Kurt Snyder, MMGT, LAC, LSW Executive Director Heartview

Kurt Snyder, MMGT, LAC, LSW
Executive Director
Heartview Foundation
Objectives
 Participants will explore compelling data regarding
PDMP and explain why direct access is necessary for
specialty care providers.
 Participants will understand how utilization of direct
access for addiction professionals will benefit primary
care, specialty care and their shared patients.
 Participants will understand the steps necessary to
gain direct access for addiction professionals in your
state.
What is a PDMP?
 According to the National Alliance for Model State
Drug Laws (NAMSDL), a PDMP is a statewide
electronic database which collects designated data on
substances dispensed in the state. The PDMP is
housed by a specified statewide regulatory,
administrative or law enforcement agency. The
housing agency distributes data from the database to
individuals who are authorized under state law to
receive the information for purposes of their
profession.
ONDCP Position
 ONDCP is aggressively working with Federal, state, and
non‐governmental partners to support the development of
operational PDMPs in every state. The programs would be
used in clinical practice and have the ability to share data
with PDMPs in other states. Incorporating PDMPs into a
comprehensive prescription drug diversion and abuse
prevention strategy that includes education for healthcare
providers, patients, and the public on prescription drug
abuse; consumer‐friendly, environmentally responsible
medication‐disposal programs; and smart law enforcement
aimed at reducing pill mills and doctor shopping, can
reduce the consequences of prescription drug abuse in our
Nation. April, 2011 FACT SHEET, Office of National Drug Control Policy
Purpose of the ND PDMP
The purpose of this program is to
improve patient therapy and the
state’s ability to identify and inhibit
the diversion of controlled
substances (including tramadol and
carisoprodol) in an efficient and cost
effective manner that should not
impede the appropriate utilization
of these drugs for legitimate medical
purposes.
Background
 North Dakota’s Prescription Drug Monitoring
Program
ND PDMP Background
Legislation: In 2005 the ND legislative session authorized the
implementation of a Prescription Drug Monitoring
Program (PDMP).
Data: This program utilizes a centralized data repository to
collect and analyze schedule II-V controlled substances
(including tramadol and carisoprodol) dispensed in the
state of North Dakota or for patients residing in North
Dakota.
Authorization/Operation: This is authorized by North
Dakota Century Code chapter 19-03.5 and operated under
the rules of the North Dakota Board of Pharmacy.
Program Facts
Drugs included: All controlled substances, schedules II-V, Carisoprodol
products(Soma), Tramadol products(Ultram)
Patients include: all outpatients, residents in assisted living facilities, &
residents of nursing homes. We currently are unable to obtain information
from Indian Health Services, Veterans Administration, or hospital
inpatient pharmacies.
Turnaround Time: Monday - Friday 8am until 4pm, the patient profile
report is processed & faxed back within 24 hours. If the report is received
after hours, it will be faxed/mailed back the following business day.
(Reports received after 4pm CST are subject to next business day
processing.)
Program Facts
Lag-time: It takes approximately 1-7 days from the date a prescription is
dispensed until it appears in a report. The report can provide a patient’s
controlled substance history from January 1st of 2007 & is stored for 3 years.
NDPDMP does not warrant any report to be accurate or complete. The
Report is based on the search criteria entered & the data entered from the
dispensing pharmacy. For more information about any prescription in an
NDPDMP report or to verify a prescription, contact the pharmacy where it
was dispensed.
Direct Access: Allows direct access to patient profile history reports for
prescribers, pharmacists, their delegate(s) & a ND Medicaid representative.
Doe, John – DOB: 01/01/01 1234 Makebelieve Ln. Jamestown, ND
PDMP Profile Hx. Report
Date
Dispensed
12/31/2007
12/31/2007
12/28/2007
12/24/2007
12/24/2007
12/21/2007
12/21/2007
12/17/2007
12/17/2007
12/17/2007
12/12/2007
12/10/2007
12/4/2007
11/29/2007
11/24/2007
11/19/2007
11/14/2007
11/13/2007
11/13/2007
11/13/2007
11/12/2007
11/8/2007
11/8/2007
11/8/2007
11/8/2007
11/7/2007
11/1/2007
Qty
.
