Prescription Monitoring Toolkit

PRESCRIPTION MONITORING PROGRAM TOOLKIT

PRESCRIPTION MONITORING PROGRAM TOOLKIT

SECTION 1

The Purpose of the Toolkit

The Southern Plains Tribal Health Board (SPTHB) developed this toolkit to assist Tribes and Tribal facilities with navigating their states’ prescription monitoring program (PMP).

SECTION 2 Overview of the PMP

Prescription Monitoring Programs are electronic databases in which pharmacies’ dispensation of Schedule II to IV controlled substances are recorded. The PMP is one of many tools that can address the opioid epidemic in Indian Country. Fortynine states in the United States have implemented a version of the PMP.

This toolkit is divided into two main sections, one for tribal health care systems and one for tribal prevention and public health programs.

1 TABLE OF CONTENTS 2

Information is provided about the Prescription Monitoring Programs (PMP) in Kansas, Oklahoma, & Texas, which are the three states within SPTHB’s service area.

4 5 3

SECTION 3

The PMP and Pharmacies/Tribal Health Systems

Benefits of the PMP and Health Care

Guidelines for Using the PMP with Patients

Registering for the PMP

View table on the resources and websites for each PMP program in Kansas, Texas, and Oklahoma.

SECTION 4

The PMP and Tribal Prevention Programs

Benefits of the PMP and Prevention Programs

Engaging with the PMP

Accessing Population-level PMP Data

View table: SPTHB outlines some of the internal and external factors that aid in initiating accurate American Indian/Alaskan Native data through partnership and education. View table: Suggested Resources for More Information on Using PMP.

References

View more information on the references used throughout this document.

SECTION 1

THE PURPOSE OF THE TOOLKIT

The Southern Plains Tribal Health Board (SPTHB) developed this toolkit to assist Tribes and Tribal facilities with navigating their states’ prescription monitoring program (PMP). This toolkit is divided into two main sections, one for tribal health care systems and one for tribal prevention and public health programs. The document provides an overview of the PMP, the benefits of the PMP, and the suitable steps in partnering with the governing organization to ensure that your community has accurate prescription drug use data. The toolkit also illustrates how SPTHB developed a relationship with the Oklahoma Bureau of Narcotics and Dangerous Drug Control (OBN), the organization that oversees the Oklahoma PMP, to help increase tribal access to accurate PMP data. This can serve as a guide for others looking to improve the quality and accessibility of tribal PMP data. Readers should keep in mind that the needs of each tribal community and state are unique and should be adapted to accommodate what is best for the Tribe, tribal organization, providers, and community.

OVERVIEW OF PRESCRIPTION MONITORING PROGRAMS (PMPS)

Prescription Monitoring Programs are electronic databases in which pharmacies’ dispensation of Schedule II to IV controlled substances are recorded. The PMP is one of many tools that can address the opioid epidemic in Indian Country. For clinicians and pharmacists working in tribal communities, the PMP can help protect patients at risk of opioid overdose, inform clinical decision-making, and implement safer prescribing practices.1 For tribal public health and prevention programs, the PMP populationlevel data reports can also be used to advise program activities and obtain funding. Tribal participation in the PMP will help create healthier communities.

Forty-nine states in the United States have implemented a version of the PMP. The Oklahoma Bureau of Narcotics and Dangerous Drug Controloversees implementation of the PMP, and houses all data collected. In Kansas and Texas, PMPs are managed by each state’s Board of Pharmacy. In Kansas, the PMP is sometimes referred to as K-TRACS, but for simplicity, this toolkit will refer to it as the PMP. The ultimate goals of PMPs are preventing and identificating diversion and misuse of prescribed controlled substances.3 The collected data is used to aid education, enforcement, and abuse prevention efforts.2 State laws, federal policies, and CDC guidelines may be a useful outline for best practices around the PMP for tribal communities. Although Tribes are not required to use the PMP, it is important to note that each Tribe has the right to access the data that represent their communities. The PMP data that can be acquired are Tribal data, and this toolkit is intended to empower tribes with that knowledge. The toolkit further outlines these laws and policies in Section 2, “The PMP and Tribal Health Systems.”

