04/25/2022 2 Prescription DSrUuBgT I TML Eonitoring Program, 2022 Epidemiology, Drug Surveillance Unit THE PRESCRIPTION DRUG MONITORING PROGRAM (PDMP) The purpose of this report is to describe opioid prescribing patterns in Georgia during 2022. Prescription data from the Georgia Prescription Drug Monitoring Program (PDMP) were analyzed by the Georgia Department of Public Health (DPH) Epidemiology Program Drug Surveillance Unit. Certain prescribing practices are considered high-risk, and may predispose patients to opioid use disorder and overdose, hence contributing to the growing opioid epidemic (for more information about the opioid epidemic in Georgia, see the Georgia opioid overdose surveillance reports available at https://dph.georgia.gov/drug-surveillanceunit). These prescribing practices are presented as PDMP indicators in this report; detailed analyses of the PDMP data were conducted to measure the total number of opioid prescriptions, number of patients receiving opioids, drug type, days dispensed, and other indicators of prescribing such as opioid and benzodiazepine prescriptions. In 2016, the Centers for Disease Control and Prevention (CDC) released opioid prescribing guidelines for healthcare providers for pain management (https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm). Appropriate prescribing and adhering to these CDC guidelines to prevent problematic prescribing may help improve patient care and safety and decrease the risk of opioid use disorder and overdose. Data in this report will be used to educate partners and inform prevention efforts across the state. The PDMP can help prescribers and dispensers of controlled substances identify patients who are at risk of a substance use disorder, who "doctor shop", or who are prescribed dangerous amounts and/or combinations of controlled substances. PDMP data is only accessible to prescribers or dispensers, who can use it to help identify inappropriate prescribing practices. The PDMP does not interfere with appropriate, professional prescribing and dispensing; it is intended only to help eliminate duplicative prescribing, overprescribing, and diversion of controlled substances. PDMP data are also used to support and inform Georgia's overarching statewide opioid and substance use response strategic plan, which spans a myriad of agencies and activities. PDMP Requirements Since July 1, 2017, dispensers have been required by Georgia law (https://dph.georgia.gov/sites/dph.georgia.gov/files/HB249_law.pdf) to enter prescription information for any Schedule II-V controlled substance within 24 hours of dispensing. Prescribers were required to register into the PDMP system by January 1, 2018. Beginning July 1, 2018, prescribers are required to check the PDMP before prescribing schedule II opioids and cocaine derivatives, or benzodiazepines, with some exceptions (https://dph.georgia.gov/pdmp). The PDMP is a tool for prescribers to review a patient's prescription history to assist with appropriate and safe prescribing of controlled substances. Only prescribers and dispensers who practice in Georgia are required to use the PDMP. Prescribers and dispensers are allowed to register two delegates (staff without a DEA number) per shift or rotation to check the PDMP and retrieve patient prescription histories. 1 PDMP Data Sharing Georgia law (2017 Georgia House Bill 249) allows DPH to share PDMP prescription information with electronic health record systems, and other States, including law enforcement from other states through subpoenas. Law enforcement agencies may need these data when they are conducting investigations into inappropriate prescribing or dispensing of controlled substances. Georgia Opioid and Substance Misuse Response For more information: County level data and other Georgia drug surveillance reports: https://dph.georgia.gov/drug-surveillance-unit Georgia Department of Public Health (DPH) Main Opioid Page: https://dph.georgia.gov/stopopioidaddiction Georgia drug overdose mortality interactive maps and statistics: https://oasis.state.ga.us/PageDirect.aspx?referer=MortalityDrugOverdoses Prescription Drug Monitoring Program (PDMP) information, GA PDMP Overview, and FAQs: https://dph.georgia.gov/pdmp Note: The data in this report should not be compared to reports prior to 2021 due to changes in data processing. 