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«Health Licensure & Regulation Controlled Substance Monitoring Database Committee February 1, 2016 Table of Contents Executive Summary Background Key ...»

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Controlled Substance Monitoring Database

2016 Report to the 109th Tennessee General Assembly

Health Licensure & Regulation

Controlled Substance Monitoring Database Committee

February 1, 2016

Table of Contents

Executive Summary

Background

Key Outcomes:

Increased Utilization of the CSMD

Outcomes Related to Ratio of Prescriptions Reported to CSMD / Request

Outcomes Related to Utilization of Benzodiazepines and Stimulants

Outcomes Related to Utilization of Opioids and Morphine Milligram Equivalents (MME)...........1 Outcomes Related to Top 50 Prescribers and Top 10 for Small Counties

Outcomes Related to Potential Doctor-Pharmacy Shopping

Outcomes Related to User Satisfaction & Perception of the CSMD

Outcomes Related to Top 10 Drugs Reported for 2015

Goals for 2016

CDC Grant Funding

CSMD Functionality Enhancements and Improvements

Interstate Data Sharing

Expand Collaboration

Results of January 2016 Data Analysis

Increased Utilization of the CSMD

Number of Registrants of the CSMD, 2010 - 2015

Outcomes Related to Number of Prescriptions Reported

Total Prescriptions Reported to CSMD, 2010-2015

Outcomes Related to Ratio of Prescriptions

Ratio of Number of Prescription to Number of Requests in the CSMD, 2010-2015*

MMEs for Declines for TN Patients, 2011 vs. 2015

MMEs of Opioids Dispensed to TN Patients and Reported to the CSMD by Age Group from 2010 to 2015

Prescriptions Dispensed to TN Patients and Reported by Class of Controlled Substances, 2010Outcomes Related to Utilization of Benzodiazepines and Stimulants

Outcomes Related to Utilization of Opioids and Morphine Milligram Equivalents (MME).................8 Opioid MMEs and Prescriptions Dispensed to TN Patients and Reported to CSMD, 2010-2015 9 Average MME Decrease per Tennessee County per Capita for TN Patients 2015 vs. 2013........10 Prescriptions Dispensed to TN Patients and Reported to the CSMD by Age Group, 2010-2015.11 FDA Approved Buprenorphine Products Indicated for Treatment of Opioid Dependence and Associated MMEs Dispensed to TN Patients and Reported to CSMD, 2010-2015

FDA Approved Buprenorphine Products Indicated For Treatment of Opioid Dependence and Associated MMEs Dispensed to TN Patients and Reported to CSMD by Age Group, 2010-201512 Average MME Increase or Decrease per Tennessee County per Capita for FDA Approved Buprenorphine Products Indicated For Treatment of Opioid Dependence Dispensed to TN Patients, 2015 vs. 2013

MMEs of All Methadone Dispensed Compared to Methadone Dispensed to TN Patients and Reported to the CSMD, 2010-2015

Outcomes Related to Top 50 Prescribers and Top 10 for Small Counties

MMEs Prescribed by Top 50 Prescribers and Dispensed in 2013 - 2015

Potential Doctor and Pharmacy Shoppers Identified in the CSMD, 2010-2015

Outcomes Related to User Satisfaction & Perception of the CSMD

2015 Prescriber and Dispenser Survey Results – Why did they check?

2015 Prescriber User Survey

2015 Dispensers User Survey

Outcomes Related to Top 10 Drugs Reported for 2015

Report Table 1. The Highest 10 Controlled Substances Reported in the CSMD, 2012-2015......19 Distribution of the Top 10 Controlled Substances Reported to the CSMD, 2015

Report Table 2A. MMEs for Long Acting Drugs Dispensed in TN and Reported to the CSMD, 2010-2015*

Reporting Table 2B. MMEs for Short Acting Drugs Dispensed in TN and Reported to the CSMD, 2010-2015*

Database Performance

Increased Interstate Data Sharing

Security Measures

Background and Summary of the Law

Educational Outreach

Goals for 2016

Findings and Recommendations

Members of the CSMD Committee

Appendix

Reference Tables

Table 1. Registered Users of CSMD, 2010 – 2015*

Table 2. Number of Requests from CSMD, 2010 – 2015*

Table 3. Number of Prescriptions Dispensed in TN and Reported to the CSMD, 2010-2015*.