The PMP collects basic data on the controlled substances dispensed to patients by pharmacies. It is important to remember that the PMP records the dispensation of the prescription medication. Therefore, if a prescription is written for a patient, but never picked up, it is not recorded into the PMP. When the prescription medication is dispensed, the following information is recorded by the pharmacy:

+ Product and its strength, form, and quantity

+ Name of the prescriber

+ Dispensing pharmacy

+ Number of days the prescription is intended to last

+ Number of authorized refills

+ Date the prescription was written and filled

+ Payment method used

+ Patient’s name, date of birth, address, and phone number

SPTHB SERVICE AREA PRESCRIPTION MONITORING PROGRAMS

Kansas PMP: In Kansas, the PMP is referred to as K-TRACS. The State of Kansas requires pharmacies to report the dispensations of all Schedule II-IV controlled substances and “drugs of concern” daily. The Kansas Board of Pharmacy oversees K-TRACS. De-identified aggregate data can be released for the purpose of research, grant writing or administration, or prevention programs. To request data or find out more information, visit: https://pharmacy.ks.gov/k-tracs/using-k-tracs/forms.

Oklahoma PMP: In 2006, the State of Oklahoma implemented a web-based PMP managed by the Oklahoma Bureau of Narcotics and Dangerous Drug Control (OBN). The Oklahoma PMP collects information on the dispensation of Schedule IIV controlled substances. State law requires dispensation to reported within five minutes. If you would like to access PMP data from OBN, you can fill out a data request form and email it to OBN’s PMP administrator at pmpadmin@obn. state.ok.us or visit the official website at: pmp. obn.ok.gov. All non-identifiable PMP data is available by request; data is no longer limited to the county-level, as it was in previous years.

Texas PMP: The Texas Prescription Monitoring Program (Texas PMP), managed by the Texas State Board of Pharmacy, collects and monitors outpatient prescription data for all Schedule II, III, IV, and V controlled substances dispensed by a pharmacy in Texas or to a Texas resident in another state. Dispensation should be reported no later than the next business day. State regulatory boards have access to PMP data, as well as prescribers or pharmacists who are inquiring about their own prescribing or dispensing.

SECTION 3 PRESCRIPTION MONITORING PROGRAMS AND TRIBAL HEALTH SYSTEMS

Benefits of the PMP and Health Care

The PMP can be a powerful tool to help strengthen communities, provide quality medical care, and reduce the diversion of prescription drugs. The following information details these benefits of the PMP for healthcare providers and clinics.

Lowering patient overdose risk and improving health outcomes

Perhaps most importantly, the PMP can help healthcare practitioners better care for those who are at risk of opioid overdose, and it can help prevent unintentional overdose. A patient’s PMP report can help identify whether the patient:

+ Has multiple opioid prescriptions,

+ Has a high-dose opioid prescription(s),

+ Has opioid prescriptions that last for more than 7 days,

+ Has overlapping benzodiazepine and opioid prescriptions,

+ Uses multiple pharmacies (sometimes called “pharmacy shopping”)

+ Uses multiples physicians (sometimes called “doctor shopping).

All of the above factors are associated with an increased risk of opioid overdose. The PMP can help a physician or pharmacist identify these factors easily and make an informed decision on whether to prescribe or dispense a controlled medication for the patient. By checking a patient’s PMP report, a doctor or pharmacist can help ensure the patient’s safety and lower the risk of opioid overdose.5

Additionally, because the PMP can identify factors associated with opioid overdose and addiction (as listed above), the PMP can help physicians

engage in honest and open conversations with their patients about their substance use. It can help providers know when a referral to a substance abuse treatment facility is appropriate. Across the country, research has shown that when prescription monitoring programs are implemented, the number of opioid-related deaths decline.7 When used as a clinical decisionmaking tool, the PMP can help patients get the care they need and help improve health outcomes among patients living in tribal communities.

*Please see Guideline for Using the PMP with Patients Section on page 12 for more information.

