Daniel M Alexander, RPh BS Clinical Chemistry Michigan State

Univ.BS Pharmacy Ferris State Univ.

President/CEO Lakeshore Pharmacies, Inc.

I have no financial relationships to disclose

Why do we need tools to monitor patients? Discuss the most common pharmaceuticals

of abuse Identify a useful tool to identify those who

many be abusing and diverting prescription medications (MAPS)

MAPS its use and information to the health care provider

The MAPS Report MAPS Limitations

U.S. Drug Overdose Deaths By Major Drug Type, 1999-2010

Opioids

Benzo’s

Heroin

Cocaine

Source CDC/NCHS, NVSS

Prescription Drug Abuse

More Americans abuse prescription drugs than the number of:

Cocaine, Hallucinogen, Heroin, and Inhalant abusers

Combined!!!

Teen Prescription Drug Abuse

- One in four teens (24%) reports having misused or abused a prescription drug at least once in their lifetime, which is approximately 5 million teens.

-In comparison, 18% of teens in 2008 and 24% of teens in 2012 reported the same

- Of those kids who said they abused prescription medications, one in five (20%) has done it before age 14.-More than a quarter of teens (27%) mistakenly believe that misusing and abusing prescription drugs is safer than using street drugs.-One in four teens (25%) says there is little or no risk in using prescription pain relievers without a prescription.Source:2012 Partnership Attitude Tracking Study, Published 4/23/2013

Teen Prescription Drug Abuse

•One-Third of teens (33%) say they believe “it’s okay to use prescription drugs that were not prescribed to them to deal with an injury, illness, or physical pain”

•One in five teens (20%) says prescription pain relievers are not addictive

•Almost one in four teens (23%) say their parents don’t care as much if they are caught using prescription drugs without a doctor’s prescription, compared to getting caught with illegal drugs.

DEA Operations Division :Source 2012 Partnership Attitude Tracking Study, Published 04/23/2013

New Initiates 2011 -12 Years and older

Note: Numbers refer to persons who used a specific drug for the first time in the past year, regardless of whether initiation of other drug use occurred prior to that year. Source 2011 NSDUH

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Source: CDC/NCHS, National Vital Statistics System

Vital Signs is there a fifth Vital Sign?

Temperature

Heart Rate

Blood Pressure

Respiration

Pain?

MAPSMichigan Automated Prescription System

Health Professional Boards. Investigation Employee or agent of the Department State, Federal, or Municipal employee or

agent whose duty is to enforce drug laws. State operated Medicaid program. Practitioner or pharmacist who certifies

info is for treatment of bona fide current patient.

Insurance Company “Patient Safety” “Fraud”

Received $20,000 grant to implement automated letter generation.

March 2012: 2144 letters. April 2012: 1799 letters 2011 Shopper list at 6 or more: 530. 2011 Shopper list at 10 or more: 49 2012 Shopper list at 6 for more: 251 2012 Shopper list at 10 or more: 9

 October 15, 2008  «Company»«FirstName» «Last Name»«Address1»«City», «State» «Postal Code»Dear «Title»: The Michigan Automated Prescription System (MAPS) program has identified your patient «Patient», «DOB», «Address2», who appears to be seeking treatment from multiple physicians and obtaining controlled substance prescriptions of a similar nature from these practitioners.  It is suggested that you obtain controlled substance prescription data on the patient identified above and communicate with other health care providers who are treating this patient. You may access MAPS data via a link on our website at: www.michigan.gov/healthlicense and click on the MAPS link. Enclosed please find a listing of physicians in Michigan that provide an office based treatment program for opiate addiction that may be shared with the patient. There are other options available in addition to opioid treatment such as referral to a pain specialist, or requiring the patient to enter into an agreement which limits their treatment to a specific physician and pharmacy. Please consider all of the options that are available to you and your patient. If you have any questions or need additional information, please contact our office at the phone number listed below, or at our e-mail address: mapsinfo@michigan.gov.  Sincerely, Bureau of Health ProfessionsHealth Investigation Division(517) 373-1737

 

New formulation by Purdue Patients calling for old formula. Canada Used callous shaver to “peel” tablets. Snorting new formula leaves a paste or gel. Oxy IR 30mg is popular. 50% to Florida Seeing Opana increase. Phenergan with Codeine (Purple)

Oxymorphone long acting Expensive 10,770 Scripts in 2010 47,979 scripts in 2011

50% to Florida31,689 Scripts in 2010113,973 Scripts 1n 2011

Used for decades to treat drug addiction

Increasingly prescribed for pain

As increased use for pain so has methadone related fatal overdoses.

