New Developments in PDMPs: South Carolina, Wisconsin and Florida

1. New Developments in PDMPs:
South Carolina, Wisconsin and Florida
Presenters:
• Christie Frick, RPh, Director, Prescription Monitoring Program, South
Carolina Department of Health and Environmental Control
• Chad Zadrazil, JD, Managing Director, Wisconsin Department of Safety and
Professional Services
• Chris Delcher, PhD, Assistant Professor, University of Florida
• Bruce Goldberger, PhD, Chief, Division of Forensic Medicine, University of
Florida College of Medicine
PDMP Track
Moderator: Karen H. Perry, Co-Founder and Executive Director,
Narcotics Overdose Prevention and Education (NOPE) Task Force,
and Member, Rx and Heroin Summit National Advisory Board

2. Disclosures
Chris Delcher, PhD; Christie Frick, RPh; Bruce
Goldberger, PhD; Chad Zadrazil, JD; and Karen H.
Perry have disclosed no relevant, real, or
apparent personal or professional financial
relationships with proprietary entities that
produce healthcare goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Describe how two states improved integration of
PDMP data into electronic health IT systems.
2. Identify challenges states may face when
integrating PDMP data into electronic health IT
systems.
3. Explain the operation and findings of Florida’s
nascent drug surveillance systems.
4. Provide accurate and appropriate counsel as
part of the treatment team.

5. New Developments in PDMPs:
South Carolina, Wisconsin and
Florida

6. Christie Frick, RPh, has disclosed no relevant, real or
apparent personal or professional financial
relationships with proprietary entities that produce
health care goods and services.

7. Learning Objectives:
1. Describe how two states improved
integration of PDMP data into
electronic health IT systems.
2. Identify challenges states may face
when integrating PDMP data into
electronic health IT systems.

8. In 2012 South Carolina joined the PMP
InterConnect to facilitate interoperability
and interstate data sharing between state
PMPs.
Currently sharing with 20 states.
MI
AZ
NM
ND
KS
OH
SC
VAKY
SD
LA
IL
CT
DE
MS
ID
IN
WI
TN
MN
CO
AR
NJ
WV
NV
PMP InterConnect: A Nationwide PMP Data
Sharing Platform
8

9. Pharmacists
Prescribers
Health Exchanges
MI
AZ
NM
ND
KS
OH
SC
VAKY
SD
L
A
I
L
CT
DE
MS
ID
IN
WI
TN
MN
CO
A
R
NJ
W
V
NV
PMP Gateway: A Health IT Connectivity
Platform for PMP Data
9

10. South Carolina’s Integrations
•Palmetto Health System (Cerner EMR)
•Lexington Medical Center (Epic EMR)
•Rx Care Plus Pharmacies (QS 1)
•Kroger Pharmacy
Patient searches between October 1- December 31, 2015
Palmetto Health Emergency Departments (3 locations) 54,443
Lexington Medical Center Emergency Department 1,543

11. So….what’s the big deal?
54,443 + 1,543 = 55,986
55,986 x 3 mins = 167,958 mins = 2,799
hours of time saved in the Emergency
Room in 3 months!!

12. So…why isn’t everyone integrating?
•Get in line for a health system IT
project
•Cost (SC was fortunate enough to get a
SAMHSA grant for funding)
•Legal Agreements/Contracts
•Authorizing Users – Must they be
signed up separately with PMP (Need
for Privacy Statement)

13. Agreements in Place
PMPs
State PMPs have MOUs in place with PMP InterConnect.
A contract is in place between Appriss/PMP Gateway and NABP/InterConnect.
Healthcare entity must have a contract in place with Appriss/PMP Gateway.
PMPs
PMPs
13SC
In SC, PMP must also have a contract with each entity receiving funds.

14. Is it worth it?
“I am working and one of the attendings came
over and said ‘your new drug check’ just saved a
man’s life. Its a long story, but it was the
highest narc score we had seen. He was here
for a pseudo medical problem that seemed legit
and he likely would have gotten more meds
from what he was saying. Since NarcRx popped
up right as soon as the doc looked at his chart,
the doctor went back into the room and the
whole story changed. He is now getting help
with his drug abuse. “

15. New Developments in PDMPs: South
Carolina, Wisconsin and Florida
Experience in Wisconsin
March 30, 2016

16. Disclosure
Chad Zadrazil, JD, has disclosed no relevant, real
or apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services.