Safer prescribing practices

For prescribers and pharmacists, the PMP can be used to help inform a patient’s treatment. It provides objective evidence of a patient’s prescription history that can aid prescribing and dispensing decisions.5 Nationwide, the implementation of PMPs has been associated with a greater than 30-percent reduction in the prescribing of Schedule II opioids.6 The PMP helps provide a more complete picture of a patient’s prescription history, and physicians can use this information to determine whether opioids or other prescription pain medications are the safest and most effective course of treatment for pain management. After the implementation of PMPs across the country, there has been a slight increase in the prescription of nonopioid analgesics.6 It seems that the PMP can help doctors prescribe nonopioid alternatives when it is necessary to do so.

Reduction of diversion of prescription medication

The PMP can also be used by law enforcement agencies to identify fraudulent pain management clinics that routinely and inappropriately prescribe controlled painkillers (e.g., without physical examination, diagnosis, monitoring, documentation, or sufficient medical history). These facilities are sometimes referred to as “pill mills.” By identifying and preventing “pill mills” and “doctor shopping,” the PMP can help reduce the number of illicit prescription pills that are available to the individual, as well as the community.

GUIDELINES FOR USING THE PMP WITH PATIENTS For prescribers and health clinics

State of Oklahoma Guidelines

The State of Oklahoma recommends checking the PMP before writing a patient’s first prescription for “opiates, synthetic opioids, semisynthetic opiates, benzodiazepine, and carisoprodol.” After the initial check, the patient’s PMP should be checked at least every 180 days while prescribing the medication. The State of Oklahoma also notes a staff member can check the PMP report on the prescriber’s behalf, and these PMP reports can be entered into the patient’s record. These recommendations do not apply to those in palliative care.9

State of Texas Guidelines

The state of Texas requires that a physician check the Texas PMP before writing any prescription for opioids, benzodiazepines, barbiturates, or carisoprodol. A Physician should document that they checked the patient’s PMP report. Delegates can query the PMP on behalf of the provider.

State of Kansas Guidelines

The state of Kansas requires all physicians and pharmacists who dispense Schedule II, III, and IV controlled substance prescriptions and designated drugs to collect and report to the state PMP K-TRACS. Colorado, Oklahoma and/or Missouri prescription drug data can be added to integrated systems by requesting access from the K-TRACS software vendor, Appriss Health.

Center for Disease Control (CDC) Guidelines

Centers for Disease Control (CDC) Guidelines. The CDC recommends checking a patient’s PMP report every three months, and prior to every opioid prescription.10 When checking the PMP, the provider should take into account the dosage of prescribed medication, the number of prescribers the patient is seeing, and the possibility of drug interactions (e.g., between concurrently prescribed benzodiazepines and opioids).7 The CDC also stresses that a patient’s PMP report should not result in a patient being discharged from the provider’s practice or denied care. The data gained from the PMP can be used to provide life-saving interventions and information.10

Indian Health Service (IHS) Guidelines

In Chapter 32 of the Indian Health Manual, IHS describes their guidelines and mandates around the PMP. IHS urges every provider to register with the state PMP, request a PMP report as part of the process of accepting a new patient, and access PMP patient data prior to the appointment.8 This will allow for meaningful interactions between the provider and patient, assist the provider in identifying possible drug interactions, help recognize any potential addiction or use issues, and verify compliance with safe medication use/pain agreements. IHS also recommends providing patient education on the findings of the PMP report, and documenting PMP monitoring through the use of a patient education code.8

FOR PHARMACISTS AND PHARMACIES

State of Oklahoma Guidelines

Oklahoma’s PMP was one of the first systems to integrate “real time” reporting. The state of Oklahoma’s PMP mandates that pharmacists should submit prescription-dispensing information into the PMP within five minutes of dispensing the scheduled narcotic.2 Many pharmacies have moved to systems that automatically report into the PMP when the narcotic is dispensed to the patient, and OBN trainings can inform pharmacists about techniques used to ensure that data are entered in an accurate and timely manner.

State of Texas Guidelines

The Texas Board of Pharmacy requests that every controlled substance that is dispensed to an outpatient be reported within one day of dispensing. If the pharmacy does not dispense any reportable drugs, then the pharmacy should file a “zero report.” Pharmacists must check a patient’s PMP report before dispensing opioids, benzodiazepines, barbiturates, or carisoprodol.