30
30
10
30
30
90
90
6
120
30
11
30
120
120
90
5
10
30
10
30
30
14
20
14
20
30
30
Day
s
Drug Name and Strength
8 CARISOPRODOL 350 MG TABLET
8 HYDROCODONE- APAP 5- 325 TABLET
3 HYDROCODONE- APAP 5- 500 TABLET
8 CARISOPRODOL 350 MG TABLET
8 HYDROCODONE- APAP 5- 325 TABLET
30 CLONAZEPAM 1 MG TABLET
30 ALPRAZOLAM 0.5 MG TABLET
2 ALPRAZOLAM 1 MG TABLET
12 TUSSIONEX PENNKINETIC SUSP
7 HYDROCODONE- APAP 5- 325 TABLET
21 ALPRAZOLAM 1 MG TABLET
7 HYDROCODONE- APAP 5- 325 TABLET
12 TUSSIONEX PENNKINETIC SUSP
12 CHERATUSSIN AC SYRUP
30 ALPRAZOLAM 1 MG TABLET
2 LORAZEPAM 1 MG TABLET
2 HYDROCODONE- APAP 5- 500 TABLET
8 HYDROCODONE- APAP 5- 325 TABLET
1 ACETAMINOPHEN- COD #3 TABLET
8 CARISOPRODOL 350 MG TABLET
7 HYDROCODONE- APAP 5- 325 TABLET
7 LORAZEPAM 1 MG TABLET
4 HYDROCODONE- APAP 10- 650 TABLET
5 LORAZEPAM 1 MG TABLET
4 HYDROCODONE- APAP 10- 650 TABLET
7 HYDROCODONE- APAP 5- 325 TABLET
5 HYDROCODONE- APAP 10- 650 TABLET
Pharmacy/Dispe
nser
Pharmacy A
Pharmacy A
Pharmacy B
Pharmacy A
Pharmacy A
Pharmacy B
Pharmacy B
Pharmacy C
Pharmacy C
Pharmacy B
Pharmacy B
Pharmacy B
Pharmacy C
Pharmacy B
Pharmacy B
Pharmacy B
Pharmacy D
Pharmacy A
Pharmacy E
Pharmacy A
Pharmacy F
Pharmacy G
Pharmacy G
Pharmacy H
Pharmacy H
Pharmacy F
Pharmacy G
City
BISMARCK
BISMARCK
FARGO
BISMARCK
BISMARCK
FARGO
FARGO
FARGO
FARGO
FARGO
FARGO
FARGO
FARGO
FARGO
FARGO
FARGO
BISMARCK
BISMARCK
BISMARCK
BISMARCK
FARGO
VALLEY CITY
VALLEY CITY
VALLEY CITY
VALLEY CITY
FARGO
VALLEY CITY
Prescriber
Prescriber A
Prescriber A
Prescriber B
Prescriber A
Prescriber A
Prescriber C
Prescriber C
Prescriber D
Prescriber D
Prescriber A
Prescriber E
Prescriber A
Prescriber D
Prescriber F
Prescriber F
Prescriber F
Prescriber G
Prescriber A
Prescriber H
Prescriber A
Prescriber A
Prescriber I
Prescriber I
Prescriber I
Prescriber I
Prescriber A
Prescriber I
The Idea
ND Licensed Addiction Counselor
 Four year degree in addiction studies or related field.
 Thirty-two credit hours in addiction studies
 1400 hours training
 Passing score on the IC & RC International written
ADC examination
 40 continuing education hours every two years
SENATE BILL NO. 2151 (2011 Leg.)
N.D.C.C. § 19-03.5-03(3)
 A licensed addiction counselor for the purpose of
providing services for a licensed treatment program in
this state.
