RxStat Presentation - The PDMP Training and Technical Assistance

NYC RxStat: A Public Health &
Safety Collaboration for
Responding to Problem Drug Use
at the Municipal/County Level
Harold Rogers Prescription Drug
Monitoring Program National Meeting
Washington, DC
September 23, 2014
Outline
• NYC RxStat Overview
• RxStat: Technical Assistance Manual
• Prescription Drug Monitoring Program
Data Analysis Review
Denise Paone, EdD, Director of Research & Surveillance
Bureau of Alcohol & Drug Use Prevention, Care & Treatment
New York City Department of Health and Mental Hygiene
RXSTAT OVERVIEW
Opioid Analgesics Are a Public Health
Crisis in New York City
*Paone D, Bradley O’Brien D, Shah S, Heller D. Opioid analgesics in New York City: misuse, morbidity and
mortality update. Epi Data Brief. April 2011. Available at http://www.nyc.gov/html/doh/downloads/pdf/epi/epidata-brief.pdf .
Why RxStat?
Four principles guide the work
• Establish timely, accurate analysis of drugrelated indicators from multiple public health
and public safety sources, side by side
• Support strategy development based on
analysis of existing and newly available data
• Direct rapid deployment of public health and
public safety resources to high priority areas
• Allow rigorous monitoring and follow-up to
ensure strategies are effective
RxStat data sources include indicators
representing opioid misuse and problem drug use
Price/Purity
Qualitative
Research
PMP
Data
Reduce
Overdose
Deaths
Drug
Prosecutions
Mortality
Medicaid
Fraud Data
Hospitalizations
Syndromic
Pharmacy
Crime
Poison
Control
DEA
ARCOS
Treatment
Admissions
Jail
Data
Daliah Heller, PhD MPH Special Advisor on Drug Policy
New York City Mayor’s Office
RXSTAT TECHNICAL
ASSISTANCE MANUAL
Developing the technical assistance
manual  Opportunity to identify the
lessons learned from RxStat
• RxStat began as the Data Committee to Mayor
Bloomberg’s Task Force on Prescription Painkillers
• Nov/Dec 2013, conducted qualitative interviews with
23 participants, representing city, state, and federal
agencies
• Interview domains of interest
– Individual/agency roles, history of involvement
– Perspectives on cross-disciplinary collaboration,
benefits/disadvantages, communication issues
– Describe new knowledge acquired, helpful data
– What’s most meaningful, what’s been
challenging, has it changed your work and how?
– How to use RxStat, how to strengthen?
The manual reviews the key elements of
RxStat (1), and details each of the RxStat
datasets, including analytic code (2)
• RxStat key elements - 5 sections
– Basics
– Getting started
– Building content
– Managing process
– Next steps – where we’re headed now
• Checklist
The basics: what is RxStat?
• Public Health + Public Safety collaboration
– Housed at NYC Health Dept (DOHMH) to
leverage expertise and infrastructure
• “Real-time” (enhanced) surveillance
• Public health framework
– Data to measure patterns/trends in population
– Drug use is a health issue requiring a shared
health-safety response
• Municipal/county focus
– Participants and stakeholders from city, state, and
federal agencies
10
RxStat indicators describe opioid
misuse and problem drug use in a
hierarchical model of severity
Mortality
Hospitalizations /
Treatment admissions
/ Pharmacy crime
Syndromic data / Poison control /
Drug prosecutions / Jail data
PMP data / DEA ARCOS / Medicaid fraud
surveillance data
Getting RxStat started:
where to begin?
• LEADERSHIP
– Informal champion
• Building interest
• Rallying support
– Formal call to action
• Mayoral/county exec convening across disciplines
– Coordinating the work
• Logistics
• Communications
Getting RxStat started:
where to begin?
• REPRESENTATION
– Public health actors
• Health department
• Others, eg, Hospital systems; SAPT authority (state);
PDMP (state); EMS; Jail health services
– Public safety actors
• Police department
• Others, eg, Prosecutor; HIDTA (federal); DEA (federal);
Probation; Parole; Medicaid fraud
– Reconciling different perspectives
• Data-driven approach
In their own words:
observations from participants
• “Data is the glue that brings everything
together.”
