient experienced a non-fatal drug overdose in the ED • Practitioners and pharmacists can view the patient information in KHIE

40. OIG Overdose Death Notification Project Letters to practitioners who prescribed one or more opioid prescriptions that were active at the time of their patient’s death. Patient Information Tips on managing pain and prescribing opioids Treatment Resource Locator: findhelpnowky.org

41. House Bill 1 Controlled SubstanceDispensing Comparison All figures based on dispensed controlled substance prescription data reported to KASPER

42. Opioid Analgesics vs. Medication Assisted Treatment Source: Kentucky All Schedule Prescription Electronic Reporting System

43. QUESTIONS? KASPER Web Site: https://chfs.ky.gov/agencies/os/oig/dai/deppb/Pages/kasper.aspx