Kentucky All Schedule Prescription Electronic Reporting (KASPER)

Kentucky All Schedule 

Prescription Electronic Reporting 

Dave Sallengs, R.Ph. 

Manager, Drug Enforcement and Professional Practices Branch 

Office of the Inspector General 

Neal Rosenblatt, MS 

KASPER Project Epidemiologist 

Office of Information Technology

Contents 

• KASPER Background 

• Problems with Controlled Substances 

• The KASPER Program 

• KASPER DData t AAnalysis l i 

• KASPER Trend Reporting Methods 

Cabinet for Health and Family Services

The Cabinet 

• In 1999 The Cabinet for Health and Family 

Services was given the challenge to establish 

a program to fight the rising incidence of the 

diversion of legal prescription drugs into the 

illegal market. 

• In response Kentucky implemented: 

– Controlled substance security prescription 

blanks blanks, and 

– The Kentucky All Schedule Prescription 

Electronic Reporting (KASPER) system. 

system 


What is KASPER? 

KASPER is Kentucky’s Prescription Monitoring 

Program (PMP). KASPER tracks Schedule II – V 

controlled t ll d substance b t prescriptions i ti di dispensed d within ithi 

the state as reported by pharmacies and other 

dispensers. 

KASPER is a Web accessed database that provides p 

a tool to help address one of the largest threats to 

patient safety in the Commonwealth of Kentucky; the 

misuse misuse, abuse and diversion of controlled 

pharmaceutical substances. 


Controlled Substance Schedules 

• Schedule I – Illegal Drugs 

– e.g. heroin, marijuana, etc. 

• Schedule II – Most addictive legal drugs; high 

abuse potential 

– ee.g. g oxycodone (Oxycontin (Oxycontin, Percocet Percocet, Tylox) 

• Schedule III – Less abuse potential than I or II 

– ee.g. g hydrocodone combinations (Vicodin (Vicodin, Lortab) Lortab). 

• Schedule IV – Less abuse potential than III. 

– e.g. benzodiazepines (Xanax, Valium). 

• Schedule V – least abuse potential 

– e.g. codeine containing cough mixtures. 


The Need for KASPER 

• Health care professionals need a tool to help 

identify patient prescription drug problems 

and when intervention may be needed. 

• Diversion of controlled substances is 

reaching epidemic proportions. 

– Diverters cover large areas to obtain drugs drugs. 

– Agencies need efficiency and value in their 

investigative tools tools. 


Statutory Authority for KASPER 

• KRS 218A.202 218A 202 

– The Cabinet for Health and Family Services shall 

establish an electronic system y for monitoring g Schedules 

II, III, IV, and V controlled substances that are dispensed 

within the Commonwealth by a practitioner or pharmacist 

or dispensed p to an address within the Commonwealth by y 

a pharmacy that has obtained a license, permit, or other 

authorization to operate from the Kentucky Board of 

Pharmacy. y 

• 902 KAR 55:110 

– The purpose of this administrative regulation is to 

establish t bli h th the criteria it i ffor reporting ti prescription i ti ddata, t ffor 

providing reports to authorized persons, and for a waiver 

for a dispenser who does not have an automated record 

keeping system. 


Problems with Controlled 

Substances

• Misuse: 

Misuse, Abuse, Diversion 

– When a schedule II – V substance is taken by an 

individual for a non-medical reason. 

• Abuse: 

– When an individual repeatedly takes a schedule 

II – V substance for a non-medical non medical reason reason. 

• Diversion: 

– When a schedule II – V substance is acquired 

and/or taken by an individual for whom the 

medication was not prescribed prescribed. 


Percent 

Increase 

The Scope of the Problem 

US Population 

212 

150 

81 

14 

1992 2003 

Adults Abusing Controlled Substances 

Number of 12 to 17 Year Olds Abusing 

Controlled Substances 

Prescriptions Written For Controlled 

Substances 


Perspective 

From 1992 to 2003 the 15.1 million Americans 

abusing controlled prescription drugs exceeded 

the combined number abusing: 

– Cocaine (5 (5.9 9 million) million), 

– Hallucinogens (4.0 million), 

– Inhalants (2 (2.1 1 million) million), and 

– Heroin (.3 million). 

