Kentucky All Schedule Prescription Electronic Reporting A KASPER

Kentucky All Schedule Prescription Electronic Reporting A KASPER Update for Family Physicians Jill E. Lee, RPh Investigator Drug Enforcement and Professional Practices Branch Office of Inspector General Kentucky Cabinet for Health and Family Services Kentucky Academy of Family Physicians November 10, 2016

Disclosure • Jill E. Lee – No relevant financial relationships. – No conflicts of interest. Cabinet for Health and Family Services

Objectives • Discuss statutory and regulatory prescriber responsibilities • Engage the Drug Enforcement and Professional Practices Branch for support • Recognize red flags that are indicative of doctor shoppers • Learn how to protect your practice Cabinet for Health and Family Services

Controlled Substance Abuse

Painkiller Prescription Rates by State CDC Vitalsigns July 2014, Source: IMS, National Prescription Audit (NPAtm), 2012 Cabinet for Health and Family Services

Painkiller Prescription Rates by State CDC Vitalsigns July 2014, Source: IMS, National Prescription Audit (NPAtm), 2012 Cabinet for Health and Family Services

Controlled Substance Usage 2015 Cabinet for Health and Family Services

Top 10 State Drug Overdose Death Rates – 2014 Cabinet for Health and Family Services

Top 10 State Drug Overdose Death Rates – 2014 Rank State Number of Drug Overdose Deaths Age-Adjusted Drug Overdose Death Rate per 100, 000 or Population 1 West Virginia 627 35. 5 2 New Mexico 547 27. 3 3 New Hampshire 334 26. 2 4 Kentucky 1, 077 24. 7 5 Ohio 2, 744 24. 6 6 Rhode Island 247 23. 4 7 Utah 603 22. 4 8 Pennsylvania 2, 732 21. 9 9 Delaware 189 20. 9 10 Oklahoma 777 20. 3 47, 055 14. 7 United States Data source: Increases in Drug and Opioid Overdose Deaths – United States, 2000 -2014. Rudd, Aleshire, Zibbell and Gladdin, CDC Morbidity and Mortality Weekly Report, December 18, 2015 Cabinet for Health and Family Services

Kentucky Drug Overdose Deaths Sources: 2015 Data: 2015 Overdose Fatality Report. Kentucky Justice and Public Safety Cabinet, June 2016. 2005 -2014 Data: U. S. Centers for Disease Control, Multiple Cause of Death Data (CDC Wonder Online Database) Cabinet for Health and Family Services

It is epidemic! CDC declares epidemic of overdose deaths from opioid pain relievers in 2011 • Second leading cause of accidental death • Overdose increased 10 -fold since 1990 Who is to blame? • Pain charts – rate your pain? • Drug companies with their aggressive marketing techniques? Oxycontin 2000 s • Reimbursement rates based on pain tx Cabinet for Health and Family Services

August 2016 Letter to all doctors • US surgeon general sends warning letter to all doctors on opioid epidemic Dear Colleague, I am asking for your help to solve an urgent health crisis facing America: the opioid epidemic. Everywhere I travel, I see communities devastated by opioid overdoses. That is why I am asking you to pledge your commitment to turn the tide on the opioid crisis. Please take the pledge. Together, we will build a national movement of clinicians to do three things: Cabinet for Health and Family Services

Diversion and Overdoses Center for Disease control and Prevention, “Policy Impact: Prescription Painkiller Overdoses” http: //www. cdc. gov/homeandrecreationalsafety/rxbrief/ Cabinet for Health and Family Services

Cabinet for Health and Family Services

CDC Recommendations • Laws to prevent prescription drug abuse and diversion • Prescription Drug Monitoring Programs • Health care provider accountability • Better access to substance abuse treatment Cabinet for Health and Family Services

Combating Prescription Drug Abuse in Kentucky

KASPER Legislation • 2012 House Bill 1 “Pill Mill Bill” • 2013 House Bill 217 Cabinet for Health and Family Services

