January 27, 2020 Sen. Gene Suellentrop Chair, Public Health and

January 27, 2020

Sen. Gene Suellentrop

Chair, Public Health and Welfare Committee

Capitol Building, Room 441-E

Topeka, Kansas 66612

Rep. Brenda Landwehr

Chair, Health and Human Services Committee

Capitol Building, Room 352-S

Topeka, Kansas 66612

RE: Report on Kansas Prescription Drug Monitoring Program (K-TRACS)

Dear Committee Chairs:

Pursuant to K.S.A. 65-1691, the Kansas State Board of Pharmacy is required to submit to the Senate Committee on Public

Health and Welfare and the House Committee on Health and Human Services a report on the Kansas Prescription Drug

Monitoring Program (PDMP) which tracks and monitors Schedule II through IV controlled substances and other drugs of

concern in Kansas. The Kansas PDMP, called K-TRACS, is a potent tool in aiding in the identification of patients with

drug-seeking behaviors, providing treatment, and educating the public. Each dispenser (pharmacy) is required to

electronically submit information to K-TRACS for each controlled substance prescription or drug of concern dispensed in

an outpatient setting. The goal of the PDMP is to prevent the misuse, abuse, and diversion of controlled substances and

drugs of concern while ensuring continued availability of these medications for legitimate medical use.

K-TRACS includes all retail and outpatient dispensing records for any controlled substance or drug of concern dispensed

in Kansas or to a Kansas resident, regardless of whether the pharmacy is located in Kansas. The only exception is for

quantities dispensed in the emergency room for 48 hours or less. If a prescriber or a pharmacist has a concern about a

patient, he/she can look up the patient’s prescription history in K-TRACS. Because K-TRACS is a real-time, web-based

system, patient information can be obtained instantly from any location at any time with the proper login credentials.

Prescribers and pharmacists must register for K-TRACS through the Board prior to utilizing the system. Law enforcement

and other state agencies have limited access to the program but may request records with proper legal authority. In

addition, de-identified or aggregate data may be provided to requestors for educational or research purposes. The Board

collaborates with the Kansas Department of Health and Environment (KDHE) to transmit such de-identified data and

receive reports and analysis based on KDHE’s research.

Advisory Committee:

The Act also created a PDMP Advisory Committee, subject to the oversight of the Board, composed of prescribers and

dispensers from various healthcare disciplines. In 2012, the Committee was authorized to review and analyze data for

purposes of identifying patterns and activity of concern; notify prescribers and dispensers who prescribed or dispensed the

prescriptions; notify law enforcement or appropriate regulatory boards for additional investigation; and utilize volunteer

peer review committees of professionals with expertise in the particular practice to create standards and review individual

cases. At the direction of the Committee, Board staff send quarterly threshold letters to each prescriber and dispenser who

has a patient that visited at least five prescribers and filled prescriptions in at least five pharmacies in a 90-day period and

recently began sending letters of concern to outlier/high-level prescribers requesting review of prescribing patterns and a

response to the Committee. Last year, at the suggestion of the legislature, the Committee began meeting monthly to more

proactively and regularly review K-TRACS data and identify patterns of concern. As part of this work, the Committee

approved specific guidelines on January 11, 2019 to aid staff in presenting K-TRACS data to the Committee to review

and make such referrals as may be necessary for the protection of the public. During 2019, the Committee reviewed a total

of 22 cases of concern. Based on discussion, 15 cases had letters sent to the appropriate entities, such as patient prescriber

or pharmacist, law enforcement, or other regulatory agency for intervention. Cases will continue to be reviewed by the

Committee in 2020 with the assistance of a new, grant-funded staff member to the Board of Pharmacy.

Operations, Funding, and Enhancements:

K-TRACS was implemented and operated using federal grant funds through June 30, 2016. The Board has now exhausted

available grant funding to sustain the program, and the only remaining grant funding is for program enhancements.

