Kentucky All Schedule
Prescription Electronic Reporting
A KASPER Update for
Family Physicians
Jill E. Lee, RPh
Investigator
Drug Enforcement and Professional Practices Branch
Office of Inspector General
Kentucky Cabinet for Health and Family Services
Kentucky Academy of Family Physicians
March 28, 2015
Disclosure
• Jill E. Lee
– No relevant financial relationships.
– No conflicts of interest.
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Contents
•
Controlled Substance Abuse
•
CS Use in KY
•
Legislative Changes Affecting
Provider Use of KASPER
•
HB1 Preliminary Results and
Evaluation
•
How to Use KASPER effectively
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Objectives
•
Discuss statutory and regulatory prescriber
responsibilities
•
Engage the Drug Enforcement and Professional
Practices Branch for support
•
Recognize red flags that are indicative of doctor
shoppers and
•
•
Learn how to protect your practice
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Controlled Substance Abuse
Misuse, Abuse, Diversion
• Misuse:
– When a schedule II – V substance is taken by an
individual for a non-medical reason.
• Abuse:
– When an individual repeatedly takes a schedule
II – V substance for a non-medical reason.
• Diversion:
– When a schedule II – V substance is acquired
and/or taken by an individual for whom the
medication was not prescribed.
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Painkiller Prescription Rates by State
CDC Vitalsigns July 2014, Source: IMS, National Prescription Audit (NPAtm), 2012
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Painkiller Prescription Rates by State
CDC Vitalsigns July 2014, Source: IMS, National Prescription Audit (NPAtm), 2012
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Most Common Drug Treatment Admissions by State
Laura Dimon, MIC Network, Inc., February 10, 2014. Image credit: Fiona Breslin.
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Drug Overdose Death Rates in Kentucky
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Controlled Substance Usage 2014
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It is epidemic!
CDC declares epidemic of overdose deaths
from opioid pain relievers in 2011
• Second leading cause of accidental death
• Overdose increased 10-fold since 1990
Who is to blame?
• Pain charts – rate your pain?
• Drug companies with their aggressive
marketing techniques? Oxycontin 2000s
• The internet?
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Diversion and Overdoses
Center for Disease control and Prevention, “Policy Impact: Prescription Painkiller
Overdoses” http://www.cdc.gov/homeandrecreationalsafety/rxbrief/
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Heather Pereira
Story reported by Ann Bowden, WLKY.com, December 8, 2014
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Amanda Foster and Douglas Allen
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Danielle Cogswell
Louisville Courier-Journal, August 29, 2014
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Adderall & Ritalin
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Addiction
Who is at Risk?
Primary Risk Factors for Addiction
• Inheritance
• Age of first use
• Availability of addictive
substances
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Who’s at Risk?
• A first degree relative -4 x risk of Addiction
• Use of an addictive substance before age 15
-5 x risk
• Some develop Addiction without either
• Approximately 15% of population
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Pill Mills
Jeff and Chris George
Photos from Palm Beach Post
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Dr. Paul H. Volkman
Story: Bill Estep, Lexington Herald-Leader, February 14, 2012. AP Photo released by U.S.
Marshals Service (undated)
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Care More Pain Management Clinic
Photo: Scott Utterback, Louisville Courier-Journal, January 25, 2012
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Care More Pain Management Clinic
Photo: Scott Utterback, Louisville Courier-Journal, January 25, 2012
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Ernest William Singleton
Photo: Lexington Community Corrections, January 2013
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CDC Recommendations
• Laws to prevent prescription drug abuse and
diversion
• Prescription Drug Monitoring Programs
• Health care provider accountability
• Better access to substance abuse treatment
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Combating Prescription Drug Abuse
in Kentucky
Legislative Changes in Kentucky
KASPER Legislation
• 2012 House Bill 1 “Pill Mill Bill”
• 2013 House Bill 217
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Pain Facility
KRS 218A.175- Pain Management Facilities
• Physician ownership required
• Subspecialty/certification required
• Can not be a cash only business
• Oversight Requirement
Definition of a Pain Management Facility
• A facility where majority of patients provided controlled
substances for pain AND
a. Primary practice component is treatment of pain
b. Facility advertises any type of pain management
services
APRNs CANNOT OWN PAIN FACILITIES
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Non-Physician Owned PMFs
• 29 non-physician owned PMFs were identified on
April 24, 2012 (HB1 passage date)
• 8 closed prior to July 20, 2012 (HB1 effective date)
• 14 closed after the HB1 effective date
• 3 illegal or non-physician owned PMFs discovered
after HB 1 effective date
• 6 PMFs were sent cease and desist letters
• 5 PMFs licensed by the Cabinet for Health and
Family Services
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Register for PMF
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You might be a pill mill if…
• You feel compelled to hire “security”
• Most people pay cash for their pills
• Patients refer to their drugs by their street name or request
specific color of pills
• You have long lines that wrap around your building by 7am.
• Patients come from long distances to see you
• You only write for the highest strength of pills
• You often write for the “holy trinity”
• You have been previously warned or disciplined by your
medical board.