The Kentucky Strategy • Limit prescriber dispensing to 48 hour supply (C-II or C-III containing hydrocodone) • Require 7. 5% of CME in addiction, pain management or KASPER • Promulgate CS prescribing regulations • Develop educational materials and conduct training • Increase drug disposal opportunities • Increase treatment funding and resources Cabinet for Health and Family Services

Pain Facility KRS 218 A. 175 - Pain Management Facilities • Physician ownership required • Subspecialty/certification required • Can not be a cash only business • Oversight Requirement Definition of a Pain Management Facility • A facility where majority of patients provided controlled substances for pain AND a. Primary practice component is treatment of pain b. Facility advertises any type of pain management services APRNs CANNOT OWN PAIN FACILITIES Cabinet for Health and Family Services

You might be a pill mill if… • You feel compelled to hire “security” • Most people pay cash for their pills • Patients refer to their drugs by their street name or request specific color of pills • You have long lines that wrap around your building by 7 am. • Patients come from long distances to see you • You only write for the highest strength of pills • You often write for the “holy trinity” • You have been previously warned or disciplined by your medical board. Cabinet for Health and Family Services

Register for PMF Cabinet for Health and Family Services

218 A. 172 Required medical boards to create regulations, prior to the initial prescribing of a schedule II (or a C 3 with hydrocodone) • Medical history • Query KASPER • Make a written plan • Discuss risks and benefits • Obtain written consent Cabinet for Health and Family Services

. Prescription Monitoring Programs

e. KASPER Accounts • e. KASPER registration is mandatory for Kentucky practitioners or pharmacists authorized to prescribe or dispense controlled substances to humans. Cabinet for Health and Family Services

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

e. KASPER Reporting KRS 218 A. 202 • Controlled substance administration or dispensing must be reported within one day effective July 1, 2013 • ASAP 4. 2 PDMP data collection standard required effective July 1, 2014 Cabinet for Health and Family Services

KASPER Data • KASPER tracks: – Retail pharmacies dispensing into KY (instate, mail order, Internet) – Hospital pharmacies if dispensing any C-II or more than a 48 hour supply of a C-III through C-V – Physician administering or dispensing a C -II through C-V in the office – Dispensing from Department for Veterans Affairs pharmacies Cabinet for Health and Family Services

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 Cabinet for Health and Family Services

e. KASPER Report Processing • 97% of reports auto-matched by e. KASPER • Manual Queue: – Processed 8: 00 a. m. to 4: 30 p. m. Monday through Friday – Weekday manual reports typically available within one hour Cabinet for Health and Family Services

What if I cannot “Query” KASPER? • If e. KASPER indicates “manual process” – Record the e. KASPER report request number in the patient’s chart • If the e. KASPER system is unavailable or Internet access unavailable – Document circumstances why e. KASPER could not be queried – If e. KASPER outage, record the date and time Cabinet for Health and Family Services

Providing Reports to Patients – KRS 218 A. 202 • e. KASPER reports can be shared with the patient or person authorized to act on the patient’s behalf • e. 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 Cabinet for Health and Family Services

e. KASPER Report Request - Master Don’t forget Border States! Cabinet for Health and Family Services

e. KASPER Report Request - Master Cabinet for Health and Family Services

When should I KASPER? • CS for pain or symptoms associated. Beginning and every 3 months • C 2 – beginning and every 3 months • Other conditions beside pain- Before prescribing and then according to standards of acceptable and prevailing practice. • If you don’t know – every 3 months Note – APRN’s regs state no less than every 3 months. Cabinet for Health and Family Services

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. Cabinet for Health and Family Services

