Wednesday, August 26, 2015

E-FORCSE and KASPER Cousins with a Cause

Since 2009, Florida has had a prescription drug monitoring program, or "PDMP." It is called E-FORCSE (Electronic-Florida Online Reporting of Controlled Substance Evaluation Program). The concept was born in a time when Florida was "a," perhaps "the," leading source of opiod narcotics in the country. The news back then was periodically peppered with stories of "pill mills" and people were reportedly visiting Florida for the specific purpose of obtaining and transporting medication. Floridians do love tourists and our beaches and other attractions are legendary, but tourism driven by obtaining narcotics?

In Florida, when a controlled substance is prescribed or dispensed, the physician is required "to report to the PDMP." Thus, Florida is collecting data on the prescribing and dispensing through the E-FORCSE

Florida does not require physicians to check the PDMP when writing a prescription. I have questioned that earlier this year in If it is Worth Having, is it Worth Checking, That post provides some references to success stories in addressing the epidemic of drug death in America. 

The CDC has complimented Florida for the efforts directed at the "pill mills." Kentucky has also won praise for its efforts. This week I sat in the SAWCA Regulator Roundtable while there was discussion of narcotics. Kentucky's Dwight Lovan referenced the efforts Kentucky has made regarding the troubling issue of drug abuse. One of the many Twitter users ("tweeters?") at #WCEC2015 posted that we are losing 40 Americans a day to drug overdose. 

In July, the  University of Kentucky College of Pharmacy’s Institute for Pharmaceutical Outcomes and Policy (IPOP) issued a report on the state of pharmaceuticals in Kentucky, and Kentucky's PDMP, called "KASPER" (Kentucky All Schedule Prescription Electronic Reporting), and it use is mandatory. This program was likewise the subject of Commissioner Lovan's comments. 

As mentioned, there have been reports of people travelling to Florida specifically to visit "pill mills." These tourists from various states would visit multiple clinics each day, over a several day visit, and obtain hundreds of pills. They would then travel home and either use them or sell them. The reselling of medications prescribed for one person, to some other person, is called "diversion." 

A less organized method (and with likely less transportation expense than flying to Florida) of obtaining medication is known as "doctor shopping." In this context, "doctor shopping" refers to a patient visiting multiple physicians for the purpose of obtaining medication. Each physician, unaware of the others, would prescribe and even dispense medication. The IPOP report claims that Kentucky's legislative efforts, including KASPER, have resulted in a 50% reduction in doctor shopping and an increase in those seeking "treatment for prescription medication addiction." FIFTY PERCENT!

Successes since 2012 noted by IPOP (the following is quoted) include: 
• More individuals are seeking office-based addiction treatment.
• The number of patients “doctor shopping” declined by 52 percent.
• 24 non-physician-owned pain management facilities have ceased operation.
• The number of opioid prescriptions to doctor-shopping individuals dropped by 54 percent.
• 5 million KASPER reports were requested in 2014.
• Each weekday, providers request more than 20,000 KASPER reports.
• For the first time in six years, Kentucky overdose deaths declined in 2013.

Drug overdose deaths in America are referred to as an "epidemic" by the Center for Disease Control. People are dying as a result of medication. They note that each day "44 people in the United States die of overdose of prescription painkillers." I am so impressed that the Tweeters at WCEC found that pertinent and worthy of communicating to their many followers. 

That 44 per day is interesting and more so tragic. There are those who argue that this is only part of the problem, pointing to the death rates from illicit drugs. That perspective certainly deserves consideration, but control of drugs like heroin is not necessarily seen as a physician or pharmacy issue. I am not saying it is not a problem, but it is beyond the scope of E-FORCSE or KASPER.

There are those who see a relationship between heroin and prescription drugs. FoxNews reported in July that "8,200 people died from heroin overdoses in 2013 alone. The efforts to restrict the supply of prescription narcotics is meeting with success. With a lower supply of those drugs, the street price of opiods has risen.   This has reportedly driven demand for substitutes, like heroin. Fox reports that the CDC  concluded "Everything we see points to more accessible, less-expensive heroin all over the country,"

The relationship is demonstrable. The CDC report referenced by Fox concludes "that nearly all people (96 percent) who use heroin also use multiple other substances, and that the strongest risk factor for heroin abuse is prescription opiate abuse." Thus, might one argue that prescription narcotics are a "gateway" drug to heroin? Texas reported at the Roundtable that their drug formulary has resulted in reduced pharmaceutical issues there. I recently addressed formularies in I am Learning More, Does That Mean I Understand More?