2 Georgia PDMP, 2022: Key Findings Georgia saw improvements in opioid prescribing practices from 2021 to 2022, as evidenced by these PDMP indicators: In 2022, there were 6,525,725 opioid prescriptions dispensed to 1,867,887 patients in Georgia. These prescriptions averaged 18.0 days of opioids dispensed per prescription. From 2021 to 2022, the number of opioid prescriptions statewide decreased by 3%, benzodiazepine prescriptions by 3%, and stimulants increased by 1%. The number of patients receiving opioid prescriptions did not change from 2021 to 2022. The average number of days dispensed per opioid prescription decreased by 1%. In the first quarter of 2021 (Q1), there were 1,669,678 opioid prescriptions dispensed compared to 1,626,586 prescriptions in the last quarter of 2022 (Q4). From 2021 to 2022, the rate of opioid prescriptions dispensed in Georgia decreased by 4% among persons aged 5-54 years, 3% among those aged 55-64 years, increased by 2% among those aged 65-74 years, increased by 7% among those aged 75-84 years, and increased by 3% among those aged 85+. Opioid prescriptions decreased by 5% among males and 3% among females. High opioid dosages are associated with an increased risk of opioid use disorder and overdose; the 2022 CDC opioid prescribing guidelines recommended that daily opioid dosages should not exceed 90 morphine milligram equivalents (MME) per day. The percent of patients in Georgia who were receiving an average daily dose of 90 (MME) of opioids decreased by 4% from Quarter 1 (Q1) 2021 to Q4 2022. Hydrocodone, Oxycodone, and Tramadol were the most-prescribed opioids in Georgia during both 2021 and 2022. The number of registered PDMP users increased by 7% from December 2021 to December 2022. Patient queries by prescribers (or their delegates) and dispensers increased from 11.7 million queries in 2021 to 13.9 million queries in 2022. 3 PDMP Data Indicators Data Source All schedule II-V drug prescriptions dispensed and reported to the Georgia Prescription Drug Monitoring Program during 20182022. PDMP Indicator Description Opioid analgesic prescriptions Opioid analgesic-controlled substance prescriptions dispensed and reported to the PDMP. Drugs administered to patients by substance abuse treatment programs are usually excluded from PDMP files and therefore are not captured by this indicator. Additional exclusion criteria include: Drugs not typically used in outpatient settings or otherwise not critical for calculating dosages in morphine milligram equivalents (MME), such as cough and cold formulations including elixirs, and combination products containing antitussives, decongestants, antihistamines, and expectorants; All buprenorphine products. Rate is calculated per 1,000 population (Georgia residents). Rate is age-adjusted except when age categories are presented. County level prescription rates are age adjusted. Opioid prescription patients The number of individual patients receiving an opioid analgesic controlled substance prescription that was dispensed and reported to the PDMP. Rate is calculated per 1,000 population (Georgia residents). Rate is age-adjusted except when age categories are presented. Days per opioid prescriptions The average number of days of opioid analgesics supplied per prescription. Patients receiving avg. daily dose 90 morphine milligram equivalents % of patients with an average of 90 MME of opioid analgesic drugs prescribed per day. Numerator: the number of patients with an average of 90 MME of opioid analgesic drugs prescribed per day Denominator: state residents who received an opioid analgesic prescription Average MME per day is calculated from total number of MMEs from all-drugs prescribed per day, inclusive of overlapping prescriptions of either the same and/ or differing drugs, divided by the total number of prescription days Other Definitions