Cabinet for Health and Family Services

Cabinet for Health and Family Services

KBML web site Cabinet for Health and Family Services

KASPER Query Exceptions (MD) • In an emergency situation • Patients in hospitals and long term care facilities – Hospitals and long term care facilities can establish institutional accounts and request reports on behalf of the facility • 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 medications Cabinet for Health and Family Services

e. KASPER Delegate Accounts – KRS 218 A. 202 • e. KASPER delegate accounts allowed for: – An employee of the practitioner’s or pharmacist’s practice acting under the specific direction of the practitioner or pharmacist DO NOT GIVE EMPLOYEES YOUR KASPER PASSWORD Cabinet for Health and Family Services

e. KASPER Delegate Account Request Cabinet for Health and Family Services

Delegate Request KASPER TIP: MANAGING YOUR DELEGATE Cabinet for Health and Family Services

e. KASPER Prescriber Reports – KRS 218 A. 202 • CS prescribers can obtain a REVERSE e. KASPER report for any 90 day period: – To review and assess the individual prescribing patterns – To determine the accuracy and completeness of information contained in e. KASPER – To identify fraudulent prescriptions Cabinet for Health and Family Services

e. KASPER Prescriber Report Request KASPER TIP: REVERSE KASPER Cabinet for Health and Family Services

Google KASPER – click link Cabinet for Health and Family Services

Reverse KASPER Cabinet for Health and Family Services

Why Reverse KASPER?

Signs of Diverters • • • High achievers Significant stresses in life Prefers night shift Takes on critical cases Works at more than one facility Smoker Disappears a lot Volunteers overtime Changes in personality Decline in job performance Cabinet for Health and Family Services

What’s New with e. KASPER! Cabinet for Health and Family Services

Be extra careful with MED Zero!

KASPER Provider REPORT Compares you vs other prescribers in the same area of work.

e. KASPER Error Correction - 902 KAR 55: 110 • Patient or provider should contact the dispenser to correct records in error • Inaccurate KASPER reports due to system errors should be reported to the Drug Enforcement and Professional Practices Branch – 502 -564 -7985 Cabinet for Health and Family Services

House Bill 1 Preliminary Results and Evaluation

Controlled Substance Dispensing Comparison Drug July 2011 through June 2012 July 2014 through June 2015 Percent Change Hydrocodone 3, 303, 453 2, 603, 642 - 21. 2% Oxycodone 977, 256 937, 530 - 4. 1% Oxymorphone 24, 485 18, 459 - 24. 6% Tramadol 431, 455 542, 930 + 25. 8% Alprazolam 947, 672 769, 814 - 18. 8% Diazepam 413, 983 350, 685 - 15. 3% Buprenorphine/ Naloxone 269, 488 491, 130 + 82. 2% All Controlled Substances 10, 417, 237 9, 927, 621 - 4. 7% Figures represent number of prescriptions dispensed as reported to KASPER

Hydrocodone Cabinet for Health and Family Services

Oxycodone Cabinet for Health and Family Services

Methadone Cabinet for Health and Family Services

Alprazolam Cabinet for Health and Family Services

Tramadol Cabinet for Health and Family Services

Buprenorphine/Naloxone Cabinet for Health and Family Services

HB 1 Evaluation Study Findings • After initial confusion and workflow disruption after HB 1, the majority of providers now report no negative impact on their professional practices • Prescribers and pharmacists discuss KASPER reports with patients and among themselves more frequently since HB 1 • The number of patients receiving prescriptions for the ‘cocktail’ (the combination of hydrocodone, with a benzodiazepine and a muscle relaxer) decreased by 30% following HB 1 • The number of doctor shoppers declined by 52% post-HB 1 • The number of opioid prescriptions to individuals meeting the doctor shopper criteria dropped by 54% post-HB 1 • The number of buprenorphine/naloxone prescriptions for medication assisted opioid addiction treatment increase by over 40% post-HB 1 • There does not appear to be a “chilling effect” on prescribers Cabinet for Health and Family Services

Health care Accountability Protecting your Practice

Contents • • • Provider Shopping Advice from the Kentucky Licensure Boards KASPER Case Studies The Drug Enforcement and Professional Practices Branch Tips from DEPPB Controlled Substance Actions & Other Drugs of Concern Cabinet for Health and Family Services

Provider Shopping Provider shopping is when controlled substances are acquired by deception. Acts related to attempting to obtain a controlled substance, a prescription for a controlled substance or administration of a controlled substance, prohibited under KRS 218 A. 140 include: • • • Knowingly misrepresenting or withholding information from a practitioner. Providing a false name or address. Knowingly making a false statement. Falsely representing to be authorized to obtain controlled substances. Presenting a prescription that was obtained in violation of the above. Affixing a false or forged label to a controlled substance receptacle. Cabinet for Health and Family Services