17. Learning Objectives
1. Describe how two states improved integration
of PDMP data into electronic health IT systems.
2. Identify challenges states may face when
integrating PDMP data into electronic health IT
systems.

18. 18
PMPi
October 2013
Connection
PMP Gateway
September 2014
Connections
October 2015
Connection
EHR Integration in Wisconsin

19. 19

20. 20
MCIS PDMP Interface

21. 21
MCIS PDMP Interface

22. Barrier to Integration
Legal Definition of “access”
Original Definition:
To obtain access to PDMP information, pharmacists,
pharmacist delegates, practitioners, and practitioner
delegates shall create an account with the board on
a form provided by the board.

23. Solution: Additions to “Access”
Definition
• Create an account with a pharmacy or other entity at which
pharmacists dispense or administer monitored prescription drugs in
the course of professional practice with which the board has
determined to have at least equivalent capability to maintain the
confidentiality of PDMP information or that is connected to and
lawfully obtains data from the state-designated entity
under ch. 153, Stats.
• Create an account with a hospital or other entity at which
practitioners prescribe, dispense, or administer monitored
prescription drugs in the course of professional practice with which
the board has determined to have at least equivalent capability to
maintain the confidentiality of PDMP information or that is
connected to and lawfully obtains data from the state-designated
entity under ch. 153, Stats.
Cite: Wisconsin Administrative Code CSB 4.09

24. Updated Definition of “Access”
Recognizes and authorizes:
• Integration into pharmacy dispensing software
• Integration into electronic medical records
and prescribing modules
• Integration into the Wisconsin Statewide
Health Information Network (WISHIN), the HIE
in WI

25. 2016: A Year of WI PDMP Evolution
In addition to our current and future
PDMP-HIT integration projects…

26. 2016: A Year of WI PDMP Evolution
• H.O.P.E. Agenda Bills (AB 364):
– Increases data submission frequency from 7 days
to 1 day
– Requires prescribers to review PDMP data prior to
issuing a prescription order for a controlled
substance (some exceptions)
– Allows law enforcement agencies and
prosecutorial units to request PDMP data without
a court order
– Adds access for non-prescriber healthcare and
substance abuse professionals

27. 2016: A Year of WI PDMP Evolution
• H.O.P.E. Agenda Bills (AB 365):
– Requires law enforcement agencies to report any
of the following to the PDMP for dissemination to
PDMP users:
• A suspected violation of the CSA involving a
prescription drug
• A person who is undergoing or who immediately prior
experienced an opioid-related overdose event
• A person who may have died as a result of using a
narcotic drug
• A report of a stolen controlled substance prescription

28. Development of the WI ePDMP
• The primary emphasis of the design of the
enhanced WI PDMP (“ePDMP”) is:
• value-added clinical workflow integration
• improved data quality capabilities
• maximized public safety use
• Stakeholders and users are closely involved in
every step of the process

29. Development of the WI ePDMP
• Possible due to federal support and inter-agency
collaboration:
• 2014 Harold Rogers PDMP Enhancement Grant
• 2015 Harold Rogers PDMP Enhancement Grant
• 2015 CDC Prescription Drug Overdose
Prevention Grant (in partnership with WI
Department of Health Services)

30. Development of the WI ePDMP
• Iterative Design and Development Process
• Modular, user-centered focus
• Continual user input and testing
• Feedback loop with stakeholders and subject
matter experts

36. New Developments in PDMPs: South
Carolina, Wisconsin and Florida
PDMP Track

37. Disclosure Statement
• Bruce Goldberger, PhD, Professor, has disclosed no relevant,
real or apparent personal or professional financial
relationships with proprietary entities that produce health
care goods and services.
• Chris Delcher, PhD, Assistant Professor, has disclosed no
relevant, real or apparent personal or professional financial
relationships with proprietary entities that produce health
care goods and services.

38. Learning Objectives
• Describe how two states improved integration of PDMP data
into electronic health IT systems.
• Identify challenges states may face when integrating PDMP
data into electronic health IT systems.
• Explain the operation and findings of Florida’s nascent drug
surveillance systems.
• Provide accurate and appropriate counsel as part of the
treatment team.