..29 Table 4A. Prescriptions Dispensed in TN and Reported to the CSMD by Class of Controlled Substances – Opioids, 2010-2015*

Table 4B. Prescriptions Dispensed in TN and Reported to the CSMD by the Class of Controlled Substances – Benzodiazepines and Muscle Relaxants, 2010-2015*

Table 4C. Number of Prescriptions Dispensed in TN and Reported to the CSMD by the Class of Controlled Substances - Stimulants, 2010-2015*

Table 4D. Number of Prescriptions Dispensed in TN and Reported to the CSMD by the Class of Controlled Substances, 2010-2015*

Table 5A. The Top 10 Most Frequently Reported Controlled Substances in 2015*

Table 5B. The Highest 10 Controlled Substances Reported to the CSMD, 2012-2015*..............31 Table 6. Comparison of Number of Overall Prescriptions, Number of Prescriptions of Opioids and Their MMEs Dispensed and Reported to CSMD, 2010 – 2015*

Table 7. Associated MMEs of FDA Approved Buprenorphine Products Indicated For Treatment of Opioid Dependence to TN Patients and Reported to CSMD, 2010-2015*

Table 8. Methadone Prescriptions and Associated MMEs Dispensed and Reported to CSMD, 2010 – 2014*

Table 9. Number of Potential Doctor and Pharmacy Shoppers Identified in CSMD, 2010-2015*33 Survey





Why do prescribers and dispensers check the CSMD?

Prescribers and Dispensers believe data contained in CSMD is an accurate representation of a patient’s controlled substance usage

Prescribers and Dispensers discuss CSMD Report with Patient

Prescribers and Dispensers think the CSMD helps them decrease doctor shoppers

After viewing information Prescribers changed treatment plan or if a Dispenser refused to fill prescription as written

Prescriber and Dispenser Practice Changes

What is an average response time for a patient request when only Tennessee data is being requested from the CSMD?

Acronyms

2015 Report to the General Assembly Page | 1

Executive Summary

Background This report addresses activities of the Controlled Substance Monitoring Database (CSMD) program. The analyses performed considered all patients in the CSMD and then provided a detailed assessment of only the patients that have a Tennessee address. The Controlled Substance Monitoring Database Committee (CSMD Committee) reports annually on the outcome of the program with respect to its effect on distribution and abuse of controlled substances along with recommendations for improving control and prevention of diversion of controlled substances and the security measures taken to ensure that only authorized persons or entities access the database.

Key Outcomes:

Increased Utilization of the CSMD  The number of registrants increased by 10.2% in 2015 to 42,835;

 The number of patient reports requested increased 27.3% overall in 2015 to 6,445,103 (6,442,965 were from Healthcare Providers and 2,138 were from Law Enforcement);

Outcomes Related to Ratio of Prescriptions Reported to CSMD / Request  Tennessee has observed sustained improvement as the number of searches has increased the

proportion of prescriptions written and dispensed without a search has decreased from 14:1

in 2010 to 3:1 in 2015.

Outcomes Related to Utilization of Benzodiazepines and Stimulants  The prescribing and dispensing of benzodiazepine drugs decreased 1.8% from 2014 to 2015  The prescribing and dispensing of drugs in the stimulants class has grown 40.0% for patients in Tennessee from 2010 to 2015

–  –  –

Outcomes Related to Top 50 Prescribers and Top 10 for Small Counties  MME dispensed from the Top 50 Prescribers in 2015 decreased by 8.3% compared to 2014.

(Please note that the 2015 analysis converted to a calendar year; therefore, there was a quarter overlap of the analysis preformed in 2014).

 The top 10 prescribers in small counties was identified and none were in the top 50 and the number one top 10 small county prescriber was ranked 64 of all prescribers.

Outcomes Related to Potential Doctor-Pharmacy Shopping  There was a noticeable sustained decrease of 50.1% of potential doctor-pharmacy shopping patients from 2011 to 2015. Analysis only includes data submitted to the CSMD, if a patient visited dispensers outside of the state they would not be identified in the analysis.

–  –  –

Outcomes Related to Top 10 Drugs Reported for 2015  Hydrocodone and oxycodone have trended down in the number of MMEs over the last three years  Hydrocodone remained the number one drug dispensed, but oxycodone rose to second place for 2015 (hydrocodone was rescheduled from a Schedule III to a Schedule II drug in 2014).