Typical Provider Shopping Behaviors Patient Behaviors Examples Multiple providers of the same type 3 or more general practitioners, dentists, etc. Dispensers and prescribers are in different localities from each other and the patient’s home address Patient lives in Fayette county; prescriber in Franklin county; dispenser in Jessamine county Overlapping prescriptions of the same drug from different prescriber types Oxycodone scripts from dentist, family physician, and pain management doctor within 30 days Excessive emergency room visits for non-emergency issues 3 or more emergency room visits in a month for chronic pain conditions Requesting replacement for lost medications regularly Patient states that controlled substance is lost and requests new prescription Requesting early refills Patient requests early refills due to extended outof-state trip Pressuring prescribers to prescribe specific controlled substances for the patient’s family members Parent requests the pediatrician prescribe a specific controlled substance for their child stating that it is the only medication that works Cabinet for Health and Family Services

Typical Provider Shopping Behaviors (Cont. ) Patient Behaviors Examples Using multiple names, social security numbers, addresses, etc. Patient fills three scripts under three different names Seeking referrals to multiple pain management clinics Patient requests referrals to pain management clinics without a specific diagnosis Associating with others known to be pharmaceutical controlled substance provider shopping Patient travels to clinic with another patient exhibiting shopping behavior and requests similar prescription Self-mutilation Patient presents with potential self-inflicted wound Cash transactions Patient prefers to pay cash when insurance available Requesting partial dispensing of controlled substance script Patient requests half of the script and returns for the rest within 72 hours After-hour, weekend and holiday calls for prescriptions Patient calls prescriber at midnight on Friday to request a controlled substance script Cabinet for Health and Family Services

Doctor Shopping Targeted Provider Characteristics: • New providers • Senior providers • Providers perceived to keep substandard records • Pain management providers Cabinet for Health and Family Services

Substance Use Disorder Substance use disorder is an illness that sometimes drives a patient to perform activities that are illegal. It is important to remember that the patient who is provider shopping may have an underlying illness that can be diagnosed and treated. Cabinet for Health and Family Services

Practitioner Judgment Practitioners must use their best professional judgment to determine: • when to intervene with a provider shopping patient and provide treatment, or refer them to treatment • when to dismiss a patient or just not write controlled substance prescriptions for them • when to contact law enforcement to report a provider shopper Cabinet for Health and Family Services

KASPER Case Studies

KASPER Case Study 1 - Male Patient – Age 36

Advice from the Kentucky Licensure Boards

Protecting Your Practice Recommendations from the Kentucky Board of Medical Licensure and Kentucky Board of Nursing • Remain up to date with rules (guidelines) and regulations: – in the Medical Practice Act (available on KBML web site: www. kbml. ky. gov) – in the Nurse Practice Act (available on KBN web site: http: //kbn. ky. gov) • Keep well-documented patient records Cabinet for Health and Family Services

Protecting Your Practice (cont. ) • Be attentive to patient needs • Be familiar with office personnel and their interactions with patients. Do not leave carte blanche orders to refill anything. • Watch for scams –non FDA approved devices/compounding Rxs • Maintain appropriate controls on prescription pads – Title 21 Code of Federal Regulations § 1306. 05(a) • No Pre-signed or post-dated prescriptions Cabinet for Health and Family Services

Protecting Your Practice (cont. ) • The Boards strongly encourage use of chaperones for sensitive examinations • Do not prescribe controlled substances for yourself or “immediate family”. • Do not leave signed scripts for staff • Run KASPER reports on patients- not yourself, neighbors, girlfriends. • Maintain appropriate controls/security on KASPER access. Delete delegates that no longer work for you. Cabinet for Health and Family Services

