An Update on KASPER David R Hopkins KASPER

An Update on KASPER David R. Hopkins KASPER Program Manager Office of Inspector General Kentucky Cabinet for Health and Family Services CAPTASA Conference January 24, 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 WI SD ID WY NE NV UT CO CA AZ KS OK NM AK MI IA IL IN PA OH WV VA NC TN SC AR LA DC KY MO MS TX NY AL NH MA RI CT NJ DE MD 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 / Person 2. 39 2. 43 2. 65 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% Andro. Gel 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% Oxy. Contin 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 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 HB 1’s impact on patients, prescribers, and other stakeholders • Overall goals: – Evaluate the impact of HB 1 on reducing prescription drug abuse and diversion in Kentucky – Identify unintended consequences associated with implementation of HB 1 that impact patients, providers and citizens of the Commonwealth – Develop recommendations to improve effectiveness of HB 1 and mitigate identified unintended consequences • Final study report planned for July 2014 Cabinet for Health and Family Services

4, 000 Jul 2009 Aug 2009 Sep 2009 Oct 2009 Nov 2009 Dec 2009 Jan 2010 Feb 2010 Mar 2010 Apr 2010 May 2010 Jun 2010 Jul 2010 Aug 2010 Sep 2010 Oct 2010 Nov 2010 Dec 2010 Jan 2011 Feb 2011 Mar 2011 Apr 2011 May 2011 Jun 2011 Jul 2011 Aug 2011 Sep 2011 Oct 2011 Nov 2011 Dec 2011 Jan 2012 Feb 2012 Mar 2012 Apr 2012 May 2012 Jun 2012 Jul 2012 Aug 2012 Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Mar 2013 Apr 2013 May 2013 Jun 2013 Jul 2013 Registrants KASPER Prescriber Accounts, 2009 -2013 16, 000 14, 000 Kentucky Prescribers 12, 000 10, 000 8, 000 6, 000 Non-KY Prescribers 2, 000 0

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 – – – – 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

KASPER and House Bill 1 Van Ingram Executive Director Office of Drug Control Policy Kentucky Justice and Public Safety Cabinet CAPTASA Conference January 24, 2014

Contents • Legislative Update • 2013 National Survey on Drug Use and Health • HB 1 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 (HB 1 passage date) • 8 closed prior July 20, 2012 (HB 1 effective date) • 12 closed after the HB 1 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 218 A. 202 • Controlled substance administration or dispensing must be reported within one day effective July 1, 2013 Justice & Public Safety Cabinet

KASPER Accounts – KRS 218 A. 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 218 A. 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 218 A. 202 • Hospitals and long term care facilities can establish “facility” KASPER accounts – e. KASPER 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 218 A. 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 218 A. 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 1 Q 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 13 Rhode 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 23 District 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

HB 1 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 HB 1 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 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 § § § § 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 Van. Ingram@ky. gov David Hopkins Kentucky Cabinet for Health and Family Services 275 East Main Street, 5 ED Frankfort, KY 40621 502 -564 -2815 ext. 3333 Dave. Hopkins@ky. gov