An Update on KASPER

An Update on KASPER

David R. HopkinsKASPER Program ManagerOffice of Inspector GeneralKentucky Cabinet for Health and Family Services

CAPTASA ConferenceJanuary 24, 2014

Cabinet for Health and Family Services

Contents

• Pill Mills

• KASPER Program Review

• House Bill 1 Preliminary Results and Evaluation

Pill Mills


Jeff and Chris George

Photos from Palm Beach Post


Dr. Paul H. Volkman

Story: Bill Estep, Lexington Herald-Leader, February 14, 2012. AP Photo released by U.S. Marshals Service (undated)


Care More Pain Management Clinic

Photo: Scott Utterback, Louisville Courier-Journal, January 25, 2012


Ernest William Singleton

Photo: Lexington Community Corrections, January 2013


Kitson Clothing Collection

Story: WXIX Fox 19 Digital Media Staff, June 21, 2013


Kitson Clothing Collection

KASPER Program Review

Status of Prescription Drug Monitoring Programs (PDMPs)

Research is current as of February 1, 2012

AK

AL

AR

CACO

ID

IL INIA

MN

MO

MT

NENV

ND

OH

OK

OR

TN

UT

WA

AZ

SD

NM

VA

WY MI

GA

KS

HI

TX

ME

MS

WI NY

PA

LA

KYNC

SC

FL

NHMARICTNJDEMD

DC

VT

WV

Operational PDMPs

Enacted PDMP legislation, but program not yet operational

Legislation pending

GU

2011 KASPER Reports Requested



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

Annual KASPER Records Total / Per Person


2.39 2.43 2.65 2.65 2.72 2.72 2.47Number of Controlled Substance Prescriptions per Person

KASPER Reports Requested



Top Prescribed Controlled Substances byTherapeutic Category by Doses - 2013

Hydrocodone 41.3% LortabLorcetVicodin

Alprazolam 11.2%Xanax

Tramadol 6.8%Ultram

Oxycodone 15.4% OxyContinPercodanPercocet

Clonazepam 6.7%Klonopin

Diazepam 4.3%Valium

Amphetamine 3.1%

Adderall

Zolpidem 3.4%Ambien

Testosterone 3.5%

AndroGel

Lorazepam 4.0%Ativan

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


House Bill 1 Preliminary Resultsand Evaluation


Controlled Substance Dispensing – One Year Comparison

Drug August 2011 through

July 2012

August 2012through

July 2013

Change

Hydrocodone 239,037,354 214,349,392 -10.3%

Oxycodone 87,090,503 77,022,586 -11.6%

Oxymorphone 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%

Figures shown in doses dispensed


Hydrocodone


Oxycodone


Alprazolam


Methadone


Oxymorphone


Tramadol


Buprenorphine


Controlled Substance Prescribing 2013


Controlled Substance Usage 2013


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

Jul 2

009

Sep 20

09

Nov 20

09

Jan 2

010

Mar 20

10

May 20

10

Jul 2

010

Sep 20

10

Nov 20

10

Jan 2

011

Mar 20

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May 20

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Jul 2

011

Sep 20

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Nov 20

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Jan 2

012

Mar 20

12

May 20

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Jul 2

012

Sep 20

12

Nov 20

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013

Mar 20

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May 20

13

Jul 2

013

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

KASPER Prescriber Accounts, 2009-2013

Reg

istra

nts

Kentucky Prescribers

Non-KYPrescribers

Jul 2

009

Sep 20

09

Nov 20

09

Jan 2

010

Mar 20

10

May 20

10

Jul 2

010

Sep 20

10

Nov 20

10

Jan 2

011

Mar 20

11

May 20

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Jul 2

011

Sep 20

11

Nov 20

11

Jan 2

012

Mar 20

12

May 20

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Jul 2

012

Sep 20

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Nov 20

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013

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13

May 20

13

Jul 2

013

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

KASPER Pharmacist Accounts, 2009-2013

Regi

stra

nts

Kentucky Pharmacists

Non-KY Pharmacists

Jul

Sep Nov Jan

MarMay Ju

lSep Nov Ja

nMar

May Jul

Sep Nov Jan

MarMay Ju

lSep Nov Ja

nMar

May Jul

0

200

400

600

800

1,000

1,200

1,400

1,600

KASPER Law Enforcement Accounts, 2009-2013

Regi

stra

nts

Non-KY

Kentucky

• 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 IngramExecutive DirectorOffice of Drug Control PolicyKentucky Justice and Public Safety Cabinet

CAPTASA ConferenceJanuary 24, 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


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.


