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New Mexico’s Prescription Monitoring Program

Carl Flansbaum, RPh. PMP Director New Mexico Board of Pharmacy

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

New Mexico and the PMP

•  In 2012, New Mexico had the 3nd Highest Overdose Death Rate in Nation.

!  492 Deaths or a rate of 23.6 per 100k

!  Had previously always been either #1 or #2, so this is a good trend

!  449 Deaths in 2013, but national data / ranking not yet available

!  The increased use of the PMP is considered a large part of this decrease

•  1 of only 2 states scoring 10 out of 10 in study looking at strategies implemented by

states to address prescription drug abuse (one of which is having a PMP) Trust for America Health: Prescription Drug Abuse Strategies to Stop the Epidemic; October 2013

•  All states (with the exception of MO) now have a PMP of some type in operation

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Dispenser (Pharmacy) Reporting

•  All dispensers (pharmacies) with a New Mexico Controlled Substance License must report to the PMP

•  This includes both in and out of state (non-resident) dispensers as well as “Dispensing Practitioners” - those dispensing > 12 doses or 72hrs worth out of their office

•  Waivers are considered for dispensers with a CS license whom do not dispense any Controlled Substances to New Mexico residents

•  Compliance is strictly monitored with a report of all dispenser reporting delinquency reported to the Board of Pharmacy for consideration and possible disciplinary action

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P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Dispenser (Pharmacy) Reporting

•  All Schedule II – V prescription related data reported

! Name, address, prescriber, pharmacy, medication, quantity, etc.

•  More specific person identifier (SSN, Driver’s License, etc.) NOT reported

! Can make exact patient matching a challenge

•  Must be reported within 1 business day of prescription being filled

! Became effective March 22nd of this year

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

27+ Million Prescription Records in NM PMP

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

> 3 Million Prescriptions uploaded / year

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Who can access the PMP?

•  A New Mexico licensed Practitioner

•  A Delegate of the above (Only one delegate per practitioner is permitted)

•  A registered Pharmacist in the state of New Mexico

•  A Law Enforcement or Regulatory Board agent vetted by the PMP to warrant access.

•  Miscellaneous other personnel (reporting agencies, out of state health care professionals, Medicaid compliance officers)

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P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Mandatory Registration

•  All Practitioners with a New Mexico Controlled Substance Registration (CSR) must have an active account with the PMP

•  Accounts must be accessed at least once every 13 months to be considered active (a practitioner can do this by just running a Practitioner

Self-Lookup)

•  CSRs will NOT be renewed by the Board of Pharmacy licensing department if Practitioner doesn’t have an active PMP account

•  Nursing Board rule16.19.29.9 NMAC requires registration as well

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Nurse Practitioners Registered in the PMP

1642

1239

905 NM Licensed NPs

NM NPs with CSR#s

NM NPs with an active PMP account

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Mandatory Training for Practitioners

Web Based PMP Training mandatory for all newly registering practitioners

! All about the PMP and how to use

! Optional but highly recommended for all other users (or those that already have a PMP account)

! Only takes 10-15 minutes to complete

! New applications will NOT be processed without completing

! Available at http://www.nmpmp.org/

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P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

PMP Access Security

•  Inactive accounts deleted after 13 months of inactivity

•  PMP Identity Confirmation form and copy of photo ID required when

registering for new account

•  Licensing credentials check

•  Auditing of access and activity as needed

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Mandatory Use

NURSING AND HEALTH CARE RELATED PROVIDERS

NMAC 16.12.9: MANAGEMENT OF PAIN WITH CONTROLLED SUBSTANCES

16.12.9.9 PRESCRIPTION MONITORING PROGRAM (PMP) REQUIREMENTS:

Upon prescribing, ordering, administering or dispensing a controlled

substance, the practitioner shall obtain and review a prescription monitoring

report covering at least a one year time period or another state’s report,

where applicable and available.

…

Prescription monitoring reports shall be requested and reviewed a minimum of once every six months during the continuous use of opioids for each established patient.

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Mandatory Use

•  Mandatory registration/use language in Rules of other Regulatory Boards :

! Medical and Surgical Practitioners 16.10.14 NMAC

! Dentistry 16.5.57.10 NMAC

! Optometric Practitioners 16.16.15.10 NMAC

! Osteopathic Medicine and Surgery Practitioners 16.17.5.10 NMAC

! Podiatrists 16.21.9.10 NMAC

•  Addressed for Certified Nurse Midwives in 16.11.2.10 NMAC

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P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

How many patient PMP Requests does the NMPMP process?

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

110000

Jan-

13

Feb-

13

Mar

-13

Apr-1

3

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov-

13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-1

4

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov-

14

Dec-

14

> 100,000 PMP Requests / Month (that’s > 3,000/day!) (includes interstate requests)

All Requests Requests FROM Other States Requests TO Other States

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Who’s requesting PMP Reports

Practitioners 54%

Delegates 7%

Pharmacists 39%

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Who should be requesting PMP reports

NM Prescriber with PMP account,

87%

[CATEGORY NAME] [VALUE]

[CATEGORY NAME] [VALUE]

[CATEGORY NAME] [VALUE]

87% of NM Prescribers have a PMP account, but only ~ 40%

of these ran a PMP report (2013

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P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Maximize PMP Usage

