12/05/2022 2 Prescription DSrUuBgT I TML Eonitoring Program, 2021 Epidemiology, Drug Surveillance Unit THE PRESCRIPTION DRUG MONITORING PROGRAM (PDMP) The purpose of this report is to describe opioid prescribing patterns in Georgia during 2021. 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. Georgia PDMP, 2021: Key Findings 2 Georgia saw improvements in opioid prescribing practices from 2020 to 2021, as evidenced by these PDMP indicators: In 2021, there were 6,624,467 opioid prescriptions dispensed to 1,908,203 patients in Georgia. These prescriptions averaged 18.0 days of opioids dispensed per prescription. From 2020 to 2021, the number of opioid prescriptions statewide decreased by 8%, benzodiazepine prescriptions by 14%, and stimulants by 8%. The number of patients receiving opioid prescriptions did not change from 2020 to 2021. The average number of days dispensed per opioid prescription decreased by 2%. In the first quarter of 2020 (Q1), there were 1,790,484 opioid prescriptions dispensed compared to 1,682,018 prescriptions in the last quarter of 2021 (Q4). From 2020 to 2021, the rate of opioid prescriptions dispensed in Georgia decreased by 4% among persons aged 5-54 years, 4% among those aged 55-64 years, increased by 1% among those aged 65-74 years, increased by 3% among those aged 75-84 years, and decreased by 2% among those aged 85+. Opioid prescriptions decreased by 3% among males and 2% among 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) per day. The percent of patients in Georgia who were receiving an average daily dose of 90 (MME) of opioids decreased by 6% from Quarter 1 (Q1) 2020 to Q4 2021. Hydrocodone, Oxycodone, and Tramadol were the most-prescribed opioids in Georgia during both 2020 and 2021. The number of registered PDMP users increased by 13.7% from December 2020 to May 2021. Patient queries by prescribers (or their delegates) and dispensers increased from 10.5 million queries in 2020 to 11.7 million queries in 2021. 3 PDMP Data Indicators Data Source All schedule II-V drug prescriptions dispensed and reported to the Georgia Prescription Drug Monitoring Program during 20162021. 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 ageadjusted 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 & Year, Georgia, 2016-2021 No. Prescriptions (millions) 10.0 2016 2017 2018 2019 2020 2021 9.0 8.6 8.0 8.0 7.5 6.9 7.0 6.3 6.0 5.8 5.0 4.0 3.9 3.6 3.5 3.0 3.0 2.6 2.3 2.4 2.3 2.5 2.2 2.0 1.8 1.7 1.0 0.0 Opioids Benzodiazepenes Stimulants From 2020 to 2021, the number of opioid prescriptions decreased by 8%, benzodiazepine prescriptions by 14%, and stimulants by 8%. Opioids are the most frequently prescribed controlled substance in Georgia, followed by benzodiazepines and stimulants. Opioid Prescriptions by Quarter, Georgia, 2016-2021 No Rx (millions) July 1, 2017 2.30 Dispensers required to 2.2 2.20 2.1 2.1 2.1 2.1 2.10 2.1 report within 24 hours; DPH begins administering PDMP 2.1 July 1, 2018 Prescribers required to check PDMP prior to prescribing March 8, 2016 CDC releases 2.00 guidelines for opioid prescribing 1.90 1.9 1.9 1.80 May 4, 2017 2.0 1.9 1.8 1.8 1.8 1.8 1.8 GA PDMP bill signed 1.70 into law January 1, 2018 Prescribers 1.6 required to 1.60 register March 11, 2020 COVID-19 pandemic declared 1.8 1.7 1.6 1.6 1.50 2016 Q1 2016 Q3 2017 Q1 2017 Q3 2018 Q1 2018 Q3 2019 Q1 2019 Q3 2020 Q1 2020 Q3 2021 Q2 2021 Q4 Year and Quarter 5 In the first quarter of 2020, there were 1,790,484 opioid prescriptions dispensed compared to 1,682,018 prescriptions in the last quarter of 2021. Rx/ 1,000 population 1800 1600 1400 1200 1000 800 600 400 200 0 2016 2017 2018 2019 2020 2021 Opioid Prescription Rates, by Age and Sex, Georgia, 20162021 2016 2017 2018 2019 2020 2021 <1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ female male 8 18 44 243 600 899 1225 1683 1699 1650 1609 953 705 7 14 37 207 517 812 1105 1566 1613 1555 1510 876 651 5 12 30 162 406 646 875 1308 1411 1415 1344 727 538 7 14 33 161 392 664 913 1406 1594 1584 1562 782 578 7 11 27 142 346 610 838 1335 1573 1573 1554 738 545 6 11 26 140 319 590 801 1283 1587 1610 1521 725 528 Age Group (years) From 2020 to 2021, the rate of opioid prescriptions dispensed in Georgia decreased by 4% among persons aged 5-54 years, 4% among those aged 55-64 years, increased by 1% among those aged 65-74 years, increased by 3% among those aged 75-84 years, and decreased by 2% among those