Program maintenance costs include the cost of software, staff, and office overhead (postage, paper, etc). While the Board

continues to pursue and has recently been awarded federal grants, funding presents the largest obstacle to maintaining a

PDMP in Kansas. In 2016, the Board received legislative approval to use approximately $200,000 of surplus dollars from

the pharmacy fee fund to cover operating expenses for FY2017. In 2017, the Board of Pharmacy, Board of Healing Arts,

Dental Board, Board of Nursing, and Board of Optometry sought and received legislative authority to use surplus fee fund

dollars to collectively support the program through FY2018 and FY2019. In 2019, the legislature authorized a transfer of

$705,000 from the KDHE Drug Manufacturer’s Rebate Fund in addition to continued and increased funding from the

aforementioned fee funds. A permanent funding solution continues to be a top priority of the K-TRACS program. The

table below represents the allocated amounts from FY2018 through FY2021.

Table 1. K-TRACS Transfers from Fee Funds, FY 2018 – FY2021

The Board employs an Assistant Director and a Program Manager to oversee and administer the PDMP. An Advanced

Epidemiologist is also funded through a recent federal grant through August 2022 to analyze K-TRACS data and provide

necessary reporting under the federal grants. In addition to daily administrative and operational duties, staff members

make regular presentations on the PDMP to prescribers, pharmacists, public health professionals, and other organizations.

Additional administrative support is provided by Board of Pharmacy licensing staff. Human resources and staff

availability limit significant expansion of the program, grant applications/awards, customer service, awareness campaigns,

and other program analysis and review. The Board is currently working to hire three additional, temporary, K-TRACS

staff members through September 2021 using Harold Rogers grant funds (see explanation below). These positions include

a Public Information Officer to create training and awareness materials for users and members of the public; a Program

Specialist to examine the accuracy and timeliness of data reported to K-TRACS for compliance with the Prescription

Monitoring Program Act; and a Physician or Pharmacist to review K-TRACS data for suspicious patterns or activity, and

referral to the Advisory Committee for consideration and possible action.

The Board began collecting data in February 2011 and the program became fully operational in September 2011. In July

2013, Kansas became the first state to launch a pilot of new software called AWARxE™ hosted by the National

Association of Boards of Pharmacy (NABP) through Appriss Health, Inc., which was offered at no charge through June

30, 2016. The Board now contracts directly with Appriss for the maintenance, support, and hosting of K-TRACS

software. Appriss is the vendor for 43 PDMPs and provides a strong PDMP solution. In FY 2018, Appriss identified a

need for greater transparency in their software planning and releases. Since that time, all PDMP administrators now have

access to an interactive Product Roadmap which outlines past and future product improvements, fixes, and enhancements

developed by other states and made available to all clients. The Board continues to have an excellent working relationship

with Appriss. Regular check-in calls are scheduled with the K-TRACS staff and in-person meetings occur annually with

Providers FY18 Actual FY19 Actual FY20 FY21

BOHA 11,788 83,945.64$ 81,847.91$ 235,500.00$ 235,500.00$

Nursing 5,301 30,704.52$ 36,806.56$ 103,500.00$ 103,500.00$

Dental 2,032 13,442.32$ 14,108.84$ 41,500.00$ 41,500.00$

Optom 695 4,694.15$ 4,825.61$ 16,500.00$ 16,500.00$

Pharm 6,527 39,120.38$ 45,319.08$ 130,500.00$ 130,500.00$

Drug Rebate Fund 705,000.00$ 705,000.00$

Totals 26,343 171,907.00$ 182,908.00$ 1,232,500.00$ 1,232,500.00$

the team. Inquires for technical assistance and customer support are generally responded to within one or two business

days.

The AWARxE™ platform accommodates large chains, independent and small pharmacies, and works seamlessly with the

National Association of Boards of Pharmacy (NABP) - PMP Interconnect® (PMPi) which is offered at no charge by

NABP. PMPi is a system which facilitates the transfer and availability of PDMP data to all participating states (48

available, Figure 1). As of December 31, 2019 Kansas is sharing data with 34 states, districts, and territories, and also now

shares data with the Military Health System, Indian Health System, and Veterans Administration. The neighboring state of

Oklahoma is Kansas’ largest requester of K-TRACS data, followed by Texas and Missouri.

Figure 1. Jurisdictions connected with the National Associations of Boards of Pharmacy PMP InterConnect (PMPi) as of

December 2019

Figure 2. Total number of K-TRACS successful PDMP searches by PMPi connected states.