Source: Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in 

the U.S. Published by The National Center on Addiction and Substance Abuse at 

Columbia University (CASA) (CASA), July 2005 2005. 


Non-medical Prescription Drug Use 

Non-medical use of prescription drugs reported 

in 2004: 

– 48 million people at least once in their 

lifetime. 

– 14.6 million people at least once in the last 

year. 

– 6 million people at least once in the last 

month. 

Source: Misuse of Prescription Drugs: Data from the 2004 National Survey on Drug Use 

and Health. Published by the Substance Abuse and Mental Health Services 

Administration 


“Pharm Parties” 

• Short for pharmaceutical party, a rapidly increasing 

problem with teens and young adults. 

• Bowls and baggies of random prescription drugs 

called “trail mix”. 

• Collecting pills from the family medicine cabinet 

called “pharming”. 

• Internet chat rooms are used to share “recipes” for 

getting i hi high h with i h prescription i i ddrugs. 

– Users sometimes refer to pills by color rather than brand 

name, content or potency. p y 

Cabinet for Health and Family Services 

Reported by Donna Leinwand, USA Today, June 13, 2006

Cough Syrup “Cocktails” 

• Mixes of codeine-containing cough medicine with soft 

drinks or sports drinks. 

• Popularized in rap songs in the late 1990s. Known 

as “Lean”, “Syrup”, Sizzurp” or “Purple Drank”. 

– Users typically mix an ounce of the medicine with a sports 

drink, Sprite or Big Red, then plop in a Jolly Rancher candy 

and pour the mixture over ice. 

• San Diego Chargers defensive back Terrence Kiel 

charged in September 2006 with illegally shipping 

cases of prescription cough medicine to a relative in 

East Texas. Texas 


Reported p by y Donna Leinwand, , USA Today, y, October 19, , 

2006

The Results of Rx Drug Abuse 

• February 2006. Eddie Cappiello 22, died of 

drug g overdose after a “pharm p pparty” y with the 

equivalent of 67 Xanax pills in his system, 

leaving behind a 6-week old daughter. 

• June 2006. Justin Knox 22, bit down on 

Fentanyl patch and died before reaching the 

hhospital. it l 

• June 2006. Two Transportation Security 

Ad Administration i i t ti screeners pleaded l d d guilty ilt tto 

stealing OxyContin pills from passengers. 


The Economics of Drug Diversion 

“Legal” Drugs Have Street Values 

Generic Name Brand Name Brand 

Cost/ 100 

Street Value 

Per 100 

Acetaminophen p 

w Codeine 30mg 

Tylenol y #3 $56.49 $800.00 

Diazepam 10 mg Valium 10 mg $298.04 $1,000.00 

Hydromorphone y p Dilaudid 4 mg g $88.94 $ $10,000.00 

$ , 

Methylphenidate Ritalin $88.24 $1,500.00 

Oxycodone Oxycontin 80 mg $1,081.36 $8,000.00 

Cough Medicine 

Phenergan VC $12 $12.00/pint 00/pint $1 $1,300.00/pint 

300 00/pint 

w/Codeine ** w/Codeine 


Goldman, MD, Brian, “Unmasking the Illicit Drug Seeker” 

** USA Today, October 19, 2006

Th The KASPER PProgram

Prescription Monitoring Programs 

• 24 states currently have PMPs for at least one class of 

controlled substance. 

• 9 states have passed legislation to implement a PMP. 

• Additional states are currently y considering g legislation g 

to implement monitoring programs. 

• Some states with reporting p g limited to Schedule II 

controlled substances are considering expanding their 

programs to include additional schedules. 

• PMPs are supported through federal funding as well 

as state funding. 