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The Kentucky Strategy
• Limit prescriber dispensing to 48 hour supply
(C-II or C-III containing hydrocodone)
• Require 7.5% of CME in addiction, pain
management or KASPER
• Develop educational materials and conduct
training
• Increase drug disposal opportunities
• Increase treatment funding and resources
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218A.172
Required medical boards to create
regulations, prior to the initial prescribing of
a schedule II (or a C3 with hydrocodone)
• Medical history
• Query KASPER
• Make a written plan
• Discuss risks and benefits
• Obtain written consent
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.
Prescription Monitoring Programs
Mandate KASPER Usage 2012
• Enhance use of Kentucky All Schedule
Prescription Electronic Reporting System
(KASPER)
– Require daily reporting to KASPER
– Mandate KASPER registration and usage
– Utilize KASPER Advisory Council to
identify inappropriate or illegal controlled
substance prescribing
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eKASPER Reporting KRS 218A.202
• Controlled substance administration or
dispensing must be reported within one
day effective July 1, 2013
• ASAP 4.2 PDMP data collection
standard required effective July 1, 2014
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eKASPER Prescriber Usage - KRS 218A.172
•
Query eKASPER 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
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KASPER Regulations – Licensure Boards
• 201 KAR 5:130
– Kentucky Board of Optometric Examiners KASPER
requirements
• 201 KAR 8:540
– Kentucky Board of Dentistry KASPER requirements
• 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.
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KBML web site
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Weight loss craze
201 KAR 9:260 Restrictions on use of amphetamine-like anorectic C.S.
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Buprenorphine
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The KASPER Program
KASPER
KASPER is Kentucky’s Prescription Monitoring
Program (PMP). KASPER tracks Schedule II – V
controlled substance prescriptions dispensed within
the state as reported by pharmacies and other
dispensers.
Enhanced KASPER (eKASPER) is the real-time web
accessed database that provides a tool to help
address the misuse, abuse and diversion of controlled
pharmaceutical substances.
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Status of Prescription Drug Monitoring Programs (PDMPs)
VT
ME
WA
MT
ND
OR
MN
ID
MI
WY
NE
NV
UT
CO
CA
AZ
KS
OK
NM
IA
IL
TX
IN
PA
OH
WV VA
NC
TN
SC
AR
LA
DC
KY
MO
MS
AK
NY
WI
SD
NH
MA
RI
CT
NJ
DE
MD
AL
GA
FL
Operational PDMPs
HI
Enacted PDMP legislation, but
program not yet operational
Legislation pending
GU
Research is current as of February 1, 2012
2011 KASPER Reports Requested
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Annual KASPER Records Total / Per Person
2.39
2.43
2.65
2.65
2.72
2.72
2.47
2.47
Number of Controlled Substance Prescriptions per Person
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KASPER Reports Requested
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Top Prescribed Controlled Substances by
Therapeutic Category by Doses - 2014
Lorazepam 4.0%
Ativan
Zolpidem 3.6%
Ambien
Amphetamine
3.3%
Adderall
Diazepam 4.2%
Valium
Clonazepam 7.0%
Klonopin
Tramadol 9.0%
Ultram
Alprazolam 10.8%
Xanax
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Oxycodone 15.7%
OxyContin
Percodan
Percocet
Phentermine
2.9%
Adipex-P
Hydrocodone 39.5%
Lortab
Lorcet
Vicodin
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
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Goals of KASPER
• KASPER was designed as a tool to help
address prescription drug abuse and
diversion by providing:
– A source of information for health care
professionals
– An investigative tool for law enforcement and
regulatory agencies
• KASPER was not designed to:
– Prevent people from obtaining prescription drugs
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To Request an eKASPER Report
• Via secure WEB application.
• Application accessible from any PC with
WEB access.
• Practitioners and pharmacists can receive a
report often within 15 seconds (as long as the
report does not require further review by the
KASPER staff).
• Available 24 / 7.
• URL: https://ekasper.chfs.ky.gov.
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eKASPER Report Processing
• 97% of reports auto-matched by
eKASPER
• Manual Queue:
– Processed 8:00 a.m. to 4:30 p.m.
Monday through Friday
– Weekday manual reports typically
available within one hour
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Providing Reports to Patients – KRS 218A.202
• eKASPER reports can be shared with
the patient or person authorized to act
on the patient’s behalf
• eKASPER 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
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eKASPER Report Request - Master
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eKASPER Report Request - Master
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What if I cannot “Query” KASPER?
• If eKASPER indicates “manual process”
– Record the eKASPER report request
number in the patient’s chart
• If the eKASPER system is unavailable
or Internet access unavailable
– Document circumstances why eKASPER
could not be queried
– If eKASPER outage, record the date and
time
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When should I KASPER?
• CS for pain or symptoms associated- Every
3 months
• Other conditions beside pain- Before
prescribing and then according to standards
of acceptable and prevailing practice.
• If you don’t know – every 3 months
Note – APRN’s regs state no less than every 3
months.
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KASPER Query Exceptions (MD)
• In an emergency situation
• Within 14 days of surgery or within three days of oral
surgery
• Patients in hospitals and long term care facilities
– Hospitals and long term care facilities can
establish institutional accounts and request reports
on behalf of the facility
• Patients in Hospice care or being treated for cancer
pain
• Single doses of anxiety medicine prior to a procedure
• Prescribing a substitute medication within 7 days of
initial prescription
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eKASPER Delegate Accounts – KRS 218A.202
• eKASPER delegate accounts allowed
for:
– An employee of the practitioner’s or
pharmacist’s practice acting under the
specific direction of the practitioner or
pharmacist
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eKASPER Delegate Account Request
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Delegate Request
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eKASPER Prescriber Reports – KRS 218A.202
• CS prescribers can obtain an eKASPER
report on themselves for any 90 day
period:
– To review and assess the individual
prescribing patterns
– To determine the accuracy and
completeness of information contained in
eKASPER
– To identify fraudulent prescriptions
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eKASPER Prescriber Report Request
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Google KASPER – click link
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Reverse KASPER
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Why Reverse KASPER?
