10/03/2022 2 Prescription DSrUuBgT I TML Eonitoring Program, 2020 Epidemiology, Drug Surveillance Unit THE PRESCRIPTION DRUG MONITORING PROGRAM (PDMP) The purpose of this report is to describe opioid prescribing patterns in Georgia during 2020. 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 chronic diseases (https://www.cdc.gov/drugoverdose/prescribing/guideline.html). 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 stakeholders 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. It can also 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 across myriad 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. Prescription Drug Monitoring Program Report, Georgia, 2020 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 Prescription Drug Monitoring Program Report, Georgia, 2020 Georgia PDMP, 2020: Key Findings Georgia saw improvements in opioid prescribing practices from 2019 to 2020, as evidenced by these PDMP indicators: In 2020, there were 6,925,603 opioid prescriptions dispensed to 1,870,321 patients in Georgia. These prescriptions averaged 18.3 days of opioids dispensed per prescription. From 2019 to 2020, the number of opioid prescriptions statewide decreased by 9%, benzodiazepine prescriptions by 12%, and stimulants by 18%. The number of patients receiving opioid prescriptions decreased by 10% from 2019 to 2020. The average number of days dispensed per opioid prescription increased by 2%. In the first quarter of 2019 (Q1), there were 1,946,048 opioid prescriptions dispensed compared to 1,786,245 prescriptions in the last quarter of 2020 (Q4). From 2019 to 2020 the rate of opioid prescriptions dispensed decreased by 12% among persons aged 5- 54 years, 5% among those aged 55-64 years, 1% among those aged 65-74 years, 1% among those aged 75-84 years, and 1% among those aged 85+. Opioid prescriptions decreased 6% among both males and females. High opioid dosages are associated with an increased risk of opioid use disorder and overdose; the 2016 CDC opioid prescribing guidelines recommended that daily opioid dosages should not exceed 90 morphine milligram equivalents (MME). The percent of patients in Georgia who were receiving an average daily dose of 90 (MME) of opioids decreased by 13.7% from Quarter 1 (Q1) 2019 to Q4 2020. Short-Acting Hydrocodone, Oxycodone, and Tramadol were the most-prescribed opioids in Georgia during both 2019 and 2020. The number of registered PDMP users increased by 12.5% from December 2019 to May 2020. Patient queries by prescribers (or their delegates) and dispensers increased from 9.0 million queries in 2019 to 10.5 million queries in 2020. Prescription Drug Monitoring Program Report, Georgia, 2020 PDMP Data Indicators Data Source All schedule II-V drug prescriptions dispensed and reported to the Georgia Prescription Drug Monitoring Program during 20162020 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: (1) 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; (2) 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 2020 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 events that occurred among Georgia residents per 1,000 population using 2018 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. Prescription Drug Monitoring Program Report, Georgia, 2020 Prescription Drug Monitoring Program Data Indicators Prescriptions by Drug Type, Georgia, 2016-2020 2016 2017 2018 2019 2020 No. Rx (millions) 10.0 9.0 8.6 8.0 8.0 7.0 6.6 6.9 6.3 6.0 5.0 4.0 3.0 2.0 1.0 0.0 Opioids 3.9 3.6 3.2 3.0 2.6 Benzodiazepines 2.4 2.3 