24 th Annual Family Practice Review and Reunion BOARD OF PHARMACY UPDATE

1. 24th Annual Family Practice Review and ReunionBOARD OF PHARMACY UPDATE February 8, 2019 State of Ohio Board of Pharmacy Compliance Specialist Ryan Bolus, PharmD

2. Objectives • Learn the role of the State of Ohio Board of Pharmacy • Review OARRS • Understand your Prescriber Report • Clarify the Narx Score • Clarify the Overdose Risk Score

3. What is the Board of Pharmacy? • 9 member panel appointed by the Governor (8 RPh, 1 Public Member) • Administrative Staff (Legal, Licensing, Policy, OARRS) • Compliance and Enforcement • Primarily field based • Specialists, Agents, Inspectors

4. What is the Board of Pharmacy? • Duties of Specialists/Agents: To conduct inspections of facilities that distribute, manufacture, store and sell controlled substances and dangerous drugs. • Additionally, Specialists/Agents are responsible for enforcing and investigating drug law violations of the Ohio Revised and Administrative Codes, as well as the US Code of Federal Regulations.

5. What is the Board of Pharmacy? • ORC 3719.18 – “The state board of pharmacy, its officers, agents, inspectors, and representatives… shall enforce Chapters 2925. and 3719. of the Revised Code…” • ORC 2925: DRUG OFFENSES • ORC 3719: CONTROLLED SUBSTANCES

6. What is the Board of Pharmacy? • ORC 4729.25 – “The state board of pharmacy shall enforce, or cause to be enforced, this chapter. If it has information that any provision of this chapter has been violated, it shall investigate the matter, and take such action as it considers appropriate.” • ORC 4729: PHARMACISTS; DANGEROUS DRUGS

7. What to expect during an inspection! • Unannounced • Usually an Inspector • Review of drug security • Only licensed healthcare professionals may have UNSUPERVISED access to dangerous drug stock (NOT JUST CONTROLLED DRUGS)! • Review of accountability • Positive ID

8. OARRS – Ohio’s PMP (www.pharmacy.ohio.gov) Prescribers and Pharmacists must be registered to access the database.

9. Purpose of a Prescription Monitoring Program (PMP) • Tool for prescribers and pharmacists to identify and prevent prescription drug abuse, misuse, and/or addiction. • Tool to assist law enforcement with investigations of prescription drug abuse.

10. Clinical Decision Toolbox OARRS is one tool. OARRS Conversations with the patient Conversation with their other prescribers Entire prescription profile Lab work ________+ Physical exam_________ CLINICAL DECISION

11. Ohio’s PMP (Ohio Revised Code ORC 4729.75) • Database of all outpatient prescriptions for controlled substances and drugs of interest as identified in the Ohio Administrative Code. As of December 1, 2016, OARRS is collecting gabapentin. It is NOT a complete medication profile. • Dispensing data submitted daily. • Prescribers must report what they personally furnish to their own patients, including samples. • If product goes home with a patient, it must be reported to OARRS, even if only one tablet. • Exception: medications personally furnished for drug treatment (federal privacy protection laws) • Wholesale sales to pharmacies, prescribers

12. OARRS • Available 24/7 • 400,000 + requests per weekday • Turnaround time (from click on “submit” request until report is ready) • 99.9% ~3-4 seconds • Lag time of data into OARRS– 1 to 2 days. (when Rx is dispensed until Rx appears in OARRS) • JUNK IN = JUNK OUT

13. Acceptable Use • DO NOT SHARE user name or password with anyone! • Each prescriber/delegate must have own account (Delegate requests prescriber, prescriber approves delegate. Linked by email which is on the OARRS account.) • No “office accounts” • DO NOT run a report to give to someone else who has the legal authority to run that report themselves. • Part of medical record? After March 20, 2015 OK to keep in chart. • Patients: You may show it to them. You may discuss it with them. Just can’t give it to them.

14. Legal reason for prescriber or RPh to request OARRS Report • Medical treatment/prescription • Current patient • Prospective patient –appointment, referral, or Rx presented • Not • Research • Pre-employment screening • Searching for forged prescriptions • Updating chart records • “Investigating” drug loss • Deceased person – not a current patient (unless you are the coroner)

15. OARRS Rules for Prescribers

16. Prescriber MUST query OARRS • A prescriber shall obtain and review an OARRS report beforeprescribing or personally furnishing an opiate analgesic or benzodiazepine to a patient, unless an exception is applicable. (2) A prescriber shall obtain and review an OARRS report when a patient's course of treatment with a reported drug other than an opioid analgesic or benzodiazepine has lasted more than ninety days, unless an exception is applicable.