Protecting your practice (cont) • Writing controlled substance prescriptions for friends, co-workers, or employees • See 201 KAR 20: 057/ 201 KAR 20: 057 for all requirements • Chart with a KASPER in it, medical history, treatment plan, diagnostic examinations, documented consent, etc. . Cabinet for Health and Family Services

Fast tract to KBML/BON • Departures from or failures to conform to “acceptable and prevailing medical practices” (this includes prescribing violations and failure to sufficiently document clinical reasoning in general) • Boundaries issues (i. e. sex with patients or prescribing to intimates) • Failure to make timely reports ( i. e. failure to report criminal conviction/plea or any action against his/her license by another state licensing board within 10 days of event) • False statements on applications (answering “no” when should have answered “yes”) • Not completing CE and specific CE • Untreated substance abuse/dependence Cabinet for Health and Family Services

Weight loss craze 201 KAR 9: 260 Restrictions on use of amphetamine-like anorectic C. S. Cabinet for Health and Family Services

Buprenorphine Prescribing • Must have DEA data waiver to prescribe buprenorphine! • Request e. KASPER prior to initiating treatment • Request e. KASPER at least once every three months to help guide the treatment plan 201 KAR 9: 270. Professional standards for prescribing or dispensing Buprenorphine-Mono-Product or Buprenorphine. Combined-with-Naloxone. http: //www. lrc. ky. gov/kar/201/009/270. htm Cabinet for Health and Family Services

Buprenorphine Cabinet for Health and Family Services

Buprenorphine Prescribing • You must include both your DEA number and your DEA data waiver number (X number) on the prescription • If you are a Medicaid provider you must accept Medicaid for this service • You may not advertise controlled substances or treatment with a named controlled substance • You must complete an additional twelve hours of addiction continuing medical education every three years • Medical offices not owned solely by practitioners must obtain additional licensing by OIG Cabinet for Health and Family Services

The Drug Enforcement and Professional Practices Branch (DEPPB)

Drug Enforcement Branch • The Drug Enforcement and Professional Practices Branch (DEPPB) is housed within the Cabinet for Health and Family Services: – Office of Inspector General (OIG) • Division of Audits and Investigations • DEPPB Responsibilities: – Enforcement of Kentucky Controlled Substances Act (KRS 218). • Conducting drug investigations. • Licensing drug manufacturers and distributors. – Enforcement of Kentucky Food, Drug and Cosmetic Act (KRS 217). – Operation of the KASPER program. Cabinet for Health and Family Services

DEPPB Investigators • Over the years DEPPB has migrated from a purely law enforcement agency to a consulting and assistance role in supporting investigations by other law enforcement agencies. • DEPPB investigators, by statute are all pharmacists thereby giving them a unique insight into drugs, provider and dispenser office procedures and record keeping/analysis. Cabinet for Health and Family Services

DEPPB Investigators DEPPB Phone Number: 502 -564 -7985 Paula York Jill Lee Amanda Ward Carrie Gentry Laura Beth Wells Duncan Mc. Cracken Cabinet for Health and Family Services Chris Johnson

Prescriber Review Considerations • Practitioner’s area of specialty • Consultation with licensure board to discuss any known problems with the practitioner • Review KASPER prescriber report • Total number of pages • Types of controlled substances prescribed (only a few types of controlled substances? ) • Prescribing unusually large quantities • Prescribing certain combinations (e. g. , hydrocodone, alprazolam and carisoprodol) • Refill frequency; are new scripts issued before all refills are exhausted? • Are patients traveling long distances to see the prescriber?

Tips from DEPPB

Tips from DEPPB - 1 How to identify doctor shoppers and avoid becoming a victim! • Use KASPER. – New patients – Before prescribing a controlled substance – Periodically for patients receiving a controlled substance • Be suspicious if a patient requests specific or brand name drugs. • Require photo id for patient records. Cabinet for Health and Family Services

Tips from DEPPB - 2 • Be suspicious of vague or inconsistent patient complaints. • Be suspicious of patients coming with family members, all wanting the same medications or with the same complaint. • Is the patient carpooling to your office with other patients? • Do patients know each other? Are they possibly mingling in the parking lot after their visits? Cabinet for Health and Family Services