Date Filled Drug Name
06/17/2013
07/05/2013
07/25/2013
08/13/2013
09/03/2013
09/23/2013
10/11/2013
10/31/2013
11/19/2013
12/09/2013
12/26/2013
01/14/2014
02/04/2014
02/28/2014
03/18/2014
04/08/2014
04/28/2014
05/19/2014
06/06/2014
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Methadone HCL 10MG
Days Between Rx's
18
18
20
19
21
20
18
20
19
20
17
20
21
24
18
21
20
21
18
Qty
270
270
270
270
270
270
270
270
270
270
270
270
270
270
270
270
270
270
270
Days Prescriber Name Prescriber City Pharmacy Name Pharmacy City
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Doctor AA
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Corbin
Signs of Diverters
•
•
•
•
•
•
•
•
•
•
High achievers
Significant stresses in life
Prefers night shift
Takes on critical cases
Works at more than one facility
Smoker
Disappears a lot
Volunteers overtime
Changes in personality
Decline in job performance
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eKASPER Error Correction - 902 KAR 55:110
• Patient or provider should contact the
dispenser to correct records in error
• Inaccurate KASPER reports due to system
errors should be reported to the Drug
Enforcement and Professional Practices
Branch
– 502-564-7985
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House Bill 1 Preliminary Results
and Evaluation
Controlled Substance Dispensing – One Year Comparison
Drug
August 2011
through
July 2012
August 2012
through
July 2013
239,037,354
214,349,392
-10.3%
87,090,503
77,022,586
-11.6%
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%
Hydrocodone
Oxycodone
Oxymorphone
Figures shown in doses dispensed
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Change
Hydrocodone
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Oxycodone
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Alprazolam
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Diazepam
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Methadone
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Oxymorphone
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Tramadol
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Buprenorphine/Naloxone
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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 4Q 2014
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Health care Accountability
Protecting your Practice
Contents
•
Provider Shopping
•
Advice from the Kentucky Licensure
Boards
KASPER Case Studies
The Drug Enforcement and Professional
Practices Branch
•
•
•
Tips from DEPPB
•
Controlled Substance Actions & Other
Drugs of Concern
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Provider Shopping
Provider Shopping
Provider shopping is when controlled substances are
acquired by deception.
Acts related to attempting to obtain a controlled substance, a
prescription for a controlled substance or administration of a
controlled substance, prohibited under KRS 218A.140 include:
•
•
•
•
•
•
Knowingly misrepresenting or withholding information from a practitioner.
Providing a false name or address.
Knowingly making a false statement.
Falsely representing to be authorized to obtain controlled substances.
Presenting a prescription that was obtained in violation of the above.
Affixing a false or forged label to a controlled substance receptacle.
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Typical Provider Shopping Behaviors
Patient Behaviors
Examples
Multiple providers of the same type
3 or more general practitioners, dentists, etc.
Dispensers and prescribers are in
different localities from each other
and the patient’s home address
Patient lives in Fayette county; prescriber in
Franklin county; dispenser in Jessamine county
Overlapping prescriptions of the
same drug from different prescriber
types
Oxycodone scripts from dentist, family physician,
and pain management doctor within 30 days
Excessive emergency room visits
for non-emergency issues
3 or more emergency room visits in a month for
chronic pain conditions
Requesting replacement for lost
medications regularly
Patient states that controlled substance is lost
and requests new prescription
Requesting early refills
Patient requests early refills due to extended outof-state trip
Pressuring prescribers to prescribe
specific controlled substances for
the patient’s family members
Parent requests the pediatrician prescribe a
specific controlled substance for their child
stating that it is the only medication that works
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Typical Provider Shopping Behaviors (Cont.)
Patient Behaviors
Examples
Using multiple names, social
security numbers, addresses, etc.
Patient fills three scripts under three different
names
Seeking referrals to multiple pain
management clinics
Patient requests referrals to pain management
clinics without a specific diagnosis
Associating with others known to be Patient travels to clinic with another patient
pharmaceutical controlled
exhibiting shopping behavior and requests
substance provider shopping
similar prescription
Self-mutilation
Patient presents with potential self-inflicted
wound
Cash transactions
Patient prefers to pay cash when insurance
available
Requesting partial dispensing of
controlled substance script
Patient requests half of the script and returns for
the rest within 72 hours
After-hour, weekend and holiday
calls for prescriptions
Patient calls prescriber at midnight on Friday to
request a controlled substance script
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Doctor Shopping
Targeted Provider Characteristics:
• New providers
• Senior providers
• Providers perceived to keep substandard
records
• Pain management providers
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Substance Use Disorder
Substance use disorder is an illness that
sometimes drives a patient to perform activities
that are illegal.
It is important to remember that the patient who
is provider shopping may have an underlying
illness that can be diagnosed and treated.