The Board received a grant in 2012 from the Substance Abuse and Mental Health Services Administration (SAMSHA)

through the U.S. Department of Health and Human Services which funded integration of K-TRACS data into the Lewis

and Clark Information Exchange (LACIE) and Via Christi Health Systems, enabling a single sign-on for access to a

patient’s medical record and K-TRACS history. The Board, in conjunction with KDHE, has been expanding that project

to provide interoperability services for all prescribers and pharmacists in Kansas to access K-TRACS through the PDMP

Gateway®. This program, called INTEGRx8, is an opportunity for Kansas to deliver a more efficient and patient-oriented

program. The project was funded by a grant from the Centers for Disease Control (CDC) awarded to KDHE from 2017 –

2019 and will continue to receive partial support from a new CDC grant awarded to KDHE through August 2022. Grant

Graphic Source: https://nabp.pharmacy/wp-content/uploads/2019/04/PMP-InterConnect-Map-August-2019.pdf

Graphic Source: https://analytics.apprisshealth.com/#/site/USA_KS/views/PMPi/DisclosuresMap as of October 29, 2019

2018

2019

funds will support INTEGRx8 for each Kansas electronic health records and pharmacy management system approved for

integration which will further the K-TRACS mission. Statewide integration increases availability, ease of access, and use

of a patient’s-controlled substance prescription history for making critical and informed prescribing and dispensing

decisions. If prescriber’s and pharmacist’s electronic systems are not currently integrated, they are required to log in to

separate systems to query patient data which takes valuable time away from patient care and interaction. INTEGRx8

simplifies the process by creating a one-stop-shop, making K-TRACS data directly available in the patient’s electronic

record, and saving 4.22 minutes per patient on average. As of November 2019, a total of 794 entities were integrated with

K-TRACS through the INTEGRx8 initiative. Figure 3 below further breaks down the type of entity and total number that

are integrated and Figure 4 graphically displays the impact of INTEGRx8 project on the proportion of Gateway® patient

searches per opioid prescription, showing an increase from 0.7 searches per prescription in July 2017 to 7.0 patient

searches per opioid prescription in July 2019. This increase signals increased collaboration in clinical decision making

among both prescribers and pharmacists to improve health care coordination for the patient.

Figure 3. Summary of K-TRACS INTEGRx8 progress as of November 2019

Figure 4. Timeline of interoperability and integration projects through the PMP Gateway and impact of prescriber and

pharmacy patient searched (Jan 2016 – July 2019)

The newest CDC grant awarded to KDHE has resulted in a continued partnership with the Board from January 2020 –

August 2022. Funding for January 2020 – August 2020 totals $981,845.84. While subrecipient funding awarded to the

Board does not replace funds previously allocated by the legislature, this funding will help support continued integration

efforts (described above) and funding for the following grant objectives:

• 1.0 FTE – Advanced Epidemiologist

• Travel to Required Grant Meetings

• Advanced Analytics Software Package

• Deidentified Data Extractions from K-TRACS

• Peer to Peer Learning National Meeting

The Board is also a recent recipient of a U.S. Department of Justice, Bureau of Justice Assistance, Harold Rogers grant in

the amount of $736,313.00 for the project period December 2019 – September 2021. Again, the award will not replace

funds previously allocated by the legislature, but will support temporary enhancements to the K-TRACS program. The

Board’s grant objectives include adding 3.0 FTE (temporary) as described above, travel to required grant meetings,

mandatory connection to the federal PDMP data-sharing hub known as RxCheck, and supplies, software, and equipment

for the new positions.

Alongside efforts to increase K-TRACS utilizations through the INTEGRx8 program, individual user registration has also

continued to increase. Table 2 below summarizes the number of

prescribers and pharmacists registered in K-TRACS, which

has almost doubled since December 2013. Current users represent approximately 71% of the active controlled substance

prescriber community in Kansas and approximately 74% of the active pharmacist community in Kansas. Currently, the

use of K-TRACS is not mandatory in Kansas.