17. Follow-up OARRS • Frequency for follow-up OARRS reports • Opioid or benzo: treatment lasting >90 days, request OARRS every 90 days • All other controlled substances: treatment lasting >90 days, request OARRS at least annually

18. Some Exceptions Apply • Not required to request the report, but still welcome to • Inpatient hospice/terminally ill • Administration in hospital/nursing home/residential care • Prescribing < 7 day supply • Inpatient • Post surgical/invasive procedure/delivery • OARRS isn’t available

19. Less than 7 Day Supply • So few pills, it can’t hurt anyone. Why request a report? • Incomplete picture of patient • You don’t know what you don’t know • OARRS validates what patient tells you; fills in missing pieces

20. Known Dentist Hopper

21. Ignorance is Not Bliss • Rules are a minimum requirement. • May request and review OARRS with any current or prospective patient. • Results may impact your ultimate treatment decision. • Just one tool in your clinical toolkit!

22. OARRS Features and Reports

23. NarxCare • New as of November 20, 2017 • Available on OARRS Website as well as in integrated EHR/Pharmacy software systems • Narcotics, Stimulant and Sedative risk scores • Overdose risk score • Red flags • Provider-to-provider communication • MAT locator

24. What’s the point of NarxCare? • Helps providers make better-informed decisions when it comes to identifying, preventing, and managing substance use disorders • Another tool in the clinical toolkit!

25. NarxCare ? ? ? ? ? ? ? ? ? ? ? ? ?

26. Narx Scores • Exist for Narcotics, Sedatives and Stimulants • Range from 000-999 (the last digit equals the number of active prescriptions for that type)

27. Narx Scores Large number of prescribers Many pharmacies High milligram equivalent value +Overlapping prescriptions_____ HIGHER NARX SCORE!

28. Narx Scores • Time Element – recent activity more heavily weighted. • Narcotic and Sedative scores overlap • In a typical statewide population, Narx Score distribution on any given day: • 75% score less than 200 • 5% score above 500 • 1% score above 650

29. High Narx Scores – So now what? • Concerning Narx Score? Discussion, NOT decision! • Narx Scores are not abuse scores, however, at very high scores, patients are likely to exhibit some form of misuse

30. Narx Scores – Clinical Guidance

31. NarxCare ? ? ? ? ? ? ? ? ? ? ? ? ?

32. Overdose Risk Score (ORS) • Based on Ohio study evaluating 1,687 unintentional overdose DEATHS from 2014 • Ranges from 000-999 • Risk of unintentional overdose death approximately doubles for every 100 point increase • Patients with a history of previous OD automatically get a score of 991, where “1” represents the number of documented previous ODs

33. Overdose Risk Score – Clinical Guidance

34. NarxCare

35. Prescriber Practice Reports • SOBP regularly provides reports to prescribers that present a snapshot of each clinician’s prescribing of controlled substance medications • DATA RICH REPORT! • Guidance document available that walks you through each piece of info

36. Prescriber Practice Reports • In order to receive, you must choose a specialty in your OARRS profile • You can view a list of all prescriptions included with report through OARRS • “MyRx”

37. This Isn’t My Patient! • Data in OARRS comes from dispensing pharmacy. • Wrong prescriber • Same/similar name? • Many prescribers printed at top of Rx and pharmacy can’t tell who wrote particular Rx? • MyRx report shows dispensing pharmacy. • Contact pharmacy for them to make correction both in their records and report correction to OARRS, too • If you suspect fraudulent activity, contact SOBP!

38. Monitoring Compliance to Requesting OARRS Reports • Audits are regularly run for monitoring compliance to requesting an OARRS report according to the rules. • Prescriptions for 7 day supply or less are already filtered out

39. Monitoring Compliance to Requesting OARRS Reports • Prescriptions which meet other “exceptions” such as hospice/post-op: • KEEP YOUR OWN DOCUMENTATION TO SHOW WHY THAT RX DID NOT REQUIRE AN OARRS REPORT. NO NEED TO CONTACT OARRS OR THE MEDICAL BOARD FOR THOSE TO BE “REMOVED.”

40. Helpful Hints • You’ve run the OARRS report and something doesn’t look right. • Your patient appears to be on medications they claim they’ve never taken • Your patient denies ever seeing the prescribers or going to the pharmacies on the report. • How can so much be wrong?

41. Merged report = Too Much Information • More than one patient is pulled into the OARRS report. • Verify the names in the box titled “patients which appear to match your search criteria.” • Most frequently occurs with patients who are twins or names are very similar. • More than one unique patient (different names, not just different addresses)? Let OARRS know and it can easily be remedied. • Prescriber or pharmacy to call OARRR; not the patient

42. “No Results Found” • Enter patient name the way the PHARMACY entered the name • Bill vs. William • Hyphenated last names • New to area? Use prior zip code

43. Reversed Prescriptions • Prescription never picked up • Reversals must also be reported to OARRS • Questions about a prescription? Contact the dispensing pharmacy.