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Practitioner Judgment
Practitioners must use their best
professional judgment to determine:
• when to intervene with a provider shopping
patient and provide treatment, or refer them to
treatment
• when to dismiss a patient or just not write
controlled substance prescriptions for them
• when to contact law enforcement to report a
provider shopper
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KASPER Case Studies
KASPER Case Study 1 - Male Patient – Age 36
Date Filled Drug Name
02/03/2012
02/28/2012
03/04/2012
03/26/2012
04/03/2012
04/23/2012
05/04/2012
05/04/2012
05/17/2012
05/30/2012
06/01/2012
06/03/2012
06/05/2012
06/20/2012
07/02/2012
07/03/2012
07/03/2012
07/16/2012
08/01/2012
08/01/2012
08/13/2012
09/01/2012
09/05/2012
09/09/2012
10/01/2012
10/07/2012
10/12/2012
10/14/2012
10/15/2012
10/31/2012
10/31/2012
11/05/2012
11/30/2012
11/30/2012
12/07/2012
Oxycodone Hcl 15MG
Alprazolam 2MG
Oxycodone Hcl 15MG
Alprazolam 2MG
Oxycodone Hcl 15MG
Alprazolam 2MG
Morphine Sulfate Er 30MG
Oxycodone Hcl 15MG
Alprazolam 2MG
Alprazolam 2MG
Alprazolam 2MG
Oxycodone Hcl 15MG
Morphine Sulfate Er 30MG
Alprazolam 2MG
Alprazolam 2MG
Morphine Sulfate Er 60MG
Oxycodone Hcl 15MG
Alprazolam 2MG
Morphine Sulfate Er 60MG
Oxycodone Hcl 15MG
Alprazolam 2MG
Oxycodone Hcl 15MG
Morphine Sulfate Er 60MG
Alprazolam 2MG
Oxycodone Hcl 15MG
Alprazolam 2MG
Alprazolam 2MG
Alprazolam 2MG
Alprazolam 2MG
Morphine Sulfate Er 60MG
Oxycodone Hcl 15MG
Alprazolam 2MG
Morphine Sulfate Er 60MG
Oxycodone Hcl 15MG
Alprazolam 2MG
Qty
180
60
180
60
180
60
60
180
60
60
75
180
60
75
75
60
180
75
60
180
75
180
60
75
180
75
75
75
150
60
180
75
60
180
120
Days
30
30
30
30
30
30
30
30
15
15
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
19
60
30
30
30
30
30
30
Prescriber Name
Prescriber City Pharmacy Name Pharmacy City
Doctor AA
Doctor BB
Doctor CC
Doctor BB
Doctor CC
Doctor BB
Doctor AA
Doctor AA
Doctor BB
Doctor BB
Doctor BB
Doctor AA
Doctor AA
Doctor BB
Doctor BB
Doctor AA
Doctor AA
Doctor BB
Doctor AA
Doctor AA
Doctor BB
Doctor DD
Doctor DD
Doctor BB
Doctor DD
Doctor BB
Doctor BB
Doctor BB
Doctor BB
Doctor AA
Doctor AA
Doctor BB
Doctor AA
Doctor AA
Doctor BB
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Pharmacy AA
Pharmacy BB
Pharmacy AA
Pharmacy BB
Pharmacy AA
Pharmacy BB
Pharmacy AA
Pharmacy AA
Pharmacy BB
Pharmacy BB
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy CC
Pharmacy AA
Pharmacy AA
Pharmacy DD
Pharmacy AA
Pharmacy BB
Pharmacy AA
Pharmacy EE
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy EE
Pharmacy DD
Pharmacy BB
Pharmacy FF
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
Lexington
KASPER Case Study 2 (Page 1) - Male Patient – Age 45
Date Filled
02/17/2010
02/22/2012
02/27/2012
03/05/2012
03/05/2012
03/14/2012
03/20/2012
03/27/2012
04/02/2012
04/04/2012
04/04/2012
04/13/2012
04/20/2012
04/20/2012
04/27/2012
04/27/2012
04/29/2012
05/03/2012
05/10/2012
05/17/2012
05/22/2012
05/23/2012
05/27/2012
06/01/2012
06/06/2012
06/12/2012
06/20/2012
06/26/2012
07/03/2012
07/03/2012
07/09/2012
07/18/2012
Drug Name
Lyrica 75MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Lyrica 75MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Hydrocodone/Acetaminophen 500MG/10MG
Lyrica 75MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Lyrica 75MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Hydrocodone/Acetaminophen 500MG/10MG
Lyrica 75MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/10MG
Lyrica 75MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Oxycodone/Acetaminophen 325MG/7.5MG
Qty
30
100
120
20
60
90
100
120
60
20
35
90
100
20
90
90
60
120
90
90
15
90
60
120
90
90
90
60
60
90
90
60
Days
15
25
30
5
30
30
25
30
30
5
6
30
25
5
22
30
30
30
22
30
3
15
30
30
15
30
15
30
15
15
30
5
Prescriber Name Prescriber City Pharmacy Name Pharmacy City
Doctor AA
Doctor BB
Doctor AA
Doctor BB
Doctor AA
Doctor CC
Doctor BB
Doctor AA
Doctor AA
Doctor BB
Doctor DD
Doctor EE
Doctor BB
Doctor BB
Doctor EE
Doctor CC
Doctor AA
Doctor AA
Doctor EE
Doctor CC
Doctor FF
Doctor EE
Doctor AA
Doctor AA
Doctor EE
Doctor CC
Doctor EE
Doctor AA
Doctor AA
Doctor EE
Doctor CC
Doctor EE
Paducah