Tips from DEPPB - 3 • Check patient address. Are patients driving long distances to see the prescriber? • Be wary of patients asking for frequent early prescriptions due to vacations, or new prescriptions when they should still have refills available. • Be suspicious of patients claiming lost or stolen medications. Require a police report, or if you believe them limit them to one time. Cabinet for Health and Family Services

Tips from DEPPB - 4 • Require patient to sign drug or pain contract with the prescriber. – Consider limiting the patient to one pharmacy in the contract. • Perform random drug screens. • Secure your prescription pads – even from staff. Serialize your secure prescription pads. • Write prescriptions in longhand to prevent further tampering. Make copies for patient files for proof if altered. Cabinet for Health and Family Services

Tips from DEPPB - 5 • Be suspicious of patients stating they are allergic to NSAIDs. • If a patient presents an MRI, verify it is from a legitimate facility. • Be suspicious of patients who frequently show up late in the day or on Friday afternoon (hoping you will be too busy to ask many questions or conduct a thorough examination). Cabinet for Health and Family Services

Tips from DEPPB- Prescribing • Identify yourself on prescription If there are 6 doctors and 4 APRN’s at your office listed on the prescription blank, make sure you circle your name. • Clearly identify the patient Be sure to write the patient’s full name on the prescription, including any suffixes. Include the patient address and date of to reduce fraudulent activity. • Spell out quantities and refills in addition to writing or circling the number on the prescription • Make copy of prescription for chart • Cancel Refills Cabinet for Health and Family Services at the pharmacy if changing medication birth

Security Prescription Blank (902 KAR 55: 105) A latent repetitive VOID at 5% in Pantone Greenif copied Void appears in pattern across entire script Federal Law Requires Prescriber Name, Address and Registration (DEA#) ¾ inch Opaque Rx Symbol 1/8 in. from top, 5/16 in. from side Rx is 4 ¼ inch high and 5 ½ inch wide 6 Quantity Check-Off Boxes The following statement at bottom of blank Refill Options on Left Side in this order Prescription is void if more than one (1) prescription is written per blank Printed Watermark on Back: “Kentucky Security Prescription” Horizontal– 5 lines-Helvetica style

Tips from DEPPB- Rx Blanks • Order controlled substance blanks that meet state security requirements – KAR 55: 105 • Store Rx pads in a secure spot – even from office staff • Do not pre-sign Rx blanks • Do not use Rx blanks pre-signed by your collaborative physician • Do not post-date prescriptions: All written and facsimile prescriptions for controlled substances shall be dated and signed by the practitioner on the date issued and shall bear the full name and address of the patient, drug name, strength, dosage form, quantity prescribed, directions for use, and the name, address and registration number of the practitioner • Scripts for compounded controlled substances are not exempt from controlled substance laws Cabinet for Health and Family Services

Questions to ask the Patient! • Are you seeing other practitioners for this or any other reason? • When did you last see the other practitioner? • What medications were you prescribed? • What pharmacy did you use? • Request identification with photo, DOB, SSN and address. Compare the above information with the KASPER report. Cabinet for Health and Family Services

APRN Sources of Confusion • APRNs must have CAPA-CS • APRNs cannot dispense controlled substance medications- see KRS 314. 011 (8) • APRNs cannot order controlled substances to dispense in office • APRNs can not supervise a PA-C – only physicians can supervise- see KRS 311. 840 • Weight Loss Clinics/Amphetamine like substances Can not dispense meds if doctor not in office Must conform to standards of practice Cabinet for Health and Family Services

Multiple prescriptions • A practitioner may provide individual patients with multiple prescriptions for the same schedule II controlled substance to be filled sequentially. The combined effect of these multiple prescriptions is to allow the patient to receive, over time, up to a 90 -day supply of that controlled substance APRNs may not issue multiple prescriptions Must adhere to prescribing standards in 201 KAR 9: 290 Cabinet for Health and Family Services