(public safety representative)
• “It’s challenging because it highlights
some different approaches to data that
could really inform different
responses.”
(public health representative)
Building RxStat content:
how to develop the work?
• DATA
– Silos
– Data-sharing and sensitivity
• Data use agreements!
• Specify (i) De-identified data, (ii) Itemized variables, (iii)
Penalty to be levied for violation
– Methods
• Epidemiologic / Rates and proportional representation
– Learning
• Terminology
Building RxStat content:
how to develop the work?
• RESOURCES
– Investment in data analysts
• Hiring and financial support
• Pooling or centralizing efforts
• Qualitative Research
– Funding sources
• Grant funding
• Policy investment with projected savings
Managing the RxStat process:
how to shepherd the work?
• STRUCTURE
– Working group
• PARTICIPATION
– Collaboration between meetings
• ACTION
– Active, visible partnerships and practice-sharing
– Coordinated investigations
• Highly publicized suspected drug fatality
• Temporal geographic cluster of adverse health events
• Law enforcement drug seizure
In their own words:
observations from participants
• “The more time we spend in RxStat, the
more we realize the importance of
educating people about drug addiction.”
(public safety representative)
• “What’s been helpful are not just the
findings, but the process of using the data
and the relationships that are built around
that, and the credibility that’s been built –
there is then the opportunity for mutual
respect, and that’s really important when
you’re trying to make big changes.”
(public health representative)
Moving RxStat forward:
what are the next steps?
• MOVEMENT TO STRATEGY
– Health and law enforcement initiatives begun
– Expand to city-wide coordinated strategy
• EXPAND TO ALL DRUGS
• EXPAND PARTICIPATION
– Shared data analysis versus public
presentation
– Non-governmental actors role?
– Legislative actors role?
Denise Paone, EdD, Director of Research & Surveillance
Bureau of Alcohol & Drug Use Prevention, Care & Treatment
New York City Department of Health and Mental Hygiene
PRESCRIPTION DRUG
MONITORING PROGRAM:
METRICS
Opioid analgesics in the dataset
Opioid Analgesic Type
Drug
Schedule
BUPRENORPHINE
CODEINE-CII
3
2
CODEINE-CIII
3
CODEINE-CV
5
FENTANYL
2
HYDROCODONE
3
HYDROMORPHONE
Brand Names
Refillable
Buprenex®, Suboxone®, Subutex®
Codeine
Acetaminophen (APAP) w/Codeine #3, APAP w/Codeine #4, Tylenol w/Codeine
#3®, Tylenol w/Codeine #4®
Dihistine DH®, Guaituss AC®, Nucofed®, Promethazine VC®, Robitussin AC®,
Tylenol w/Codeine Elixir®
Actiq®, Duragesic®, Fentanyl®, Fentora®
A-Tuss®, Alor®, Anexia®, Azdone®, B-Tuss®, Bancap HP®, Ceta Plus®,
Cleartuss-DH®, Codal DH®, Codamine®, CoGesic®, Comptussin HC®,
Damason P®, Diagesic®, Dolacet®, Duocet®, Endagen HD®, Extendryl HC®,
Histinex®, Hycodan®, Hycomine®, Hydrogesic®, Hydromet®, Hydromide®,
Hydron®, HyPhen®, Lolorex Forte®, Lorcet®, Lortab®, Margesic®, Medcodin®,
Nalex®, Norco®, Panacet®, Panasal®, Pneumotussin®, Polygesic®, Pro-Cof®,
Protuss®, PV Tussin®, Quintex®, S-T Forte 2 S/F®, Stagesic®, T-Gesic®,
Tussionex®, Vanacet®, Vanacon®, Vapocet®, Vicodin®, Vicoprofen®, Xodol®,
Zydone®
Yes
No
2
Dilaudid®
No
MEPERIDINE
METHADONE
2
2
No
No
MORPHINE
2
Demerol®
Dolophine®, Methadose®
Astramorhp®, Avinza®, Depo-Dura®, Duramorph®, Kadian®, MS Contin®,
MSIR®, Oramorph®, RMS®, Roxanol®
OXYCODONE
2
Endocet®, Endocodone®, Endodan®, OxyContin®, Oxydose®, OxyIR®,
Percocet®, Percodan®, Percolone®, Roxicodone®, Roxilox®, Roxiprin®, Tylox®
No
OXYMORPHONE
2
Opana®,
No
PENTAZOCINE
4
Talwin®
Yes
Yes
Yes
No
Yes
No
Analysis plan for
RxStat
Drug types include: Codeine, Fentanyl, Hydrocodone,
Hydromorphone, Meperidine, Methadone, Oxycodone,
Oxymorphone, and Pentazocine.