Marion
Paducah
Marion
Paducah
Paducah
Marion
Paducah
Paducah
Marion
Paducah
Paducah
Marion
Marion
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Pharmacy AA
Pharmacy AA
Pharmacy BB
Pharmacy AA
Pharmacy AA
Pharmacy CC
Pharmacy AA
Pharmacy BB
Pharmacy AA
Pharmacy AA
Pharmacy DD
Pharmacy EE
Pharmacy AA
Pharmacy AA
Pharmacy EE
Pharmacy CC
Pharmacy AA
Pharmacy BB
Pharmacy EE
Pharmacy AA
Pharmacy FF
Pharmacy EE
Pharmacy AA
Pharmacy BB
Pharmacy EE
Pharmacy AA
Pharmacy EE
Pharmacy AA
Pharmacy BB
Pharmacy EE
Pharmacy AA
Pharmacy EE
Paducah
Paducah
Wickliffe
Paducah
Paducah
Paducah
Paducah
Wickliffe
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Wickliffe
Paducah
Paducah
KY City A
Paducah
Paducah
Wickliffe
Paducah
Paducah
Paducah
Paducah
Wickliffe
Paducah
Paducah
Paducah
KASPER Case Study 2 (Page 2) - Male Patient – Age 45
Date Filled
07/23/2012
07/29/2012
07/31/2012
08/06/2012
08/07/2012
08/14/2012
08/21/2012
08/28/2012
09/04/2012
09/20/2012
09/27/2012
10/04/2012
10/28/2012
11/19/2012
11/23/2012
11/27/2012
12/01/2012
12/03/2012
12/10/2012
12/17/2012
01/07/2013
01/14/2013
01/21/2013
Drug Name
Hydrocodone/Acetaminophen 500MG/10MG
Lyrica 75MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/7.5MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/10MG
Lyrica 75MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/10MG
Lyrica 75MG
Hydrocodone/Acetaminophen 500MG/10MG
Lyrica 75MG
Oxycodone/Acetaminophen 325MG/5MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/10MG
Lyrica 75MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/10MG
Hydrocodone/Acetaminophen 500MG/5MG
Hydrocodone/Acetaminophen 500MG/5MG
Hydrocodone/Acetaminophen 500MG/5MG
QTY
Days
90
60
60
24
90
60
90
60
90
90
60
90
30
35
35
35
60
35
35
35
35
35
35
15
30
15
4
22
15
22
30
22
30
30
30
60
4
5
4
30
5
5
4
5
8
8
Prescriber Name Prescriber City Pharmacy Name Pharmacy City
Doctor EE
Doctor AA
Doctor AA
Doctor GG
Doctor EE
Doctor AA
Doctor EE
Doctor AA
Doctor EE
Doctor EE
Doctor AA
Doctor EE
Doctor AA
Doctor DD
Doctor DD
Doctor DD
Doctor AA
Doctor DD
Doctor DD
Doctor DD
Doctor DD
Doctor DD
Doctor DD
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Pharmacy EE
Pharmacy AA
Pharmacy BB
Pharmacy AA
Pharmacy EE
Pharmacy AA
Pharmacy EE
Pharmacy AA
Pharmacy EE
Pharmacy EE
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Pharmacy AA
Paducah
Paducah
Wickliffe
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Paducah
Advice from the
Kentucky Licensure Boards
Fast tract to KBML/BON
• Departures from or failures to conform to “acceptable and
prevailing medical practices” (this includes prescribing
violations and failure to sufficiently document clinical
reasoning in general)
• Boundaries issues (i.e. sex with patients or prescribing to
intimates)
• Failure to make timely reports ( i.e. failure to report criminal
conviction/plea or any action against his/her license by
another state licensing board within 10 days of event)
• False statements on applications (answering “no” when
should have answered “yes”)
• Untreated substance abuse/dependence
Cabinet for Health and Family Services
Protecting Your Practice
Recommendations from the Kentucky Board of
Medical Licensure and Kentucky Board of Nursing
• Remain up to date with rules (guidelines) and
regulations:
– in the Medical Practice Act (available on
KBML web site: www.kbml.ky.gov)
– in the Nurse Practice Act (available on KBN
web site: http://kbn.ky.gov)
• Keep well-documented patient records
Cabinet for Health and Family Services
Protecting Your Practice (cont.)
• Be attentive to patient needs
• Be familiar with office personnel and their
interactions with patients
• Remain up to date with current billing methods
and insurance procedures
• Maintain appropriate controls on prescription
pads
– Title 21 Code of Federal Regulations
§1306.05(a)
• No Pre-signed or post-dated prescriptions
Cabinet for Health and Family Services
Protecting Your Practice (cont.)
• The Boards strongly encourage use of
chaperones for sensitive examinations
• Do not prescribe controlled substances for
yourself or “immediate family”.
• Run KASPER reports on patients.
• Maintain appropriate controls/security on
KASPER access.