Table 2. Total number of

prescribers and pharmacists registered in K-TRACS (December 2013 – October 2019)

12/2013

12/2014

12/2015

12/2016

12/2017

12/2018

10/2019

Registered Prescribers

5,287

5,724

6,747

7,755

8,968

9,428

10,175

Registered

Pharmacists

1,042

1,272

1,652

1,976

2,400

2,886

3,195

NarxCare is the newest upgrade to the K-TRACS system beginning January 2019. NarxCare provides patient and clinical

decision support beyond the patient’s prescription history by: 1) compiling multiple state reports into one cohesive profile;

2) analyzing data to provide reports, use scores, predictive scores, red flags, visualizations, and K-TRACS data including

narcotics, sedatives, and stimulants; 3) including resources such as Medication Assisted Treatment (MAT) locators and

Centers for Disease Control and Prevention printable educational handouts; and 4) creating Care Team Communications,

perhaps the most powerful tool within NarxCare in the prevention and treatment of substance use disorder coordination of

care (Figure 5).

Figure 5. NarxCare report summary

K-TRACS Impact in Kansas:

The opioid crisis continues to impact the United States; Kansas is no exception. However, progress is being made. For the

first time since the opioid epidemic began in the 1990’s, the Department of Health and Human Services (HHS) reported a

5.1% decline in drug overdoses during the 12-month period between 2017 and 2018 (Source: US Health and Human

Services (HHS Statement)

). However, during this same time frame, Kansas observed an increase in the number of drug-

related overdose deaths by 6.1% (figure 6). In the past 10 years, Kansas drug-related overdose deaths have increased by

15.7%. In addition, CDC has highlighted growing concern related to increases in stimulant use and poly substance use,

which may be contributing to a fourth wave of the US drug crisis (Source: Boston Medical Center, Health System (

BMC

source article)). This trend has also been observed in Kansas, with psychostimulant deaths increasing by 413.3% over the

past 10 years from 15 in 2009 to 77 in 2018. K-TRACS data also indicates prescribing of stimulants in Kansas has

increased 14.7% from 2015 to 2018. It is also noteworthy that many death certificates in Kansas list multi-drug toxicity as

a contributing cause of death which may lead to underreporting of death attributed to controlled substances overall. While

declining, in 2018, 58 deaths were classified as unspecified drug overdose and 181 reported unknown cause of death.

Figure 6. Age adjusted mortality rates attributed to drug poisoning per 100,000 Kansas residents (2005-2018)

Note: Rates based on small cell counts are generally thought to be unstable. The Kansas Department of Health and Environment define

small cell counts as less than 6 events. The only category impacted by this suppression rule is Heroin for the time frame 2005-2007, which is

not displayed in this figure.

In Kansas, controlled substance prescribing is changing. Overall, the number of Kansas patients receiving opioid

prescriptions with greater than or equal to 100 MME has declined by 35% from first quarter 2018 to third quarter 2019

(table 3). Despite this, the percent of opioid naive patients receiving long-acting opioid prescriptions has increased

steadily from first quarter 2018 (5.13%) to third quarter 2019 (6.10%) (table 3). Benzodiazepine prescribing has also

declined by almost 10% from 2015 (table 4). It is thought these changes may be attributed to both national and state level

provider education efforts. These efforts are continuing as a result of federal grant programs and statewide initiatives.

Table 3. Summary of Opioid Dispensation Reported to K-TRACS, January 2018 – October 2019

2018

2019

Number of Kansas Patients Receiving more

than an average daily dose of >= 100 MME

17,331

16,063

14,608

13,834

12,904

11,962

11,264

Number of opioid prescriptions greater than

100 total MME

490,538

483,581

465,238

459,140

434,000

430,142

422,707

Percent of patient receiving more than an

average daily dose of morphine milligram

equivalent of 90 or greater (across all in state

opioid prescriptions)

11.64%

8.70%

8.20%

8.00%

7.80%

7.20%

6.80%

Percent of Long Acting or Extended Release

Opioid Prescriptions Dispensed to an Opioid

Naive Patient

5.13%

5.30%

5.50%

5.80%

5.60%

6.10%

Percent of prescribed opioid days that

overlap with a benzodiazepine prescription

18.26%

19.10%

18.00%

17.80%

17.20%

16.40%

15.30%

Rate of Multiple Provider Episodes for

prescription Opioids (5 or more prescribers

and 5 or more pharmacies per 100,000

residents)