 Hydrocodone MMEs decreased by 13.1% (2013 to 2015)  Oxycodone MMEs decreased by 7.5% (2013 to 2015)  Tennessee patient’s MMEs declined 23.7% for long acting and 9.0% for short acting opioids comparing 2015 to 2012

Goals for 2016

CDC Grant Funding  In September 2015, TDH was awarded a $3.4 million dollar grant from the Centers for Disease Control and Prevention (CDC) to assist with funding epidemiologic studies pertaining to the nation’s prescription drug overdose (PDO) epidemic o Enhance and maximize CSMD o Policy Evaluations o Develop and Implement Rapid Response Project CSMD Functionality Enhancements and Improvements  Work with dispenser to transition to daily reporting  Continue to evolve clinical decision support  Work with stakeholders to identify and develop new functionality such as better utility for law enforcement and drug court requests, better integration with TennCare and enhance models for high risk patients, prescribers and dispensers Interstate Data Sharing  Continue work with borders states  Work with other states to share data, in conversations with Minnesota, Louisiana, Rhode Island and Maryland

–  –  –

Results of January 2016 Data Analysis The primary purpose of this section is to report on the outcome and the efficacy of the CSMD Program.

The CSMD team compiled the following data describing the controlled substances prescriptions reported to the CSMD from January 1, 2015 to December 31, 2015. Tenn. Code Ann. § 53-10-306 (a) (2) allows CSMD program staff to access database information for the purposes of compiling this report.

The goal is to release the most current information for 2015 by February 1, 2016. It should be noted that this report uses Centers for Disease Control and Prevention (CDC) conversion factors and updates to conversion factors for opioids and the classification of controlled substances published in or about June each year. If new drug products were introduced after the CDC update, they are not included.

Increased Utilization of the CSMD

The Prescription Safety Act of 2012 has facilitated a substantial increase in utilization of the CSMD:

 The number of registrants increased by 10.2% in 2015 to 42,835;

 The number of patient reports requested increased 27.3% overall in 2015 to 6,445,103 (6,442,965 were from Healthcare Providers and 2,138 were from Law Enforcement);

 Details for the number of registrants since 2010 are located in Appendix (Table 1).

Law enforcement requests to the CSMD (Table 2 in Appendix) continued to be a critical use of the CSMD as we all worked together to address questionable controlled substance use in Tennessee.

Effective July 1, 2011, law enforcement was granted access to the CSMD without a court order or subpoena by sending a request to the CSMD Program.

 The process to best respond to requests from the Pilot Program for Drug Courts was improved during 2015 and forms to streamline the process are located on the CSMD website.

We have been successful in utilizing the new system to provide these patient reports during 2015.

Number of Registrants of the CSMD, 2010 - 2015 2015 Report to the General Assembly Page | 5 Outcomes Related to Number of Prescriptions Reported This analysis was performed by considering all patients in the CSMD and by then providing a detailed assessment of only the patients that have a Tennessee address. A significant change occurred in 2011 when Tennessee scheduled tramadol and carisoprodol as schedule IV controlled substances resulting in added reporting volume to the CSMD. During 2015, the CSMD program noticed a decrease in overall reporting of prescriptions to the CSMD by 1.8% and a 1.7% decrease for patients with a Tennessee address compared to 2014. Table 3 in Appendix and Figure 2 best illustrates this welcome news to hopefully demonstrate that the partnership of the CSMD with the clinicians, the legislature, state government and law enforcement has created a culture of utilizing the database as a clinical tool as was intended in 2002 when the first CSMD Legislation was passed in Tennessee.

Total Prescriptions Reported to CSMD, 2010-2015 2015 Report to the General Assembly Page | 6 Outcomes Related to Ratio of Prescriptions The CSMD continued to gain overall use as Tennessee worked to fight the prescription drug crisis. In order to illustrate this gain in utilization of the CSMD, Figure 3 below presents a ratio of prescriptions in the CSMD to the number of requests made to the CSMD. Since 2010, Tennessee has observed sustained improvement in this ratio of requests to dispensed prescriptions from 14:1 in 2010 to 3:1 in 2015. This trend suggest that mandatory checking required by the Prescription Safety Act benefitted prescribers to assure the most current and complete information about the patient.

Ratio of Number of Prescription to Number of Requests in the CSMD, 2010-2015* 2015 Report to the General Assembly Page | 7 For 2015, the CSMD program provided a more detailed analysis of the MME for trends by age groups for patients with a Tennessee address (Figure 4). It is encouraging to see some decline in MME since the Prescription Safety Act of 2012 was passed for the 20 to less than 60 age ranges. Comparing 2015 with 2011 (the peak year for age groups with MME declines in opioids), MME decreased 54.7% (20 to less than 30 years), 38.8% (30 to less than 40 years), and 28.8% (40 to less than 50 years) in these age groups. It is concerning to see increases for certain age groups above 60 since those groups may be more at risk for adverse events such as falls.



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