Cabinet for Health and Family Services
Protecting your practice (cont)
• Writing controlled substance
prescriptions for friends, co-workers,
or employees
•
See 201 KAR 20:057/ 201 KAR 20:057 for
all requirements
•
Chart with a KASPER in it, medical
history, treatment plan, diagnostic
examinations, documented consent, etc..
Cabinet for Health and Family Services
The Drug Enforcement and
Professional Practices Branch
(DEPPB)
Drug Enforcement Branch
• The Drug Enforcement and Professional Practices
Branch (DEPPB) is housed within the Cabinet for
Health and Family Services:
– Office of Inspector General (OIG)
• Division of Audits and Investigations
• DEPPB Responsibilities:
– Enforcement of Kentucky Controlled Substances Act
(KRS 218).
• Conducting drug investigations.
• Licensing drug manufacturers and distributors.
– Enforcement of Kentucky Food, Drug and Cosmetic Act
(KRS 217).
– Operation of the KASPER program.
Cabinet for Health and Family Services
DEPPB Investigators
• Over the years DEPPB has migrated from a
purely law enforcement agency to a consulting
and assistance role in supporting investigations
by other law enforcement agencies.
• DEPPB investigators, by statute are all
pharmacists thereby giving them a unique
insight into drugs, provider and dispenser office
procedures and record keeping/analysis.
Cabinet for Health and Family Services
DEPPB Investigators
DEPPB Phone Number: 502-564-7985
Paula York
Jill Lee
Amanda Ward
Carrie Gentry
Laura Beth Wells
Duncan McCracken
Cabinet for Health and Family Services
Chris Johnson
Prescriber Review Considerations
• Practitioner’s area of specialty
• Consultation with licensure board to discuss any
known problems with the practitioner
• Review KASPER prescriber report
• Total number of pages
• Types of controlled substances prescribed (only a few types
of controlled substances?)
• Prescribing unusually large quantities
• Prescribing certain combinations (e.g., hydrocodone,
alprazolam and carisoprodol)
• Refill frequency; are new scripts issued before all refills are
exhausted?
• Are patients traveling long distances to see the prescriber?
KASPER Case Study
• Physician identified as one of top 10 prescribers of hydrocodone in
Kentucky
• The analysis was based on criteria established by the KASPER
Advisory Council
• Physician referred to Drug Enforcement and Professional Practices
Branch for Review
• DEPPB pharmacist/investigator reviewed KASPER report from
1/8/2011 to 1/8/2012 (498 pages)
• Physician specialty identified by KBML as pain management
• No prior complaints against physician
• Physician wrote >50 controlled substance prescriptions on 23 days
between 10/1/2011 and 12/31/2011 (67 working day period)
• Physician used KASPER (running 783 KASPER reports on patients
from 1/8/2011 to 1/8/2012)
• DEPPB investigator indicated that the KASPER report did not provide
any evidence of inappropriate prescribing, and no further action was
taken.
Tips from DEPPB
Tips from DEPPB - 1
How to identify doctor shoppers and avoid
becoming a victim!
• Use KASPER.
– New patients
– Before prescribing a controlled substance
– Periodically for patients receiving a controlled
substance
• Be suspicious if a patient requests specific or
brand name drugs.
• Require photo id for patient records.
Cabinet for Health and Family Services
Tips from DEPPB - 2
• Be suspicious of vague or inconsistent patient
complaints.
• Be suspicious of patients coming with family
members, all wanting the same medications
or with the same complaint.
• Is the patient carpooling to your office with
other patients?
• Do patients know each other? Are they
possibly mingling in the parking lot after their
visits?
Cabinet for Health and Family Services
Tips from DEPPB - 3
• Check patient address. Are patients driving
long distances to see the prescriber?
• Be wary of patients asking for frequent
early prescriptions due to vacations, or new
prescriptions when they should still have
refills available.
• Be suspicious of patients claiming lost or
stolen medications. Require a police
report, or if you believe them limit them to
one time.
Cabinet for Health and Family Services
Tips from DEPPB - 4
• Require patient to sign drug or pain contract
with the prescriber.
– Consider limiting the patient to one pharmacy in
the contract.
• Perform random drug screens.
• Secure your prescription pads – even from
staff. Serialize your secure prescription pads.
• Write prescriptions in longhand to prevent
further tampering. Make copies for patient
files for proof if altered.
Cabinet for Health and Family Services
Tips from DEPPB - 5
• Be suspicious of patients stating they are
allergic to NSAIDs.
• If a patient presents an MRI, verify it is from
a legitimate facility.
• Be suspicious of patients who frequently
show up late in the day or on Friday
afternoon (hoping you will be too busy to
ask many questions or conduct a thorough
examination).
Cabinet for Health and Family Services
Tips from DEPPB- Prescribing
• Identify yourself on prescription
If there are 6 doctors and 4 APRN’s at your office listed on the
prescription blank, make sure you circle your name.
• Clearly identify the patient
Be sure to write the patient’s full name on the prescription,
including any suffixes. Include the patient address and date of
birth to reduce fraudulent activity.