39. Florida Medical Examiners Commission
• Temporal Coverage
– Drug-related death data available since 2000
• Submission Source
– District Medical Examiners
• Autopsy, toxicology results, decedent's drug use history, physical
evidence, etc.
• Cause of death versus present in the body at the time of death
• Accidental, natural, suicide, homicide and undetermined
• Specificity
– Data collected in 2014 (# of drugs reported)
• Amphetamines (2), Benzodiazepines (13), Ethanol,
Hallucinogenics (3), Inhalants (4), Opioids (12), Other (9)

40. Florida Prescription Drug Monitoring
Program
• Implementation
– September 2011
• Controlled substance schedules monitored
– II, III, IV
• Voluntary registration
• On-going updates
– Veteran’s Administration began reporting on October 1,
2014.

41. Period 1: 2003 - 2009
1.3
4.4 (+233.8%)
0.7
0.7 (0%)
1.4
0.5 (-62.2%)
1.3
1.6 (+26.2%)
1.8
6.4 (+264.6%)
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
DeathRate(per100,000population)
Alprazolam Fentanyl Heroin Morphine Oxycodone
The original controlled-release
formulation OxyContin® was approved in
December 1995 (launched in 1996).
Oxycodone is one of the most frequently
abused prescription opioids (Cicero et al.
2005)
Percent change shown reported in (Goldberger et al., 2011)

42. Period 1 con’t: 2010
1.3
5.2
0.7
0.6
1.4
0.3
1.3
1.4
1.8
8.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
DeathRate(per100,000population)
Alprazolam Fentanyl Heroin Morphine Oxycodone
Oxycodone and alprazolam-caused death rate peaked in 2010
Heroin death rate reached its lowest in 2010
(Lee et al., 2014)

43. Period 2: “PILL Zone” (Interventions)
1.3
5.2
0.7
0.6
1.4
0.3
1.3
1.4
1.8
8.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
DeathRate(per100,000population)
Alprazolam Fentanyl Heroin Morphine Oxycodone
Industry
Reformulated OxyContin® came on the market in August 2010
Legislative Actions
1Jan 2010: Pain clinics must register
2Oct 2010: Pain clinic regulation expanded
3July 2011: Physician dispensing prohibited/strike forces activated
4Sep 2011: Florida PDMP implemented
5July 2012: Wholesale distributor regulations expanded
Law Enforcement (DEA Actions)
Operation Pill Nation
6Feb 2010, 7Feb 2011, 8Aug 2012
(Johnson et al., 2014)
PDMP
Implementation
PILL: Public Health, Industry, Legislation, Law Enforcement

44. Period 3: 2010 – 2014 (Effects)
5.2
2.9 (-45.1%)
0.6
2.0 (+229.9%)
0.3
2.1 (+705.2%)1.4
3.5 (+154.9%)
8.0
2.4 (-70.6%)
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
DeathRate(per100,000population)
Alprazolam Fentanyl Heroin Morphine Oxycodone
Legislative and Regulatory Effect
• Rx drug overdose deaths -23.2%, 2010-2012 (Johnson et al., 2014)
• Rx opioid diversion declined, 2009-2012 (Surratt et al., 2014)
• Oxycodone-caused mortality abruptly declined 25% month after PDMP
(Delcher et al., 2015)
• Opioid prescriptions -1.4%, volume -2.5%, MME/transaction -5.6%,
2011-2012 (Rutkow et al, 2015)
• ~1,029 lives saved from rx opioid overdose, 2010-2012
(Kennedy-Hendricks et al., 2016)
Heroin
• Connection b/w nonmedical use of prescription opioids and heroin use
(Compton et al., 2016)
PDMP
Implementation

45. 2003 - 2014
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
DeathRate(per100,000population)
Alprazolam Fentanyl Heroin Morphine Oxycodone

46. Surveillance Opportunities: Time
0
50
100
150
200
250
300
350
400
450
0
20
40
60
80
100
120
140
160
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Prescriptions,No.
Thousands
Deaths,No.
Alprazolam (Deaths) Oxycodone (Deaths) Alprazolam (Rx)
Oxycodone Long Acting (Rx) Oxycodone Short Acting (Rx)
PDMP
Implementation