State of Kansas Guidelines

The State of Kansas passed legislation that requires pharmacists to report Schedule II-V drugs and “drugs of concern” into the Kansas PMP within 24 hours of dispensation. Kansas defines a “drug of concern” as the following:

+ Any product containing all three of these drugs: butalbital, acetaminophen, and caffeine;

+ Any compound, mixture, or preparation that contains any detectable quantity of ephedrine, its salts or optical isomers, or salts of optical isomers, and that is exempt from being reported to National Precursor Log Exchange (NPLEx);

+ Any compound mixture or preparation that contains any detectable quantity of pseudoephedrine, its salts or optical isomers, or salt of optical isomers, and is exempt from being reported to NPLEx;

+ Promethazine with codeine; or

+ Any product, compound, mixture, or preparation that contains gabapentin.

If a pharmacy does not dispense any of the reportable drugs, they can file “zero-claim” reports. These reports should be made every seven days.

Centers for Disease Control (CDC) Guidelines

The CDC recommends that a pharmacist check a patient’s PMP report and enter all appropriate medications when dispensed. They should contact prescribers with questions or concerns about a patient, as well as talk to the patient.7 Pharmacist can serve as the first line of defense by engaging patients and providers with concerns about opioid use disorder and overdose.7

Indian Health Service (IHS) Guidelines

IHS states that pharmacists should check a patient’s PMP report prior to dispensing an outside prescription for a controlled substance, and every three months prior to reissuing or refilling chronic controlled substance prescription medication.4 Pharmacists should also discuss concerns about potential misuse or diversion with the prescriptions. Pharmacists may also assist with conducting PMP queries upon prescriber request and assist with report interpretation.4

REGISTERING FOR THE PMP AND ACCESSING PMP DATA

Each state has a different process for registering for the PMP, but it is free for all providers and pharmacists. To register for your state’s PMP and begin accessing patient-level data, please visit the resources listed below.

STATE RESOURCES | WEBSITE

OK Oklahoma PMP Website: http://pmp.obn.ok.gov/

Texas PMP Website: https://txpmp.org/faq

Texas PMP Toolkit: Prescriber’s Guide to using the Texas Prescription Monitoring Program: https://cdn.ymaws.com/www.texasnp.org/re+ source/resmgr/2019_fall_conference/2019_fall_handouts/pmp_toolkit.pdf

https://pharmacy.ks.gov/k-tracs

https://www.ihs.gov/sites/opioids/themes/responsive2017/dis+ play_objects/documents/PDMPcheckdocedcodes.pdf

Once registered for the system, physicians and pharmacists can access PMP reports for each patient to help inform prescribing and dispensing decisions. If there is a DEA number associated with the account, prescribers also have the ability to run a self-report to see the prescriptions that have been dispensed for which they were listed as a prescriber.6 In Oklahoma and Kansas, aggregate-level de-identified PMP data is available by request. If you would like to request data from the OK PMP, you can email: pmpadmin@obn.state.ok.us. In Kansas, you can visit the web page: https://pharmacy.ks.gov/k-tracs/using-k-tracs/forms to request data. In Texas, data is available to regulatory boards and healthcare providers inquiring about their own dispensing or prescribing.

THE PRESCRIPTION MONITORING PROGRAM AND TRIBAL PREVENTION PROGRAMS

Benefits of PMP for Tribal Prevention Programs

The population-level reports that are available from the PMP can be used as a public health tool to advise tribal public health programs, funding, and guide the longevity of prevention programs.1 Given the lack of accurate data in tribal communities, IHS has developed a partnership with the Oklahoma PMP to identify medication misuse, abuse, and diversion while also developing solutions at every level.2 As mentioned in the previous section, IHS requests that prescribers and dispensers participate in each state’s PMP program. IHS also acknowledges that it is important for tribes and tribal organizations to have a relationship with their state’s PMP.6 However, this does not mean all tribes are participating in the state PMP. Participation has varied across the United States. Check with your tribal pharmacy and health clinic to get a better understanding of your tribe’s participation in the PMP.