2.0 2.2 1.8 Stimulants Opioids are the most frequently prescribed controlled substance in Georgia, followed by benzodiazepines. From 2019 to 2020, the number of opioid prescriptions decreased by 9%, benzodiazepine prescriptions by 12%, and stimulants by 18%. Opioid Prescriptions by Quarter, Georgia, 2016-2020 March 8, 2016 2.30 CDC releases 2.2 guidelines for opioid 2.20 2.10 2.1 2.1 2.1 prescribing 2.1 2.1 2.1 July 1, 2017 Dispensers required to report within 24 hours; DPH begins administering PDMP March 11, 2020 COVID-19 pandemic declared No Rx (millions) 2.00 1.90 May 4, 2017 GA PDMP bill signed into law 1.80 1.9 1.9 1.70 January 1, 2018 Prescribers 1.60 required to register 2.0 1.9 1.8 1.8 1.8 1.8 1.8 July 1, 2018 Prescribers required to check PDMP prior to prescribing 1.8 1.6 1.50 2016 Q1 2016 Q3 2017 Q1 2017 Q3 2018 Q1 2018 Q3 2019 Q1 2019 Q3 2020 Q1 2020 Q3 Year and Quarter In the first quarter of 2019, there were 1,896,713 opioid prescriptions dispensed compared to 1,945,362 prescriptions in the last quarter of 2020. Prescription Drug Monitoring Program Report, Georgia, 2020 Opioid Prescription Rates, by Age and Sex, Georgia, 2016-2020 Rx/ 1,000 population 1800.0 1600.0 1400.0 1200.0 1000.0 800.0 600.0 400.0 200.0 0.0 <1 2016 8.2 2017 6.8 2018 5.0 2019 7.1 2020 6.9 2016 2017 2018 2019 2020 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ female male 17.6 43.8 242.5 599.8 899.4 1225.3 1683.3 1699.4 1650.0 1608.8 953.4 704.9 14.0 37.3 206.9 517.0 812.1 1105.4 1565.6 1612.5 1554.9 1510.2 875.9 651.0 11.8 29.8 161.7 406.4 646.1 875.2 1307.6 1411.0 1414.8 1344.4 727.3 537.7 14.1 33.2 161.4 391.6 663.7 912.5 1405.9 1593.8 1583.8 1562.0 781.6 578.4 10.7 27.1 141.7 346.4 610.2 838.4 1334.5 1572.5 1572.5 1553.5 738.0 544.6 Age Group (years) From 2019 to 2020, the rate of opioid prescriptions dispensed in Georgia decreased by 12% among persons aged 5-54 years, 5% among those aged 55-64 years, 1% among those aged 65-74 years, 1% among those aged 75-84 years, and 1% among those aged 85+. Opioid prescriptions decreased 6% among both males and females. Average No. Days Supplied per Rx No. Rx or Patients (millions) Opioid Prescriptions, Patients, and Average Days Supplied per Rx, Georgia, 2016-2020 10.0 17.8 18.1 18.2 17.9 18.3 20.0 8.0 8.6 6.0 4.0 2.0 2.3 0.0 2016 8.0 2.2 2017 7.5 2.0 2018 7.2 2.1 2019 15.0 6.9 10.0 5.0 1.9 0.0 2020 No. Rx No. Patients/1000 Days/Rx The number of opioid prescriptions and patients receiving opioid prescriptions decreased by 9% and 10%, respectively, from 2019 to 2020. The average number of days dispensed per opioid prescription increased by 2%. Prescription Drug Monitoring Program Report, Georgia, 2020 % of Patients Percent Patients Receiving an Average Daily Dose 90 Morpine Miligram Equivalents of Opioids, by Quarter, Georgia, 2016-2020 9.0 8.0 7.0 8.0 7.9 7.8 7.9 8.1 7.8 7.9 7.7 7.9 7.3 7.1 7.2 7.7 7.7 7.4 7.1 6.8 6.4 6.9 6.7 6.0 5.0 4.0 3.0 2.0 1.0 0.0 2016 2016 2016 2016 2017 2017 2017 2017 2018 2018 2018 2018 2019 2019 2019 2019 2020 2020 2020 2020 Q1 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 2016 CDC Opioid Prescribing Guidelines recommended that daily opioid dosages should not exceed 90 morphine milligram equivalents (MME). The graph above represents the quarterly percent of patients in Georgia who were receiving an average daily dose of 90 (MME) of opioids during 2016-2020. The percent of patients in Georgia who were receiving an average daily dose of 90 (MME) of opioids decreased by 13% from Q1 2019 to Q4 2020. Prescription