• Spell out quantities and refills in addition to writing or circling the
number on the prescription
•
Make copy of prescription for chart
•
Cancel Refills at the pharmacy if changing medication
Cabinet for Health and Family Services
Security Prescription Blank (902 KAR 55:105)
A latent
repetitive VOID
at 5% in
Pantone Greenif copied Void
appears in
pattern across
entire script
Federal Law Requires Prescriber Name, Address and
Registration (DEA#)
¾ inch
Opaque Rx
Symbol 1/8
in. from top,
5/16 in. from
side
Rx is 4 ¼
inch high and
5 ½ inch
wide
6
Quantity
Check-Off
Boxes
The following statement
at bottom of blank
Refill
Options on
Left Side
in this order
Prescription is void if more than one (1) prescription is written per blank
Printed Watermark on Back:
“Kentucky Security Prescription”
Horizontal–5 lines-Helvetica style
Tips from DEPPB- Rx Blanks
• Order controlled substance blanks that meet state
security requirements – KAR 55:105
• Store Rx pads in a secure spot – even from office staff
• Do not pre-sign Rx blanks
• Do not use Rx blanks pre-signed by your collaborative
physician
• Do not post-date prescriptions:
All written and facsimile prescriptions for controlled substances shall be dated
and signed by the practitioner on the date issued and shall bear the full name
and address of the patient, drug name, strength, dosage form, quantity
prescribed, directions for use, and the name, address and registration number
of the practitioner
• Scripts for compounded controlled substances are not
exempt from controlled substance laws
Cabinet for Health and Family Services
Questions to ask the Patient!
• Are you seeing other practitioners for this or
any other reason?
• When did you last see the other practitioner?
• What medications were you prescribed?
• What pharmacy did you use?
• Request identification with photo, DOB, SSN
and address.
Compare the above information with the
KASPER report.
Cabinet for Health and Family Services
APRN Tips from DEPPB-Know the limits
Drug
Schedule
II
III
IV (Ativan,
Klonopin,
Valium,
Xanax and
Soma
IV(other)
V
KASPER Query
Maximum Prescription
Required before
72 hours** (see
prescribing and at least
psychiatric mental health
every three months during
exemption below)
treatment
Required before
prescribing and at least
30 days
every three months during
treatment
Required before
prescribing and at least
every three months during
treatment
Required before
prescribing and at least
every three months during
treatment
not required
30 days
Refills
Prescription Expiration
No
60 days after date of issue
No
Six months after date of
issue
No
Six months after date of
issue
Original quanity
prescribed
Maximum six-month Six months after date of
supply
issue
Original quanity
prescribed
Maximum six-month Six months after date of
supply
issue
**APRNs nationally certified in psychiatric mental health nursing may prescribe a 30-day supply of psychostimulants.
Your CAPA-CS may place additional restrictions on your prescribing authority.
Jlee2014
Cabinet for Health and Family Services
Sources of Confusion






Unless you are certified as a psych/mental heath APRN,
you cannot write for more than a 72 hour supply of a C-II
psychostimulant (ADHD meds).
Even if you are certified as a psych/mental health APRN,
you cannot write for more than a 72 hour supply of any
other C-II.
APRNs cannot write Suboxone prescriptions for
addiction; only physicians can be Data Waived
APRNs cannot issue multiple prescriptions (see KRS
314.011)
Nubain (not federally scheduled) –schedule IV in Ky
Talwin (pentazocine), Phenobarb, and all butalbital are
schedule III in KY
Cabinet for Health and Family Services
Sources of Confusion (Cont.)
• APRN’s cannot dispense controlled substance
medications- see KRS 314.011 (8)
• APRN’s cannot order controlled substances to
dispense in office
• APRN’s can not supervise a PA-C – only
physicians can supervise- see KRS 311.840
• Weight Loss Clinics/Amphetamine like
substances
Can not dispense meds if doctor not in office
Must conform to standards of practice
Cabinet for Health and Family Services
Dispensing CS from office
• All administered and dispensed controlled
substances must be reported to KASPER
(doctor’s offices are not exempt and must
adhere to all the reporting laws as pharmacies
do)
• Only pharmacist and physicians are allowed
to dispense medication (not APRNs, PAs,
RNs, office staff)
Cabinet for Health and Family Services
Multiple prescriptions
• A practitioner may provide individual patients
with multiple prescriptions for the same
schedule II controlled substance to be filled
sequentially. The combined effect of these
multiple prescriptions is to allow the patient to
receive, over time, up to a 90-day supply of
that controlled substance
APRNs may not issue multiple prescriptions
Must adhere to prescribing standards in 201
KAR 9:290
Cabinet for Health and Family Services
Diversion
Definition- When a substance is acquired and/or taken by an
individual for whom the medication was not prescribed.
What do you do when diversion is suspected?
• If you suspect an individual is involved in diverting controlled
substances, we ask that you please report them to the
proper law enforcement authorities.
• If unsure who to contact please call the Drug Enforcement
and Professional Practices Branch of the Office of the
Inspector General for assistance.
– (502) 564-7985
– http://www.chfs.ky.gov/os/oig/auditsinv
Cabinet for Health and Family Services
Diversion
Reporting Provider Shoppers/Diverters
• KRS 218A.280 Controlled substances –
Communications with practitioner not
privileged.
– Information communicated to a practitioner in an
effort unlawfully to procure a controlled substance,
or unlawfully to procure the administration of any
controlled substance, shall not be deemed a
privileged communication.