11.9

10.8

8.8

8.6

5.6

6.0

6.1

Table 4. Total number of prescriptions dispensed in Kansas, as reported to K-TRACS for select substances (2015-2018)

2015 2016 2017 2018

Percent

Change from

2015 to 2018

Total opioid Prescriptions

2,537,373

2,584,622

2,379,221

2,163,908

-14.7

Total Stimulant Prescriptions

667,774

731,538

755,611

766,236

14.7

Total Benzodiazepine

prescriptions

1,151,720

1,194,996

1,136,395

1,041,203

-9.6

In addition to controlled substances, K-TRACS monitors other drugs of concern in Kansas, identified by the Board in

Kansas Administrative Regulation 68-21-7. In FY 2018, the Board amended K.A.R. 68-21-7 to include the drug

“gabapentin” as a drug of concern. This change is the result of similar scheduling in surrounding states and significant

evidence of abuse and misuse by patients in recent years, often resulting in death. Gabapentin reporting in K-TRACS has

increased dramatically since the regulation change effective July 25, 2018 (Table 5). In 2018, four deaths occurred in

which gabapentin was listed as a contributing cause of death.

Table 5. Summary of Gabapentin reporting to K-TRACS by fiscal year (2015-2019)

FY 2015

FY 2016

FY 2017

FY 2018*

FY 2019*

Total Number of Gabapentin Prescriptions

Reported to K-TRACS

10 1,134 2,616 75,714 821,786

Total Number of Patients with a Gabapentin

Prescription

7 296 618 58,384 247,045

*Gabapentin became a drug of concern in Kansas as of 2018. Mandatory reporting of gabapentin dispensations to K-TRACS was implemented July

25, 2018. Prior to this date, all reports of gabapentin dispensations to K-TRACS was voluntary.

Drug seeking behaviors among patients also seem to be declining. The rate of multiple provider episodes for prescription

opioids (5 or more prescribers and 5 or more pharmacies per 100,000 residents) has dramatically declined from first

quarter 2018 (11.9 per 100,000) to third quarter 2019 (6.1 per 100,000) (Table 3). However, deaths associated with drug

overdoses among Kansas residents has increased by 44% since 2005. Also, a special analysis of 158 Kansas deaths

associated with prescription drug use, occurring from January 1, 2018 to May 1, 2019, found that 45.5% of decedents had

both benzodiazepine and opioids listed on the death certificate. These findings indicate that Kansas is still being

negatively impacted by the misuse of prescription drugs and illicit drug use, despite national declines.

Naloxone Dispensing in Kansas:

In 2017, after the passage of HB 2217, the Board adopted K.A.R. 68-7-23 which permits any licensed pharmacist to

dispense an emergency opioid antagonist and necessary medical supplies needed to administer an emergency opioid

antagonist to a patient, bystander, first responder agency or school nurse without a prescription, in accordance with a

physician-approved statewide protocol. The protocol summarizes indications for use of Naloxone, signs and symptoms of

an opioid-related overdose, including environmental signs, precautions, and contraindications for use of Naloxone,

documentation and record keeping procedures, and authorization for dispensations of Naloxone. To increase public

awareness of this protocol and where pharmacists are located throughout that state that have signed a Naloxone protocol,

an interactive Tableau map has been created for upcoming public dissemination on the Board website. Figure 7 is a screen

shot version of this map.

Figure 7. Screen shot of Interactive Naloxone Distribution Map

Ongoing Initiatives and Public Information:

Currently, the Board maintains a website for K-TRACS at

https://ktracs.ks.gov, with updated forms, frequently asked

questions/answers, and other helpful resources for healthcare workers and the public. K-TRACS data is available on the

PreventOverdoseKS.org website, where a Tableau Dashboard is embedded into the website. Plans are in place to update

the K-TRACS dashboard with current data in early 2020. In addition, with support from the aforementioned Harold

Rogers grant, the Board plans to implement a public media campaign focusing on best practices for K-TRACS use for

pharmacists and prescribers and increased dissemination of K-TRACS data for public consumption.

Respectfully submitted,

Alexandra Blasi, JD, MBA

Executive Secretary