Drug Monitoring Program Report, Georgia, 2020 Prescription Drug Monitoring Program Report, Georgia, 2020 Prescription Drug Monitoring Program Report, Georgia, 2020 Top Ten Opioids Prescribed, Georgia, 20192020 No. prescriptions No. prescription Rank Opioid drug 2019 2020 1 Hydrocodone 2,395,539 2,161,64 2 Oxycodone 1,664,550 1,490,319 3 Tramadol 1,545,906 1,457,583 4 Codeine 402,845 351,153 5 Buprenorphine 268,732 219,944 6 Morphine 175,396 159,344 7 Fentanyl 106,358 91,953 8 Methadone 68,764 61,037 9 Oxycodone 72,384 63,223 10 Morphine 86,992 87,522 Prescription Drug Monitoring Program Registrations and Patient Queries, Georgia, 20192020 No. registered No. registered No. patient No. patient PDMP user type as of 12/31/2019 as of 12/31/2020 queries 2019 queries 2020 Dentist 4,804 4,906 68,296 56,497 Dispensing Physician 38 39 956 759 Medical Resident 2,619 3,155 31,309 48,709 Midwife 140 159 1,324 4,514 Nurse Practitioner 6,416 7,197 862,643 1,197,243 Optometrist 966 1,002 3,732 3,700 Out-of-State Pharmacist 142 164 4,460 2,209 Out-of-State Prescriber 190 282 6,674 8,564 Pharmacist 11,877 282 3,404,914 4,001,188 Pharmacist's Delegate 330 377 51,081 50,569 Physician (MD, DO) 27,059 29,034 3,657,990 4,154,509 Physician Assistant 3,209 3,517 396,128 503,405 Podiatrist 440 463 9,312 10,229 Prescriber Delegate 1,451 1,665 542,430 481,806 Veterans Affairs Prescriber 106 156 4,232 7,190 TOTAL 59,787 50,451 9,045,481 10,531,091 Prescription Drug Monitoring Program Report, Georgia, 2020 Prescription Drug Monitoring Program Indicators, Georgia, 20192020 See Prescription Drug Monitoring Program Data Indicators table for description of indicators below 2019 2020 Indicator description Total Jan-Mar Apr-Jun Jul-Sep Oct-Dec Total Jan-Mar Apr-Jun Jul-Sep Oct-Dec No. opioid prescriptions 6,899,412 1,763,003 1,756,751 1,710,762 1,668,896 6,251,867 1,585,454 1,523,364 1,610,562 1,532,487 No. stimulant prescriptions No. benzodiazepine prescriptions 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 2,179,301 601,541 2,979,620 782,361 757.1 N/A 3,526,947 915,145 335.3 87.0 18.0 17.8 7.5 7.7 555,320 776,638 N/A 880,836 83.7 17.9 7.7 524,873 737,419 N/A 853,030 81.1 18.0 7.4 497,567 1,795,379 520,162 683,202 2,853,933 702,282 N/A 726.0 N/A 877,936 3,219,308 850,103 83.5 306.0 80.8 18.1 18.3 18.2 7.1 6.7 6.8 432,637 657,931 N/A 740,428 70.4 18.9 6.4 422,443 885,978 N/A 814,667 77.4 18.1 6.9 420,137 607,742 N/A 814,110 77.4 18.1 6.7 Prescription Drug Monitoring Program Report, Georgia, 2020 Prescription Drug Monitoring Program Indicators by Age and Sex, Georgia, 2020 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 870 6 517 6.9 1,212 6.5 8.9 1-4 years 5,652 882 7,778 10.7 5,073 9.6 7.9 5 -14 years 38,350 507,543 33,542 27.1 32,326 22.9 9.7 15-24 years 204,694 330,789 87,388 141.7 163,457 113.1 5.9 25-34 years 510,321 283,592 273,811 346.4 256,295 173.9 10.6 35-44 years 837,576 267,382 473,945 610.2 286,240 208.5 15.2 45-54 years 1,183,291 201,950 663,711 838.4 331,648 234.9 18.2 55-64 years 1,715,750 116,465 832,763 1,334.5 378,679 294.5 20.5 65-74 years 1,408,039 41,784 642,606 1,572.5 309,183 345.2 20.8 75-84 years 649,907 6,894 338,322 1,553.5 151,197 361.4 20.4 85+ years 226,572 1,101 142,768 1,545.2 51,864 353.7 19.1 Sex Male 2,785,882 930,499 1,141,282 544.6 769,808 150.5 18.2 Female 3,988,339 873,195 2,237,245 738 1,098,045 203.2 18.0 DPH Epidemiology, Drug Surveillance Unit https://dph.georgia.gov/drug-overdose-surveillance-unit Prescription Drug Monitoring Program Report, Georgia, 2020