Utilizing the PMP can bring data autonomy to your tribal community. It is important to keep in mind that this is your community’s data, and you have the right to access it. Population-level PMP reports can provide information about how readily available opioids are in an area, and the rate at which certain indicators are present across the county. For example, an aggregate PMP data report can indicate the percentage of opioid prescriptions in the county that are high-dose, or the total number of opioid pills dispensed per 100 residents of the county. This data can help opioid overdose prevention programs focus their education and prevention efforts. Aggregate-level PMP data reports can also be used to strengthen grant applications and provide additional funding for public health and healthcare programs.

Engaging with the PMP

Engaging with your state’s PMP can take many forms and can be a foreign road to navigate for many. In the early stages of SPTHB’s partnering with Oklahoma’s PMP, there were questions that had to be answered concerning the state and how this database can benefit Tribal healthcare systems, as well as prevention and public health programs. It is important to know that the PMP data is yours to access and reflects the Tribal community that you serve.

ENGAGING WITH THE PMP

SPTHB outlines some of the internal and external factors that aid in initiating accurate American Indian/Alaskan Native data through partnership and education. To address these factors, this model recommends a multifaceted approach to engage with state PMPs.

TRAIN WITH PMP REPRESENTATIVES

THINGS TO CONSIDER BEFORE ENGAGING WITH THE PMP

Joining professional workgroups and meetings that have similar outcomes

Attending opioid- centered or PMP-centered meetings can aid in your decision to incorporate this system into your tribal communities and obtain the best outcomes. SPTHB staff joined a State and Tribal Epidemiology Outcome Workgroup, where representatives from throughout the state share resources and new findings pertaining to specific data. Through this workgroup, staff were able to meet with Bureau of Narcotics staff to start a partnership.

Determine how this data can be used

For tribal prevention programs, having access to PMP reports can aid in applying for grant funds and help steer public health programs based on zip code and age. For example, a tribe has requested specific zip code data from their state’s PMP and identified that there are multiple painkiller prescriptions in 40% of the households in the zip code. This information helps the tribe identify what type of prescriptions are being used and can further their efforts in preventing misuse.

The policies in place that impact how providers and pharmacist use the PMP

Learning about certain policies that are relevant to your state and clinic will allow meaningful interactions between the provider and patient, thus impacting your prevention programs by working as a multidisciplinary unit. This can aid in take-back events, accessing population-level data, and obtaining Native-specific data.

ACCESSING POPULATION-LEVEL PMP DATA

Race demographics and the PMP

Unfortunately, Oklahoma, Kansas, and Texas PMPs do not have a race question on the PMP query system; therefore, the data cannot be directly organized by all American Indian/Alaskan Native. However, SPTHB is committed to advocating the inclusion of race demographics on the PMP, so that the data may better serve tribal organizations. OBN has also begun advocating to the American Society of Automated Pharmacy, the organization that determines the questions the PMP system asks, to include a race/ethnicity question on the Oklahoma PMP. However, the next section discusses ways that Native demographics can be estimated within aggregate-level PMP data reports.

Other ways to get Native-specific data

Tribal facilities can request aggregate-level de-identified PMP reports from the Oklahoma Bureau of Narcotics and Dangerous Drugs Control (OBNDD), the organization that oversees the Oklahoma PMP. Aggregate-level deidentified PMP Data from K-TRACS, the Kansas PMP System, can also be requested.

How to request population- level PMP data

If you wish to access PMP data from OBN, you can contact OBN’s PMP administrator at pmpadmin@obn.state.ok.us. SPTHB is also readily available to assist in requesting and/or analyzing PMP data. If you would like to request data from the K-TRACS system, you can visit the website: https://pharmacy.ks.gov/k-tracs/using-k-tracs/forms. If you would like more information or assistance, please visit spthb.org/resources/technicalassistance or email tahelp@spthb.org

Suggested Resource

NAME

DESCRIPTION

Southern Plains Tribal Health Board (SPTHB)’s Technical Assistance Request

SPTHB can help with grant writing, programmatic planning, and accessing PMP data. Please visit spthb.org for more information