47. Surveillance Opportunities: Person
0
50
100
150
200
250
300
350
400
450
18-24 25-34 35-44 45-54 55-64 65 and
older
#ofRxper1,000population
Stimulants
Female
Male
0
200
400
600
800
1,000
1,200
1,400
1,600
18-24 25-34 35-44 45-54 55-64 65 and
older
#ofRxper1,000population
Benzodiazepines
0
200
400
600
800
1,000
1,200
1,400
18-24 25-34 35-44 45-54 55-64 65 and
older
#ofRxper1,000population
Opioids

48. Surveillance Opportunities: Place
OPIOIDS

49. Surveillance Opportunities: Place
OPIOIDS

50. Surveillance Opportunities con’t: Place
BENZODIAZEPINES

51. Surveillance Opportunities con’t: Place
BENZODIAZEPINES

52. US and State Rx Opioid Poisoning Mortality,
1999-2014
US Rate
Source: National Center for Health Statistics, CDC WONDER Online Database, released 2015.

53. References
Cicero, T. J., Inciardi, J. A., & Muñoz, A. (2005). Trends in abuse of Oxycontin and other opioid analgesics in the United States:
2002-2004. The Journal of Pain: Official Journal of the American Pain Society, 6(10), 662–672.
Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016). Relationship between Nonmedical Prescription-Opioid Use and Heroin Use.
The New England Journal of Medicine, 374(2), 154–163.
Delcher, C., Wagenaar, A. C., Goldberger, B. A., Cook, R. L., & Maldonado-Molina, M. M. (2015). Abrupt decline in oxycodone-
caused mortality after implementation of Florida’s Prescription Drug Monitoring Program. Drug and Alcohol Dependence.
Goldberger, B., Thogmartin, J., Johnson, H., Paulozzi, L., Rudd, R., & Ibrahimova, A. (2011). Drug Overdose Deaths — Florida,
2003–2009. Morbidity and Mortality Weekly (MMWR), 60, 869–872.
Johnson, H., Paulozzi, L., Porucznik, C., Mack, K., Herter, B., & Hal Johnson Consulting and Division of Disease Control and Health
Promotion, Florida Department of Health. (2014). Decline in drug overdose deaths after state policy changes - Florida, 2010-2012.
MMWR. Morbidity and Mortality Weekly Report, 63(26), 569–574.
Kennedy-Hendricks, A., Richey, M., McGinty, E. E., Stuart, E. A., Barry, C. L., & Webster, D. W. (2016). Opioid Overdose Deaths and
Florida’s Crackdown on Pill Mills. American Journal of Public Health, 106(2), 291–297.
Lee, D., Delcher, C., Maldonado-Molina, M. M., Bazydlo, L. A. L., Thogmartin, J. R., & Goldberger, B. A. (2014). Trends in licit and
illicit drug-related deaths in Florida from 2001 to 2012. Forensic Science International.
Rutkow, L., Chang, H.-Y., Daubresse, M., Webster, D. W., Stuart, E. A., & Alexander, G. C. (2015). Effect of Florida’s Prescription Drug
Monitoring Program and Pill Mill Laws on Opioid Prescribing and Use. JAMA Internal Medicine, 175(10), 1642–1649.
Surratt, H. L., O’Grady, C., Kurtz, S. P., Stivers, Y., Cicero, T. J., Dart, R. C., & Chen, M. (2014). Reductions in prescription opioid
diversion following recent legislative interventions in Florida. Pharmacoepidemiology and Drug Safety, 23(3), 314–320.

54. Acknowledgements
• Florida Medical Examiners Commission (FDLE)
• Florida Prescription Drug Monitoring Program
(FDOH)
• Prescription Behavioral Surveillance System
(CDC)
• BJA Grant #: 2013-PM-BX-0010

56. New Developments in PDMPs:
South Carolina, Wisconsin and Florida
Presenters:
• Christie Frick, RPh, Director, Prescription Monitoring Program, South
Carolina Department of Health and Environmental Control
• Chad Zadrazil, JD, Managing Director, Wisconsin Department of Safety and
Professional Services
• Chris Delcher, PhD, Assistant Professor, University of Florida
• Bruce Goldberger, PhD, Chief, Division of Forensic Medicine, University of
Florida College of Medicine
PDMP Track
Moderator: Karen H. Perry, Co-Founder and Executive Director,
Narcotics Overdose Prevention and Education (NOPE) Task Force,
and Member, Rx and Heroin Summit National Advisory Board