Well, at the Roundtable, Texas reported that there is evidence there of reduced opiod abuse and death. They credit the formulary and believe that there has not been a significant migration to the illicit alternatives like heroin as prescription opiod access is constrained. 

This opiod crisis is a complicated situation, which has national implications. The top three states for overdose death are West Virginia, New Mexico and Kentucky according to Statistica.  Florida is fifteenth on that list. I guess we can be glad that we are not in the top three on this one, but even at fifteenth, it is a significant issue here. I do not think we can assuage ourselves with our knowedge that is worse elsewhere. 

Kentucky considers KASPER to be a "national model," setting the standard for this type of effort. But, the report notes that “the war on drugs is ever-evolving. It is important that we as lawmakers act as quickly as we can to identify and prevent new drugs from spreading in our communities.” That is a quote that perhaps does more than most to state our challenge. There are relationships between narcotics and illicit drugs. Both are killing people. 

Kentucky is also reporting success with enforcement. In the three years since passage of prescription reform and the creation of KASPER, "the Kentucky Board of Medical Licensure took 196 controlled substance prescribing disciplinary actions against 142 physicians, ranging from emergency orders of suspension or restriction, to license suspensions or surrenders and revocations." I need to do some research and find out what Florida's record was in that time period. 

Attendance at national conferences like WCEC will support the conclusion that there is significant discussion about concerns with opiods. A national chorus is erupting with questions about when these are appropriate, and for how long. Some have begun suing drug manufacturers alleging that a "campaign of deception (was) aimed at boosting sales of potent pain killers," as reported by the Los Angeles Times. The municipalities that face the costs associated with opiod abuse or misuse are seeking to hold the manufacturers liable for those costs. 

It is a complex and significant problem. Some 100 million Americans are affected by chronic pain According to This is "more than the number affected by heart disease, diabetes, and cancer combined." This article asserts that pain medication is a significant issue in workers' compensation. Pain is a natural consequence of injury. Even a minor injury can result in pain. I recently cracked my knee on the desk edge, and from that alone I limped most of the rest of the day. Not a huge injury, but the pain was real. We all understand that with injury comes pain. 

The Insurance Journal claims that an "opiod epidemic plagues workers' comp." The article notes that medication abuse is a problem that is growing, despite efforts to combat it. Efforts to address this are lauded, including "statewide databases" and "ferreting out and punishing overprescribing doctors" and "dealing with the growing number of pain management clinics." Thus despite the impressive statistics touted by Kentucky and the formulary success noted by Texas, the industry still perceives not only a problem but one that is growing despite our best efforts.

We have pain. We see evidence that pain medication use can have serious implications. So, having been a leader to the PDMP concept in 2009, what is Florida doing now to address this complex problem? Will Florida move to mandatory reference of the E-FORCSE before medications are prescribed or dispensed? If we have the data, why aren't we mandating its use?

Will Florida move to a forumulary. I hear increasing rumblings of this. There seems to be some misconception that such a formulary is only possible if we likewise adopt treatment guidelines and/or some commercially produced impairment guides. The references are "that is how Texas did it." But, it appears that a forumlary could be easily implemented as a stand-alone improvement to our efforts. 

Florida already has impairment guides. After a long experience with the AMA Guides, we moved to our own Florida Guides twenty years ago. I have heard no explanation as to why those guides are inconsistent a drug formulary. Likewise, while treatment guidelines might well compliment a forumlary there is nothing to support that one cannot be implemented without the other. 

If we adopt a forumlary by legislation or regulation, will that mean a quicker process for recovering workers to obtain their medications from the pharmacy? There is much to discuss. I struggle with the various implications, but I consider myself privileged to be able to learn about these subjects from the industry and professional and regulator luminaries at the WCEC this week. 

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