Heartview Foundation
Data Collection
 For 4 months we did direct searches (through the
PDMP) on all patients who scheduled an appointment
 Search covered the past 12 months
 Start date 4/18/2011- End date 8/18/2011
 Total: 246
Heartview Foundation
Data Collection
We divided the data into
3 categories:
No History with the
PDMP: 123 (50%)
Minimal History (less
than 4 Rx): 52 (21%)
Significant History (=>
than 4): 71 (29%)
Female Ratio Per Category
Total: 246
No Show Ratio Per Category
Total: 246
ASAM III.5 Recommendations Per
Category
(Of those that showed-Total 183)
30.0%
30%
III.5 Recommendations
25%
20%
15%
12.0%
10%
8.0%
5%
0%
No Hx (100)
Min Hx (37)
Sig. Hx (46)
Recommendation of Level I or
Higher per Category
(of those that showed for their appointment
and received recommendations)
Program
Licensed Addiction Counselors
Recommended Guidelines
 Evaluations
 Ongoing Treatment
 Discharge Planning
 Integration of Behavioral Health with Primary Care
 Medication-Assisted Therapies
 Limitations
 Ethical & Professional Implications
 OUTCOMES
Evaluations
 Direct searches are strongly encouraged on all
evaluations.
 50% of those accessing addiction services have some
history with the PDMP. (Heartview Foundation Data
Apr 18, 2011 - Aug 18, 2011)
 Information purposes only: Diagnosis should still
come from interview process, usage history, DSM
criteria
 LACs should develop a relationship with a pharmacist
as a resource for medication information
Evaluations
 Bridging the Gap to Primary Care Physicians, (PCP)
 Position ourselves as the experts, resource and gate
keepers for access to treatment.
 With proper ROI we can contact the prescribers for
collateral information
 Enlist PCP in a multi-disciplinary approach to patient
care, (treatment planning, referrals,
recommendations)
Ongoing Treatment
 PDMP as a tool to monitor patient adherence to
treatment (weekly/monthly searches for new activity)
 Use PDMP list to help patients close the doors to
inappropriate prescription access. (Therapeutic
letters) "Dear prescriber, I have been dishonest with
you regarding my health status. I am sorry. I ask that
you no longer prescribe narcotics as I am now in
recovery..."
 Re-engage a PCP for “Recovery Based Services”
 Act as “Recovery Navigators” for Rx drug users to find
PCP familiar with addiction process
Discharge Planning
 Develop Recovery Plan in coordination with patient,
family and PCP
 Clear understanding of re-intervention strategies
 Clear understanding of expectations
 Discuss and plan for ongoing “Recovery Based Health
Care”


Future surgeries
Pain management
Integration of Behavioral Health with
Primary Care
 Access will give us knowledge of Primary Care
Physicians that are also serving our patient
 We need to become the contact point for Primary Care
 We need to advocate for "Recovery Based Care”
 Better relationships will help break down the barriers
of access to care (both ways!)
Medication-Assisted Therapies
 Direct searches should be done on all MAT patients
 PDMP as a tool to monitor patient adherence to
medication (weekly/monthly searches for new
activity)
 Direct searches should be done on all patients in
Medically Managed and Social Setting DETOX
Limitations
 PDMP Does Not Collect Data from:
 Veterans Administration
 Inpatient Hospital Pharmacies
 Unlicensed Out-Of-State Pharmacies
 No History in PDMP does not indicate “no use”
 History in PDMP does not indicate “problem use”
 Multiple prescribers and multiple pharmacies does not
always equal “doctor shopping”
 The PDMP is a tool, and we need to be careful to not
assume or jump to conclusions.
Ethical & Professional Implications
 Vote of confidence from other healthcare professionals and




legislators
Connects addiction professionals with primary care in new
and exciting ways. Opportunity to demonstrate the
importance of addiction treatment as a necessary link in
dealing with the new Rx drug abuse trends.
The misuse of the PDMP is a Class C Felony subject to
$5,000 and 5 years imprisonment.
PDMP information is 3rd Party Information and cannot be
re-disclosed.
Electronic access does not require a ROI but any direct
contact with PDMP staff regarding a patient would require
patient consent.