or Limitations Not all out of state pharmacies report to the Georgia PDMP, therefore some prescriptions obtained in another state, or by mail, could be missing from these data. Some 2021 prescription data were missing sex and age (<2% missing), therefore the race and age data represents only prescriptions for which sex and age where completed. Rate indicates the number of events that occurred among Georgia residents per 1,000 population using 2020 census data as the denominator, and all rates are age-adjusted unless age category is presented. We report on three categories of controlled substances in this report, these categories include: Opioids: Buprenorphine, Butorphanol, Codeine, Dezocine, Dihydrocodeine, Fentanyl, Fentanyl, Hydrocodone, Hydromorphone, Meperidine, Methadone, Morphine, Nalbuphine, Opiate Agonists, Oxycodone, Oxymorphone, Pentazocine, Tapentadol, Tramadol, and other opioids Benzodiazepines: Alprazolam, Chlordiazepoxide, Clonazepam, Clorazepate, Diazepam, Estazolam, Flurazepam, Lorazepam, Oxazepam, Temazepam, Triazolam, and other benzodiazepines Stimulants: Amphetamine, Benzphetamine, Desoxyephedrine, Dexmethylphenidate, Dextroamphetamine, Lisdexamfetamine, Methylphenidate, and other stimulants. 4 Prescription Drug Monitoring Program Data Indicators Prescriptions by Drug Type and Year, Georgia, 2018-2022 N No. Prescriptions (millions) 1P8327610.0 2018 2019 2020 2021 2022 9.0 7.9 8.0 7.0 7.4 6.9 6.7 6.5 6.0 5.0 4.0 3.0 2.0 3.6 3.4 3.3 3.2 3.1 2.7 2.2 1.8 1.7 1.7 1.0 0.0 Opioids Benzodiazepenes Stimulants From 2021 to 2022, the number of opioid prescriptions decreased by 3%, benzodiazepine prescriptions by 3%, and stimulants increased by 1%. Opioids are the most frequently prescribed controlled substance in Georgia, followed by benzodiazepines and stimulants. No Rx (millions) 2.2 2.1 2.1 2.0 1.9 1.8 Opioid Prescriptions by Quarter, Georgia, 2018-2022 2.0 1.9 1.8 1.8 1.8 1.8 1.8 March 11, 2020 COVID-19 pandemic declared 1.8 1.8 1.7 July 1, 2018 Prescribers required 1.6 to check PDMP prior to prescribing 1.5 1.7 1.6 1.6 1.6 1.6 1.6 2018 Q1 2018 Q3 2019 Q1 2019 Q3 2020 Q1 2020 Q3 2021 Q1 2021 Q3 2022 Q1 2022 Q3 Year and Quarter In the first quarter of 2021, there were 1,643,937 opioid prescriptions dispensed compared to 1,586,318 prescriptions in the last quarter of 2022. 5 Rx/ 1,000 population 2000 1800 1600 1400 1200 1000 800 600 400 200 0 <1 2018 5 2019 7 2020 7 2021 6 2022 5 Opioid Prescription Rates, by Age and Sex, Georgia, 2018-2022 2018 2019 2020 2021 2022 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ female male 12 30 162 406 646 875 1308 1411 1415 1344 727 538 14 33 161 392 664 913 1406 1594 1584 1562 782 578 11 27 142 346 610 838 1335 1573 1573 1554 738 545 11 26 140 319 590 801 1283 1587 1610 1521 725 528 10 26 132 295 566 775 1244 1616 1720 1565 702 503 Age Group (years) From 2020 to 2021, the rate of opioid prescriptions dispensed in Georgia decreased by 4% among persons aged 5-54 years, 3% among those aged 55-64 years, increased by 2% among those aged 65-74 years, increased by 7% among those aged 75-84 years, and increased by 3% among those aged 85+. Opioid prescriptions decreased by 5% among males and 3% among females. Average No. Days Supplied per Rx No. Rx or Patients (millions) Opioid Prescriptions, Patients, and Average Days Supplied per Rx, Georgia, 2018-2022 8.0 18.2 7.0 7.5 6.0 5.0 4.0 3.0 2.0 1.0 2.0 0.0 2018 17.9 7.2 2.1 2019 18.3 6.9 1.9 2020 18.0 6.6 1.9 2021 17.9 20.0 18.0 16.0 6.5 14.0 12.0 10.0 8.0 6.0 4.0 1.9 2.0 0.0 2022 No. Rx No. Patients/1000 Days/Rx The number of opioid prescriptions decreased by 1% and no changes seen in patients receiving opioid prescriptions, from 2021 to 2022. The average number of days dispensed per opioid prescription decreased by 2%. 6 % of Patients Percent Patients Receiving an Average Daily Dose 90 Morpine Miligram Equivalents of Opioids, by Quarter, Georgia, 2018-2022 9.0 8.0 7.0 7.3 7.1 7.2 7.7 7.7 7.4 7.1 6.8 6.4 6.9 6.7 6.2 6.4 6.3 6.3 6.0 6.0 5.8 6.