Diversion Definition- When a substance is acquired and/or taken by an individual for whom the medication was not prescribed. What do you do when diversion is suspected? • If you suspect an individual is involved in diverting controlled substances, we ask that you please report them to the proper law enforcement authorities. • If unsure who to contact please call the Drug Enforcement and Professional Practices Branch of the Office of the Inspector General for assistance. – (502) 564 -7985 – http: //www. chfs. ky. gov/os/oig/auditsinv Cabinet for Health and Family Services

Diversion Reporting Provider Shoppers/Diverters • KRS 218 A. 280 Controlled substances – Communications with practitioner not privileged. – Information communicated to a practitioner in an effort unlawfully to procure a controlled substance, or unlawfully to procure the administration of any controlled substance, shall not be deemed a privileged communication. Cabinet for Health and Family Services

Reporting Provider Shoppers/Diverters • 902 KAR 55: 110 Section 10 (4) (b): In addition to the purposes authorized under KRS 218 A. 202(8)(e), and pursuant to KRS 218 A. 205(2)(a) and (6), a practitioner or pharmacist who obtains KASPER data or a report under KRS 218 A. 202(6)(e)1. or who in good faith believes that any person, including a patient, has violated the law in attempting to obtain a prescription for a controlled substance, may report suspected improper or illegal use of a controlled substance to law enforcement or the appropriate licensing board. Cabinet for Health and Family Services

Controlled Substance Actions and Other Drugs of Concern

Kentucky Actions - Butalbital • The KY controlled substance exempt list now mirrors the Federal exempt list found in Title 21 Code of Federal Regulations § 1308. 32 EXCEPT butalbital containing products (e. g. , Fioricet, Bupap, Esgic). • Effective September 17, 2014 all butalbital containing products are Schedule III controlled substances in KY and must be reported to KASPER. Cabinet for Health and Family Services

Prescription drugs • • Clonidine Cyclobenzaprine Gabapentin Promethazine – Purple drank=promethazine/codeine cough syrup • Seroquel – Q-ball Cabinet for Health and Family Services

Promethazine w/codeine • Purple drank*Lean*Sizzurp Very popular with teens – typically mixed with sprite or Mt Dew and optionally a Jolly Rancher added for sweetness. • Plain promethazine potentiates the effects of just about every drug Cabinet for Health and Family Services

Please call police if you are getting calls from pharmacies to verify promethazine w/cod prescriptions you did not prescribe. Louisville 502 -574 -6272 Cabinet for Health and Family Services

Atypical Antipsychotics • Used to potentiate high from other drugs or avoid AE • St. Luke’s and Roosevelt Hospitals in NYC: – 73 of 429 patients in detox/rehab units used atypical antipsychotics illegally/non-medically – 88% of atypical antipsychotic users were polysubstance users – 84. 9% used quetiapine Presented at American Academy of Addiction Psychiatry 24 th Annual Meeting & Symposium. 2013. Cabinet for Health and Family Services

Gabapentin Abuse • Abusers report – – – Euphoria Psychedelic disassociation Feeling “laid back” “Fully-sedated opiate buzz” Cocaine-like high (when snorted) • Often abused to potentiate the effects of other substances – Alcohol, marijuana, opiates, quetiapine – Methadone in OAT patients • Risk is higher with history of alcohol/drug abuse • Can reduce cravings for alcohol Cabinet for Health and Family Services

Street Value • http: //streetrx. com • Louisville, KY – Adderall 30 mg = $4 -5 – Lorazepam 0. 5 mg= $5 – Vyvanse 60 mg= $10 • http: //www. bluelight. org open information board about how to take legal/non-legal drugs Cabinet for Health and Family Services

The Take-Away Messages • • • Recognize the problem Report to police diversion The Drug Enforcement and Professional Practices Branch is available to support your practice. Use KASPER regularly Increase your knowledge of addiction & how to properly prescribe CS. Please remain alert and be careful! Cabinet for Health and Family Services

Jill Lee RPh Office of Inspector General 275 East Main Street 5 E-E Frankfort, KY 40601 Jille. lee@ky. gov KASPER Web Site: www. chfs. ky. gov/KASPER 502 -564 -7985