SUGGESTED RESOURCES FOR MORE INFORMATION ON USING PMP BELOW

NAME LINK | HOW TO FIND

Appriss Health’s Data Submission Guide for Dispensers: Oklahoma Prescription Monitoring Program

Southern Plain Tribal Health Board’s Safer Opioid Prescribing Practices for Tribal Physicians Training

OBN’s Trainings on the PMP

https://pmp.obn.ok.gov/sites/default/files/re+ source-files/OK%20Data%20Submission%20Dispenser%20Guide% 204.2B.pdf

Amartinez@spthb.org

Indian Health Manual’s Chapter 32-State Prescription Drug Monitoring Programs

IHS guidelines around PMP monitoring documentation and patient education

Risk Scoring in the PDMP to Identify At-Risk Patients

Pharmacists: On the Front Lines (CDC Fact Sheet)

Prescription Drug Monitoring Programs (CDC Fact Sheet)

Respond’s Prescription Drug Monitoring Toolkit and online course for pharmacists

Talking to Patients about their Drug Use by the National Institute on Drug Abuse

How Do You Address Patient Resistance? by the National Institute on Drug Abuse

3 Steps for Talking to Patients about Substance Use Disorder

OBN will provide free trainings about a variety of topics. Email pmpadmin@obn.state.ok.us

https://www.ihs.gov/ihm/pc/part-3/p3c32/

https://www.ihs.gov/sites/opioids/themes/responsive2017/dis+ play_objects/documents/PDMPcheckdocedcodes.pdf

https://apprisshealth.com/blog/risk-scoring-in-the-pd+ mp-to-identify-at-risk-patients/

https://www.cdc.gov/drugoverdose/pdf/pharmacists_bro+ chure-a.pdf

https://www.cdc.gov/drugoverdose/pdf/PDMP_Factsheet-a.pdf

https://pharmacistrespond.org/

https://archives.drugabuse.gov/initiatives/about-addic+ tion-performance-project/talking-to-patients-about-their-drug-use

https://archives.drugabuse.gov/initiatives/about-addic+ tion-performance-project/how-do-you-address-patient-resistance

https://www.ama-assn.org/delivering-care/opi+ oids/3-steps-talking-patients-about-substance-use-disorder

REFERENCES

1. Center for Disease Control and Prevention [CDC] (2017, October 3). What States Need to Know about PDMPs. Retrieved from https://www. cdc.gov/drugoverdose/pdmp/states.html.

2. Oklahoma PMP (2020). About PMP System. Retrieved from http:// pmp.obn.ok.gov/about

3. Kansas Pharmacy (2017, July 7). Kansas State Board of Pharmacy PDMP Statewide Integration Frequently Asked Questions (FAQs). Retrieved from https://pharmacy.ks.gov/k-tracs-responsive/k-tracs-statewide-integration

4. Texas Pharmacy (2014 ). Quick Reference Guide – Making a Request in PMP AWARxE. Retrieved from https://www.pharmacy.texas.gov/PMP/ PMPIntegration.asp

5. Indian Health Service Chapter 32 - State Prescription Drug Monitoring Programs. Retrieved from https://www.ihs.gov/ihm/pc/part-3/p3c32/

6. Indian Health Service [IHS] (2017). Opioid Crisis Data Understanding the Epidemic. Retrieved from https://www.ihs.gov/opioids/data/

7. Texas Prescription Monitoring Program (2020) FAQ - Texas rescription Monitoring Program. Retrieved from https://txpmp.org/faq

8. Center for Disease Control and Prevention [CDC] (2019, July 29). Information for Providers. Retrieved from https://www.cdc.gov/ drugoverdose/providers/index.html

9. Indian Health Services [IHS] (2018). Chapter32 – State Prescription Drug Monitoring Program. Retrieved from https://www.ihs.gov/ihm/pc/ part-3/p3c32/

10. Centers for Disease Control and Prevention 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Surveillance Special Report 2pdf icon. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2018.

PRESCRIPTION MONITORING PROGRAM TOOLKIT