Cheapest Narcotic Pain Reliever (Synthetic)

Insurance companies love it

The Problem? CDC Vital Signs Report July 2012. Almost one-third of prescription painkiller overdose deaths involve methadone

Six times as many people died of methadone overdoses in 2009 than a decade before.

Methadone accounts for only 2 percent of painkiller prescriptions in the U.S. but is involved in more than 30 percent of prescription painkiller overdose deaths.

Fentanyl Patches, Fentanyl Citrate berry flavored lollipop

Fentanyl 100 times more potent than morphine Intended to be used for chronic cancer pain and opioid

tolerant people Abused for its intense euphoric effects Laws changed in dispensing lollipops Must be on at

least 60mg of morphine daily or 50MCG/Fentanyl Transdermal daily. Used for breakthrough pain only.

Pharmacists must sign off on following these guidelines to purchase and dispense transmucosal immediate release fentanyl called TIRF REMS

This program is required to prescribe, distribute, or dispense transmucosal immediate release fentayl

alprazolam 1mg 539,215 Scripts in 2010 alprazolam 1mg 582,656 Scripts in 2011 alprazolam 2mg 139,400 Scripts in 2010 alprazolam 2mg 188,134 Scripts in 2011

One in Eight Teens (about 2.7 million) now report having misused or abused prescription stimulants at least once in their lifetime.

9% of teens (1.9 million) report having misused or abused these prescription stimulants in the past year

6% of teens (1.3 million) report abuse of these prescription stimulants in the past month

One in four teens (actually 26%) believe that prescription stimulants can be used as a study aid

More than one in five teens (22% say there is little or no risk in using Ritalin/Adderall without a prescription

Source 2012 Partnership Attitude Tracking Study, published 4/23/2013

Popular in street culture Purp, Spritz, Wholesale price $11.00 Pint (480ml) Pharmacy sells for $300.00 Pint Dealer sells for $35-40 an ounce. Mixed with hydrocodone Grape Jolly Rancher

264,210 Scripts in 2010298,492 Scripts in 2011Most scripts are for a Pint (480ml)

Schedule IV in January 2012Reportable to MAPSPopular with hydrocodone combos (Trinity, alprazolam)

Higher dose appears to be alcohol.

Eventually NABP wants to collect data. Leverage PMP’s with chains to run data

reports automatically when script dispensed.

Incorporate into EMR open automatically. Talk of adding non-controlled drugs for

disasters and other emergencies such as visit to ER when unconscious.

Interstate data sharing is included in MAPS! Ohio now operational. Hub operated by NABP (National Association

of Boards of Pharmacy) located in Chicago Illinois.

VA, IN, SC, WVA added. More coming

Lack of knowledge. False beliefs (time consuming, staff) Laziness. Don’t want to be bothered. Stubborn. Practiced for years w/o database. Fear that knowledge will require action. Lack of reimbursement. Time consuming.

Prescription for Methadone 10mg #240 12/23MAPS for New Patient -Eight physicians have been writing for drug-Noticed MAPS report showed Medicaid-Using CHAMPS looked up Medicaid Number-Billed Claim to Medicaid and Rejected (Too

Soon)-Claim for drug filled other pharmacy other Dr.

two days previous same quantity.-Called other pharmacy to verify picked RX up-Confronted Patient and Kept Prescription, hand

delivered prescription to prescribing physician

Patient enters pharmacy with prescription for Methylpenidate 5mg #270 SIG: 3 t.i.d.

MAPS for new patient: -Two physicians prescribing medication-Paying cash with one physician’s prescription-Pharmacy Billing Private Insurance with other

Individual was very popular hair stylist. Never

a problem obtaining clients. Co-workerscouldn’t understand why so popular,not the best stylist in the salon.