Cabinet for Health and Family Services
Reporting Provider Shoppers/Diverters
• 902 KAR 55:110 Section 10 (4) (b): In addition to the
purposes authorized under KRS 218A.202(8)(e), and
pursuant to KRS 218A.205(2)(a) and (6), a
practitioner or pharmacist who obtains KASPER data
or a report under KRS 218A.202(6)(e)1. or who in
good faith believes that any person, including a
patient, has violated the law in attempting to obtain a
prescription for a controlled substance, may report
suspected improper or illegal use of a controlled
substance to law enforcement or the appropriate
licensing board.
Cabinet for Health and Family Services
Controlled Substance Actions
and
Other Drugs of Concern
Federal Actions
• FDA approved C-II pure hydrocodone product
– Zohydrotm ER manufactured by Zogenix, Inc.
– Available March 2014
– Not abuse-resistant formulation
•
Tramadol scheduled federally C-IV
–
•
Effective August 20, 2014
Hydrocodone combination products
rescheduled to C-II
– Effective October 6, 2014
Justice & Public Safety Cabinet
Kentucky Actions - Butalbital
• The KY controlled substance exempt list now mirrors
the Federal exempt list found in Title 21 Code of
Federal Regulations §1308.32 EXCEPT butalbital
containing products (e.g., Fioricet, Bupap, Esgic).
• Effective September 17, 2014 all butalbital
containing products are Schedule III controlled
substances in KY and must be reported to
KASPER.
Cabinet for Health and Family Services
Prescription drugs
•
•
•
•
Clonidine
Cyclobenzaprine
Gabapentin
Promethazine
– Purple drank=promethazine/codeine cough syrup
• Seroquel
– Q-ball
Cabinet for Health and Family Services
Clonidine
• Reduce sx of alcohol and opioid withdrawal
• Causes euphoria, hallucinations, & sedation
• Use at high doses (2mg+) causes hypomanic
excitation
• Boost effects of benzos, cocaine, opioids
• Withdrawal= rebound HTN
Cabinet for Health and Family Services
Gabapentin
• Cocaine-like high when snorted
• Used with other substances to potentiate
effects
• Can reduce craving for alcohol
Cabinet for Health and Family Services
Promethazine
• Promethazine w/ codeine
Very popular with teens – Purple Drank
typically mixed with sprite or Mt Dew and
optionally a Jolly Rancher added for
sweetness.
• Plain promethazine
potentiates the effects of just about every
drug
Cabinet for Health and Family Services
Atypical Antipsychotics
• Used to potentiate high from other drugs or
avoid AE
• St. Luke’s and Roosevelt Hospitals in NYC:
– 73 of 429 patients in detox/rehab units used
atypical antipsychotics illegally/non-medically
– 88% of atypical antipsychotic users were
polysubstance users
– 84.9% used quetiapine
Presented at American Academy of Addiction Psychiatry 24th Annual Meeting &
Symposium. 2013.
Cabinet for Health and Family Services
Stimulants
• Immediate release formulations preferred
– Rapid increase in dopamine = Euphoria
• Used for energy (“study drugs” for college
age students) and weight loss
• Cardiovascular dangers at high doses:
BP spike, hyperthermia, stroke, arrhythmia
Red Flags- claims of lost prescriptions, reports of
Missing meds, early RF and higher dose request
Cabinet for Health and Family Services
Street Value
• http://streetrx.com
• Louisville, KY
– Adderall 30mg = $4-5
– Lorazepam 0.5mg= $5
– Vyvanse 60mg= $10
• http://www.bluelight.org
open information board about how to
take legal/non-legal drugs
Cabinet for Health and Family Services
Philip Seymour Hoffman
US Weekly Celebrity News, February 3, 2014
Cabinet for Health and Family Services
Heroin vs. OxyContin
Source: National Survey on Drug Use and Health
OxyContin users (for nonmedical reasons)
Heroin users
Cabinet for Health and Family Services
Heroin
Source: Kentucky Justice & Public Safety Cabinet
Cabinet for Health and Family Services
Heroin
Cabinet for Health and Family Services
How Did We Get Here?
•
•
•
•
•
•
Long history of opioid/painkiller abuse
Increasing numbers of IV drug usage
Abuse deterrent formulations
Crackdown on rogue pain clinics
Greater awareness by prescribers
Established drug cartels recognized
increasing demand
Cabinet for Health and Family Services
How Did We Get Here?
PRICE
AVAILABILITY
PERCEPTION OF RISK
Cabinet for Health and Family Services
How Do We Address the Problem?
• Public Education
• Increased access to treatment
• Enhanced penalties for major
traffickers
• Greater access to naloxone
Cabinet for Health and Family Services
KY Kids Recovery Program
• $19.2 million in funding for adolescent
substance abuse treatment
• Expanding treatment beds at existing facilities
• Developing new treatment facilities
• Providing full continuum of care including
intensive outpatient and follow up
• 19 substance abuse treatment grants
awarded by Governor Beshear’s Substance
Abuse Treatment Advisory Committee
• www.kykidsrecovery.ky.gov
Cabinet for Health and Family Services
The Take-Away Messages
•
•
•
•
•
•
Recognize the problem
Report to police diversion
The Drug Enforcement and Professional
Practices Branch is available to support
your practice.
Use KASPER regularly
Increase your knowledge of addiction &
how to properly prescribe CS.
Please remain alert and be careful!
Cabinet for Health and Family Services
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 1Q 2014
Cabinet for Health and Family Services
KASPER Web Site: www.chfs.ky.gov/KASPER
502-564-7985