aged 85+. Opioid prescriptions decreased by 3% among males and 2% among females. Average No. Days Supplied per Rx No. Rx or Patients (millions) Opioid Prescriptions, Patients, and Average Days Supplied per Rx, Georgia, 2016-2021 10.0 17.8 18.1 18.2 17.9 18.3 18.0 20.0 8.0 8.6 6.0 4.0 2.0 2.3 0.0 2016 8.0 7.5 7.2 6.9 2.2 2017 No. Rx 2.0 2.1 2018 2019 No. Patients/1000 1.9 2020 Days/Rx 15.0 6.6 10.0 5.0 1.9 0.0 2021 6 % of Patients The number of opioid prescriptions decreased by 4% and no changes seen in patients receiving opioid prescriptions, from 2020 to 2021. The average number of days dispensed per opioid prescription decreased by 2%. Percent Patients Receiving an Average daily Dose 90 Morpine Miligram Equivalents of Opioids, by Quarter, Georgia, 2017-2021 10.0 8.0 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 6.2 6.4 6.3 6.3 6.0 4.0 2.0 0.0 2017 2017 2017 2017 2018 2018 2018 2018 2019 2019 2019 2019 2020 2020 2020 2020 2021 2021 2021 2021 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 graph above represents the quarterly percent of patients in Georgia who were receiving an average daily dose of 90 (MME) of opioids during 2017-2021. The percent of patients in Georgia who were receiving an average daily dose of 90 (MME) of opioids decreased by 6% from Q1 2020 to Q4 2021. 7 8 9 Top Ten Opioids Prescribed, Georgia, 20202021 Rank Opioid drug No. prescriptions No. prescription 2020 2021 1 Hydrocodone 2,322,421 2,256,119 2 Oxycodone 1,717,871 1,740,226 3 Tramadol 1,495,536 1,445,006 4 Codeine 507,528 473,779 5 Buprenorphine 328,838 321,426 6 Morphine 260,887 246,195 7 Fentanyl 95,092 84,778 8 Hydromorphone 63,665 60,210 9 Methadone 65,148 57,270 Codeine, 10 Bultabital 23,476 21,401 Prescription Drug Monitoring Program Registrations and Patient Queries, Georgia, 20202021 PDMP user type No. registered as No. registered as No. patient of 12/31/2020 of 12/31/2021 queries 2020 No. patient queries 2021 Dentist 4,906 5,085 56,497 61,705 Dispensing Physician 39 42 759 2,612 Medical Resident 3,155 3,695 48,709 59,915 Midwife 159 164 4,514 7,295 Nurse Practitioner 7,197 7,840 1,197,243 1,459,237 Optometrist 1,002 1,049 3,700 5,042 Out-of-State Pharmacist 164 177 2,209 1,498 Out-of-State Prescriber 282 275 8,564 7,242 Pharmacist 282 13,536 4,001,188 4,087,125 Pharmacist's Delegate 377 429 50,569 54,074 Physician (MD,DO) 29,034 30,916 4,154,509 4,889,312 Physician Assistant 3,517 3,835 503,405 632,821 Podiatrist 463 554 10,229 12,521 Prescriber Delegate 1,665 1,839 481,806 480,392 Veterans Affairs Prescriber 156 202 7,190 13,739 TOTAL 50,451 69,638 10,531,091 11,774,530 10 Prescription Drug Monitoring Program Indicators, Georgia, 20202021 See Prescription Drug Monitoring Program Data Indicators table for description of indicators below 2020 2021 Indicator description Total Jan-Mar Apr-Jun Jul-Sep Oct-Dec Total Jan-Mar Apr-Jun Jul-Sep Oct-Dec No. opioid prescriptions 6,251,867 1,585,454 1,523,364 1,610,562 1,532,487 6,743,732 1,669,675 1,708,774 1,683,265 1,682,018 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 1,795,379 520,162 2,853,933 702,282 726.0 N/A 3,219,308 850,103 306.0 80.8 18.3 18.2 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 1,656,746 414,064 607,742 3,192,057 804,775 N/A 726.0 N/A 814,110 3,210,428 791,281 77.4 305.0 75.2 18.1 17.9 17.9 6.7 6.3 6.2 406,160 801,127 N/A 815,268 77.5 17.8 6.4 418.422 800,520 N/A 798,907 75.9 18.0 6.3 418,100 785,635 N/A 804,972 76.5 17.9 6.3 11 Prescription Drug Monitoring Program Indicators by Age and Sex, Georgia, 2021 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 747 7 408 5.9 617 4.0 12.0 1-4 years 5,917 804 7808 11.2 4,888 11.5 9.0 5 -14 years 38,922 447,151 33,073 27.5 28,496 20.2 10.0 15-24 years 207,835 312,905 77,398 143.8 152,023 105.2 6.0 25-34 years 482,624 274,911 241,504 333.0 232,380 157.7 10.0 35-44 years 828,722 266,557 448,840 603.8 274,230 199.8 15.0 45-54 years 1,155,328 197,158 567,128 818.5 306,698 217.3 18.0 55-64 years 1,677,706 110,610 714,739 1,304.9 358,588 278.9 20.0 65-74 years 1,440,719 38,780 617,866 1,608.9 310,465 346.7 21.0 75-84 years 682,358 6,886 341,317 1,631.0 161,827 386.8 20.0 85+ years 225,330 979 141,976 1,536.6 57,163 389.8 19.0 Sex Male 2,747,044 835,330 1,065,204 537.0 773,438 151.2 18.0 Female 3,993,426 821,301 2,123,392 738.9 1,111,675 205.7 18.0 DPH Epidemiology, Drug Surveillance Unit https://dph.georgia.gov/drug-overdose-surveillance-unit 12