1.  Use a Delegate to run PMP Reports on behalf of a Practitioner

2.  Use Alerts as a way to communicate with other PMP users regarding patient concerns and behavior

3.  Run Practitioner Self-Lookups pro-actively to review all CS prescriptions filled

under your DEA#

Just remember - only authorized account holders can access the PMP and

sharing login information is a violation of both federal and state regulations

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Maximize PMP Usage

Use a Delegate to run PMP Reports on behalf of the Practitioner

1.  Fill out and send in the Authorized Agent form available on the nmpmp.org website

2.  Then have the designated delegate apply for their own PMP account

•  NM Regulations allow for only 1 Delegate per Practitioner

•  Be sure to notify the PMP staff of any personnel changes

•  You can track your Delegate’s request history

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Maximize PMP Usage

Use Alerts as a way to communicate with other PMP users

regarding patient concerns and behavior

•  An Alert allows users to post information

on documented and/or suspected

activity

•  Any Alerts associated with a person will

show when a Request is submitted on that

person

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P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Maximize PMP Usage

Run Practitioner Self-Lookups pro-actively to

review all CS prescriptions filled under your DEA#

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Interstate Data Sharing

PMP users can now search other states PMPs through the New Mexico PMP.

However, a few things to know about interstate sharing:

•  Not all states share PMP data (NM currently shares with 22 other states).

•  States differ widely on what type of Health Care Professionals from other states they will allow to access PMP data.

•  Reference http://www.nmpmp.org/Interstate/ for more information and the latest updates

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Interstate Data Sharing

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P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Unsolicited Reports

•  E-mail notices sent via the PMP system to Practitioners on persons exceeding certain thresholds in prescription behavior; contains web link to Patient

Request Report in the PMP

•  Currently sent out quarterly on patients receiving prescriptions from > 5 different Practitioners and filled at > 5 different pharmacies within a 6 month

period (doctor/pharmacy shopping), but no standard and may change in

the future

•  Rough screening tool and meant only as a notice, no judgment on reason for patients receiving prescriptions

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Prescribing Patterns of Interest

•  Long term use of Opioids

•  High doses of opioids (MME)

•  Overlapping prescriptions of Opioids from different prescribers

•  The combination of opioids + sedative-hypnotics

•  The combination of opioids, benzodiazepines + carisprodol

•  Multiple Provider Episodes (Doctor and pharmacy shopping)

Source: Jim Davis, NM DOH; Relative Hazards of Certain Controlled Substance Prescription Patterns

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Relative Risk of Prescription Overdose Death by Risk Factor (NM 2007-2011)

76.4

78.0

60.0

235.0

68.5

56.4

47.8

83.0

87.1

0.0 50.0 100.0 150.0 200.0 250.0

Opioid Overlap 10+ days

Benzodiazepine Overlap 1+ days

Opioid/Sedative-hypnotic overlap 10+ days

Holy Trinity (opioid/benzo/carisprodol) 1+ days

Sedative-Hypnotic dose x time interaction

6mo avg daily MME >200

Opioid dose x time interaction

Prescriber MPE (4+ & overlap)

Pharmacy MPE (3+ & overlap)

Relative Risk of prescription overdose death

Source: Jim Davis, NM DOH; Relative Hazards of Certain Controlled Substance Prescription Patterns

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P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Licensing/Regulatory Board Reports

The BOP submits a report to various Licensing/Regulatory Boards each quarter listing

Practitioners whose prescribing behavior contains High Risk Criteria with indices regarding:

! Concurrent prescriptions for opioids + benzodiazepines (and carisprodol)

! MME 120-200 and MME > 200/day

•  This is information gained from the Prescribing Patterns of Interest discussed previously

•  Patients’ Doctor shopping behavior and PMP use are also included

•  It is up to each board to determine course of action

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Example PMP Report to Licensing/Regulatory Board

In reality a very, very small percentage of prescribers show up on this list…

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Coming Soon!

•  Last October, the BOP was awarded a federal grant to enhance the NM PMP. Plans include:

! Change to requirement for dispenser daily reporting to the PMP

! Ability to distinguish individual prescribers using a DEA suffix

! Expansion of PMP Unsolicited Reports and new pre-emptive notification

! Integration of NARxCHECK PMP report format (but just for 1 year)

! Prescriber Report Cards!

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P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Coming Soon!

NARxCHECK provides a propriety

“NARxCHECK” score as well as

graphical representations of

prescription history.

We are hoping that this will help in

users’ ability to quickly digest the

sometimes dense PMP information

on their patients.

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

Coming Soon!

Prescriber Report Cards: Statistics of practitioner

prescribing behavior (along with NM PMP usage

rates) will be correlated and reported to

practitioners on a quarterly basis.

This will not only show prescription volumes, but

also “High Risk Prescribing Criteria” that have

already been determined in conjunction with the

NM DOH. Additionally, each practitioner’s

information will be shown compared to others in

their peer specialty field.

P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

And now for something completely different

•  E - Prescribing

!  All controlled substance prescriptions can be sent electronically but not required in NM.

!  Prescriber and Dispenser must have approved software to support.

•  CII prescribing

!  No refills (partial fills okay in certain instances)

!  Must give hard copy to patient (no faxes)

!  Can be called in for emergencies

•  CII-V prescribing

!  Can have 5 refills within 6 month period

!  can be faxed, but must be physically signed (no electronic signatures)

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P r e s c r i p t i o n M o n i t o r i n g P r o g r a m N E W M E X I C O B O A R D O F P H A R M A C Y

For all your PMP needs…

•  Resources

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•  User Surveys