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 2018 2018 2018 2019 2019 2019 2019 2020 2020 2020 2020 2021 2021 2021 2021 2022 2022 2022 2022 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Year and Quarter High opioid dosages are associated with an increased risk of opioid use disorder and overdose. The graph above represents the quarterly percent of patients in Georgia who were receiving an average daily dose of 90 (MME) of opioids during 2018-2022. The percent of patients in Georgia who were receiving an average daily dose of 90 (MME) of opioids decreased by 6% from Q1 2021 to Q4 2022. 7 8 9 Top Ten Opioids Prescribed, Georgia, 20212022 Rank Opioid drug No. prescriptions No. prescriptions 2021 2022 1 Hydrocodone 2,256,119 2,136,284 2 Oxycodone 1,740,226 1,734,241 3 Tramadol 1,445,006 1,376,600 4 Codeine 473,779 471,805 5 Buprenorphine 328,838 336,005 6 Morphine 246,195 237,222 7 Fentanyl 84,778 75,227 8 Hydromorphone 60,210 61,148 9 Methadone 57,270 52,493 Codeine, 10 Bultabital 21,401 19,862 Prescription Drug Monitoring Program Registrations and Patient Queries, Georgia, 20212022 PDMP user type No. registered as No. registered as No. patient of 12/31/2021 of 12/31/2022 queries 2021 No. patient queries 2022 Dentist 5,085 5,214 61,705 51,082 Dispensing Physician Medical Resident Midwife Nurse Practitioner Optometrist Out-of-State Pharmacist Out-of-State Prescriber Pharmacist Pharmacist's Delegate Physician (MD,DO) Physician Assistant Podiatrist Prescriber Delegate Veterans Affairs Prescriber TOTAL 42 3,695 164 7,840 1,049 177 275 13,536 429 30,916 3,835 554 1,839 202 69,638 34 4,312 171 8,583 1,057 183 301 14,489 507 32,341 4,189 567 2,004 203 92,132 2,612 59,915 7,295 1,459,237 5,042 1,498 7,242 4,087,125 54,074 4,889,312 632,821 12,521 480,392 13,739 11,774,530 10,188 86,380 2,938 1,491,945 92 1,442 11,500 4,338,460 72,030 4,667,013 617,114 10,367 238,972 13,571 11,602,906 10 Prescription Drug Monitoring Program Indicators, Georgia, 20212022 See Prescription Drug Monitoring Program Data Indicators table for description of indicators below 2021 2022 Indicator description Total Jan-Mar Apr-Jun Jul-Sep Oct-Dec Total Jan-Mar Apr-Jun Jul-Sep Oct-Dec No. opioid prescriptions 6,743,732 1,669,675 1,708,774 1,683,265 1,682,018 6,525,725 1,625,268 1,641,479 1,633,868 1,625,110 No. stimulant prescriptions 1,656,746 414,064 406,160 418,422 418,100 1,674,106 433,840 403,245 399,606 437,415 No. benzodiazepine prescriptions 3,192,057 804,775 801,127 800,520 785,635 3,092,130 778,461 780,494 775,351 757,824 Opioid Rx/ 1,000 population (age adjusted) No. opioid patients Opioid patients/ 1,000 population Days/ opioid prescription % Patients receiving avg. daily dose 90 morphine milligram equivalents 726.0 N/A 3,210,428 791,281 305.0 75.2 17.9 17.9 6.3 6.2 N/A 815,268 77.5 17.8 6.4 N/A 798,907 75.9 18.0 6.3 N/A 737 N/A 804,972 3,040,343 755,828 76.5 281.4 70.0 17.9 17.9 18.0 6.3 6.1 6.1 N/A 766,053 70.9 18.0 6.0 N/A 761,458 70.5 18.0 6.0 N/A 757,004 70.0 17.9 6.1 11 Prescription Drug Monitoring Program Indicators by Age and Sex, Georgia, 2022 See Prescription Drug Monitoring Program Data Indicators table for description of indicators below Indicator No. opioid No. No. benzo. Rx stimulant Rx Rx Opioid Rx/ 1,000 population No. opioid patients Opioid patients/ 1,000 population Avg days/ opioid Rx Age Group <1 year 680 3 113 5.4 572 4.5 12.0 1-4 years 5,227 755 7,580 10.0 4,275 8.0 9.0 5 -14 years 34,774 433,566 32,164 24.6 26,582 18.8 10.0 15-24 years 185,918 317,310 72,222 128.6 142,857 98.8 6.0 25-34 years 422,545 283,359 218,671 286.8 214,639 145.6 10.4 35-44 years 757,299 280,743 427,090 551.7 261,568 190.5 15.0 45-54 years 1,066,912 201,179 543,603 755.9 295,441 209.3 18.0 55-64 years 1,567,657 110,808 676,915 1,219.3 352,336 274.0 20.0 65-74 years 1,421,657 38,982 610,748 1,587.7 317,559 354.6 20.0 75-84 years 707,509 7,094 357,631 1,691.1 174,297 416.6 19.0 85+ years 226,778 911 145,498 1,546.6 58,834 401.2 18.0 Sex Male 2,600,988 830,783 1,034,311 493.5 755,131 143.2 18.0 Female 3,792,185 843,809 2,054,975 685.7 1,092,342 197.5 18.0 DPH Epidemiology, Drug Surveillance Unit https://dph.georgia.gov/drug-overdose-surveillance-unit 12