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

KASPER Reporting KRS 218A.202

• Controlled substance administration or dispensing must be reported within one day effective July 1, 2013


KASPER Accounts – KRS 218A.202

• KASPER registration is mandatory for Kentucky practitioners or pharmacists authorized to prescribe or dispense controlled substances to humans.


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


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.


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


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


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


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


National Survey onDrug Use and Health

January 8, 2013

NATIONAL TRENDSStates with Rates between 5.33 and 6.371 Oregon 6.37 5.25-7.712 Colorado 6.00 4.96-7.243 Washington 5.75 4.76-6.924 Idaho 5.73 4.74-6.915 Indiana 5.68 4.68-6.896 Arizona 5.66 4.60-6.947 Nevada 5.62 4.57-6.898 Delaware 5.61 4.61-6.829 Arkansas 5.55 4.60-6.6810 New Mexico 5.45 4.47-6.64


States with Rates between 4.80 and 5.3211 Alaska 5.32 4.41-6.4212 Oklahoma 5.19 4.26-6.3013Rhode Island 5.18 4.26-6.2714 Vermont 5.13 4.24-6.1915 Michigan 5.11 4.57-5.7216 Ohio 5.00 4.49-5.5617 Tennessee 5.00 4.14-6.0218 Louisiana 4.87 4.09-5.8019 Montana 4.84 4.02-5.8020 Missouri 4.83 4.03-5.78

NATIONAL TRENDS


States with Rates between 4.46 and 4.7921 West Virginia 4.79 3.97-5.7522 California 4.68 4.13-5.3023District of Columbia 4.68 3.79-5.7624 Wyoming 4.68 3.85-5.6825 South Carolina 4.62 3.81-5.5926 Virginia 4.60 3.79-5.5827 Minnesota 4.57 3.79-5.4928 New Hampshire 4.57 3.77-5.5329 Kansas 4.56 3.77-5.5030 Wisconsin 4.51 3.68-5.5231 Kentucky 4.48 3.70-5.41

NATIONAL TRENDS


Among persons aged 18 to 25, the ratesof 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.

NATIONAL TRENDS


HB1 Provider Training

ODCP, OPERATION UNITE and KENTUCKY COALITION OF NURSE PRACTITIONERS/NURSE MIDWIVES HAVE SPONSORED 4 TRAININGS

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

HB 1 TRAININGS


MOREHEAD119 TRAINEES83 PRESCRIBERSPAINTSVILLE147 TRAINEES55 PRESCRIBERSBOWLING GREEN239 TRAINEES170 PRESCRIBERSMANCHESTER110 TRAINEES80 PRESCRIBERS

HB 1 TRAININGS


615 TOTAL TRAINEES 388 PRESCRIBERS AVAILABLE ONLINE MEETS LICENSING BOARDS

REQUIREMENTS

HB 1 TRAININGS


HB 1 TRAININGS


The Good, Bad, and Ugly of Addiction


Kentucky Overdose Data

1004 OVERDOSE FATALATIES IN 2012

19 FEWER THAN 2011. THE FIRST DECLINE IN OVER A DEACDE

• 888 UNINTENTIONAL• 59 SUICIDES• 57 UNDETERMINED

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

2012 OVERDOSE DATA


DEATHS ATTRIBUTABLE TO HEROIN ROSE 550%

ALPROZOLAM MOST DETECTED SUBSTANCE AT 41.44% OF ALL MEDICAL EXAMINER CASES

2012 OVERDOSE DATA


YOUNGEST OD DEATH AGE 16 OLDEST 72 AVERAGE AGE 40 MALE 58% FEMALE 42%

2012 OVERDOSE DATA


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


2013 JEFFERSON 94 FAYETTE 26 KENTON 26 BOONE 20 CAMPBELL 8 FRANKLIN 5 17 COUNTIES 1 or 2 97 COUNTIES NONE


HEROIN


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 DEMANDCabinet for Health and Family Services

HOW DID WE GET HERE?

PRICE

AVAILABILITY

PERCEPTION OF RISK

PUBLIC ATTITUDES


HOW DO WE ADDRESS IT?

PUBLIC EDUCATION INCREASED ACCESS TO

TREATMENT ENHANCED PENALTIES FOR MAJOR

TRAFFICKERS GREATER ACCESS TO NALOXONE


Van IngramKentucky Justice and Public Safety Cabinet

125 Holmes StreetFrankfort, KY 40601

[email protected]

David HopkinsKentucky Cabinet for Health and Family Services

275 East Main Street, 5EDFrankfort, KY 40621

502-564-2815 ext. [email protected]

An Update on KASPER

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