Ethical & Professional Implications
 How do the Federal confidentiality rules apply to
PDMPs?
 PDMPs generally do not meet the definition of a
federally-assisted substance abuse programs for the
purposes of 42 CFR part 2. Therefore, authorized
disclosures by state PDMPs would not be considered
disclosures of substance abuse patient records and not
subject to these regulations.
Ethical & Professional Implications
 Should Patients be Notified of PDMP Access?
 LACs should consider notifying patients that
prescription information is monitored by the state
PDMP and by the LAC. This serves the purpose of
facilitating open communication with patients about
their prescriptions. LACs can clarify to patients that
prescription medication histories are routinely
monitored by LACs.
Ethical & Professional Implications
 Is Patient Consent Necessary to Access Information
from a PDMP?
 A request for information by a Licensed Addiction
Counselor would not be considered a disclosure of
patient health information under 42 CFR part 2,
therefore, patient consent is not required.
 Adapted from: DR. Westley Clark, SAMHSA letter dated September 27, 2011
 SAMSHA has prepared this guidance regarding the implementation of federal
regulations at 42 CFR part 2 for educational purposes only. This information is
not intended to serve as legal advice.
OUTCOMES
 More accurately diagnose Rx drug abuse
 Make more appropriate Level Of Care
recommendations (Better TX outcomes)
 During the course of Treatment
 Monitor PDMP for adherence to treatment plan
 Reduce or eliminate “doctor shopping”
 Monitor compliance with Medication Therapy
 Reduce overdose related deaths
 Increase treatment admissions
 “Mental Health and Addiction Professionals
can serve as what is called ‘Recovery
Navigators,’ helping to connect patients with
health screenings, as well as counseling, and
medication management, housing and job
training.” Kathleen Sebelius, Secretary U.S.
Department of Health & Human Services
(December 16, 2009)
 “New health insurance reform legislation
emphasizes the importance of integrating
behavioral health and primary health care. By
doing so, the quality of health care available to
these populations will improve – along with
their health status.” Westley Clark, Director of
CSAT (July 12, 2010)
FOLLOW THE YELLOW BRICK ROAD
Building Linkages to Key
Stakeholders
 Initial support came from the ranks of the addiction
professionals
 Association
 Provider Coalition
 We engaged the ND Department Of Human Services and
the SSA
 Our group met with the NDPDMP Advisory Council to
request support. ND Board of Medical Examiners, ND
Medical Association, ND Board of Pharmacy, ND Board of
Nursing, ND Attorney Generals Office.
 The verdict: Support form each entity would be required
Planning and Other Considerations
 Direct Access would require a change to the law
 Who wrote and introduced initial legislation?
 Will you amend if we have support from all?
 Who were allies?
 ND Attorney General
 ND Board of Pharmacy
 ND Board of Nursing
 Who needed convincing?
 ND Board of Medical Examiners
 ND Medical Association
Preparing to Meet with the Boards
 Gaining support and momentum
 Attorney General
 Other Boards
 Dates and times
 Identify list of board members
 Make contacts and have face-to-face meetings
 Request to be added to board agendas
 Request letters of support (ND Board of Nursing & ND Board
of Pharmacy)
 ND Board of Medical Examiners
 “We are part of the solution. Here is how we can help you.”
Introducing the Legislation
 Uncontested Legislation
 Attorney General gave direct testimony at the
introduction of the legislation
 Letters of support from members of the NDPDMP
 Passed both House and Senate with no opposition
 Governor Jack Dalrymple signed Senate Bill 2151 into
law on April 25, 2011
 Licensed Addiction Counselors officially gained direct
access on August 1, 2011
Unanticipated Rewards
 Addiction professionals are seated at the NDPDMP
Advisory Council
 Medical Marijuana on the ballot
 Contacted directly by the ND Attorney General
 Contacted by the ND Medical Association
 Addiction Professionals successfully defeated an
insurance companies draft policy on behavioral health
that would deny access and discriminate against SUDs
 Increased credibility with legislators through process
of Health Care Reform
Thank You
Questions?