RxStat indicators:
 Number of prescriptions filled overall and by type
 Number of patients filling prescriptions by
demographics (age, gender, residence)
 Number of prescribers
 Number of pharmacies
 Median day supply of prescriptions
 Morphine equivalent dose (MED) of prescriptions
 Number and rate of high dose (morphine
equivalent dose ≥ 100) prescriptions filled
Opioid analgesic (OA) prescriptions
NYC, 2008–2012
2,500,000
Opioid Analgesics
Number of Prescriptions
2,000,000
Note: Schedule II opioid analgesics
1,500,000
Oxycodone
1,000,000
Hydrocodone
500,000
0
2008
2009
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2008–2012
2010
Year
2011
2012
Unique Patients,
NYC 2008-2012
• In 2008-2012 there were unique patients receiving
prescriptions
• 57% of the patients were female
• 45% of prescriptions were paid with commercial
insurance
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2008-2012
Unique Prescribers,
NYC 2008-2012
• In 2008-2012 there were 117,797 unique
prescribers to patients that reside in NYC
• There were 9,919,712 prescriptions
• The median number of prescriptions per
prescriber was 3 (minimum:1; maximum:52,471)
• The median number of patients per prescriber
was 2 (minimum: 1; maximum: 12,092)
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2008-2012
Unique Pharmacies,
NYC 2008-2012
• In 2008-2012 there were 5,051 unique pharmacies
• There were 9,919,712 prescriptions
• The median number of prescriptions per
pharmacy was 311 (minimum:20; maximum: 109,693)
• 56% of pharmacies were outside NYC
• Brooklyn has the highest proportion within the 5 boroughs at 29%
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2008-2012
15% of prescribers wrote 83% of
opioid analgesic prescriptions
Prescriptions filled by NYC residents, 2012
100%
90%
15%
1%
Very Frequent
Prescribers
530-10,185 Rx/year
14%
Percent
80%
70%
34%
Frequent
Prescribers
50-529 Rx/year
37%
60%
50%
Occasional
Prescribers
4-49 Rx/year
40%
30%
20%
Note: Schedule
II opioid
analgesics
83%
49%
Rare Prescribers
1-3 Rx/year
48%
10%
15%
0%
2%
Prescribers
Prescriptions
Prescribing frequency
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2012
27
Staten Islanders filled OA prescriptions
at higher rates in 2012
Age-adjusted rate of prescriptions filled per
1,000 residents
500
450
Opioid Analgesics
400
Oxycodone
Hydrocodone
Note: Schedule II opioid analgesics
350
300
250
200
150
100
50
0
NYC
Bronx
Rates are adjusted to 2000 US Standard population
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2012
Brooklyn
Manhattan
Borough of Residence
Queens
Staten Island
OA prescriptions filled by Staten Islanders
had longer median day supply in 2012
30
Note: Schedule II opioid analgesics
Median day supply is calculated from day supply of each prescription filled in the year.
Median Supply, Days
25
20
15
10
5
0
NYC
Bronx
Brooklyn
Manhattan
Borough of Residence
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2012
Queens
Staten Island
OA prescriptions filled by Staten Islanders
were more frequently high dose (>100 MED)
in 2012
Age-adjusted rate of prescriptions filled per 1,000
residents
140
Note: Schedule II opioid analgesics
120
100
High dose is any opioid analgesic prescription with a
calculated morphine equivalent dose (MED) greater than 100.
Among patients receiving opioid prescriptions, overdose rates
increase with increasing doses of prescribed opioids.
80
60
40
20
0
NYC
Bronx
Brooklyn
Manhattan
Rates are adjusted to 2000 US Standard population
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2008–2012
Borough of Residence
Queens
Staten Island
Questions
• Please contact Denise Paone & Ellenie
Tuazon at:
– dpaone@health.nyc.gov
– etuazon@health.nyc.gov