Department of Licensing and Reg. Affairs Bureau of Health Professions Health Investigation Division www.michigan.gov/healthlicense www.michigan.gov/mimapsinfo 517-373-1737

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Michigan.gov Home | Help/FAQs | Contact Us

Maps Login Page

The MAPS Report Information:_____________________________________________________________________________________Patient’s Name Date of Birth Medication Name Rx Number Practitioner DispenserAddress Issue Date Form/ Quantity RX TYPE Transmission DEA DEA

Fill Date Strength Auth Refills Payment Address Address_____________________________________________________________________________________Doe, John 01/01/1990 Hydrocodone/Acetam 4600001 Bad, Joe Narcotics R US123 Anywhere 06/14/2013 TAB / 120.00 Original Written AB1234563 AN1234563

06/14/2013 5mg/500mg 0 Medicaid 123rd St Easy Way DR.Holland, MI 49423 Holland, MI Holland, MI_____________________________________________________________________________________Doe, John 01/01/1990 Hydrocodone/Acetam 6874512 Bad, Joe Cartel Apothecary123 Anywhere 06/14/2013 TAB / 120.00 Original Faxed AB1234563 AC1234563

06/14/2013 5mg/500mg 0 Private Pay 123 rd St South BorderHolland, MI 49423 Holland, MI Holland, MI______________________________________________________________________________________Doe, John 01/01/1990 Hydrocodone/Acetamin 9876541 Fix, I Can Fill’em Now RX123 Anywhere 06/13/2013 TAB / 240.00 Refill Written AF1234563 AF1260734

06/13/2013 5mg /325mg 4 Private Pay 56 Michigan Skid RowHolland, MI 49423 Holland, MI Holland, MI_______________________________________________________________________________________

Page 1 of 30

Q. Do practitioners have to dispense controlled substances to be able to register to MAPS Online? A. No. All practitioners who prescribe controlled substances have the ability to register to MAPS Online to request patient reports on their patients.Q. If a practitioner requests a MAPS report and detects possible illegal activity, can the practitioner give the MAPS report to a law enforcement agency?A. No, the practitioner cannot give a MAPS report to anyone. The practitioner can call their local law enforcement agency and state their concerns. Law enforcement agencies have the ability to request MAPS reports for cases that involve illegal activity, ie, drug diversion.

Q. Can a practitioner request a MAPS report on any individual?A. No. MAPS reports can only be requested for individuals that are a bona fide current patient of the practitioner.

Q. Can a practitioner request a MAPS report on other practitioners?A. No. Practitioners may not request reports on other practitioners.

Q. Is MAPS compliant with the HIPAA Privacy Act?A. Yes. All data is received and transmitted behind the State of Michigan firewall, which allows practitioners to comply with HIPAA security requirements. All data in the MAPS database is protected and only released to practitioners who certify they are treating the patient.

Q. What is the definition of a "dispensing practitioner"?A. A dispensing practitioner is a practitioner who gives a prescription drug to a patient (to be consumed at a later date) in a container with written labeling instructions as to usage. Dispensing practitioners who dispense controlled substances in Schedules 2-5 must report this prescription data to MAPS.

Q. Does a practitioner that administers controlled substances need to report to MAPS?A. No. When a practitioner administers a prescription drug, the full dose of the prescription drug is administered in the practitioner's office; no doses of the prescription drug leave the practitioner's office with the patient.

Q. If a practitioner dispenses controlled substances and does not have online computer capabilities, how does the practitioner report dispensed controlled substances to MAPS?A. A MAPS waiver form is available for practitioners who do not have online computer capabilities. If the waiver is approved, a paper claim form is completed by the dispensing practitioner for each controlled substance that is dispensed, which is then mailed to the MAPS program for manual entry into the MAPS database. Waivers are only granted for practitioners in remote areas and/or who do not have computer equipment.

Q. How often do pharmacies and dispensing practitioners report prescription data to MAPS?A. Submission of prescription data are currently required on the 1st and 15th of every month. Pharmacies and practitioners may report more frequently than twice a month, for example, weekly or daily.