States With Prescription Monitoring Programs 

WA 

OR 

CA 

NV 

AK 

ID 

UT 

MT 

WY 

States with Monitoring Programs 

CO 

AZ NM 


HI 

ME 

ND 

V N 

MN 

T H 

SD WI NY 

MI 

N 

IA 

PA 

NE 

IL IN 

OH 

VA 

KS MO KY 

TN 

NC 

N J 

W 

V 

OK 

TN 

AR 

MS 

TX 

LA 

AL GA SC 

NC 

PR 

FL 

C-II only 

C-II, III 

C-II, III, IV 

C-II, III, IV,V 

VV 

CT 

MA 

RI 

DE 

MD 

DC 

(Selective scheduled drugs drugs, used 

for disciplinary purposes only.)

Responsibility for KASPER 

• KASPER is “housed” within the Cabinet for 

Health and Family Services: 

– Office of the Inspector General (OIG), 

• Division of Fraud Fraud, Waste & Abuse Identification and 

Prevention. 

• The Division has responsibility p y for: 

– Drug Enforcement and Professional Practices 

(enforcement ( of KY Controlled Substances Act), ), 

– Medicaid programs enforcement, and 

– The eKASPER S poga 

program. 


History of KASPER 

1997 - Attorney General’s task force recommends development 

of Prescription Monitoring Program. 

1998 - KASPER llegislation i l ti passes and d signed i d iinto t llaw. 

(Estimated 2,000 reports per year). 

1999 - KASPER launched in July July. 33,105 105 reports processed by 

year-end. 

2000 to 2002 - Volume increases to 95,000 , reports. p OIG 

recognizes need for user self-service. 

2003 - Legislature allocates $1.4 million to develop enhanced 

KASPER (eKASPER). 


History of KASPER Cont. 

2004 - DDrug EEnforcement f t and d PProfessional f i l PPractices ti BBranch h 

moved to OIG. 

2004 - OIG assumes responsibility for continued development 

of eKASPER, and for the Hal Rogers Grants. 

2004 – Legislature expands KASPER statutes, mandating: 

• enhanced usage of system by Medicaid, 

• continuing education for prescribers, dispensers, law enforcement, and 

attorneys, 

• sharing data with other states, 

• use of data for trend analysis. 

2005 - eKASPER launched in March March. Volume increases to 

186,000 reports. 


History of KASPER Cont. 

2005 – Legislature allocates $5 million for eKASPER Phase II 

Capital p Project j to enhance the system. y 

2005 – Hal Rogers Grant Focus Groups chartered to provide 

recommendations for improving KASPER. 

2006 – Initial KASPER trend data analysis completed. Reports 

reviewed with focus groups and posted on KASPER Web site. 

2006 – Volume increases to 273,576 reports. 

2007 – Kentucky selected to participate in interstate data 

sharing pilot project project. 


KASPER Operation 

• KASPER tracks most Schedule II – V substances 

dispensed in KY. 

– Between 8 and 9 million controlled substance 

prescriptions reported to the system each year. 

• KASPER data is 16-20 days old. 

– Dispensers have 8 days to report. 

– Atlantic Associates processes & provides data every 8 

days. 

• Reports available to authorized individuals. 

– Available via fax in 2-8 hours. 

– Available via Web within 15 seconds (90% of 

requests). 

– Available 24/7 from any PC with Web access. 


Tylenol #3 

Tylenol #4 

Valium 

Oxycontin 

Percodan 

Percocet 

Ativan 

Top Prescribed Controlled Substances by 

Therapeutic Category by Doses 

Ritalin 

Methylphenidate II 

3% 

Carisoprodol IV 

3% 

Phenobarbital III 

3% 

Soma 

Lorazepam IV 

6% APAP with 

Lortab 

APAP with Codeine 

III 

8% 

Hydrocodone III 

33% 

Diazepam IV 

8% 

Oxycodone and 

Combinations II 

9% 

Darvocet 

Propoxyphene with 

APAP IV 

10% 


Alprazolam IV 

17% 

Xanax 

Lorcet 

Vicodin

Who May Obtain KASPER Reports? 

UUnder d KRS 218A.202 218A 202 (6) (6): 

• Licensing Boards - for licensees only (including licensees 

based upon relationships or geographic trend data) 

• Law Enforcement Officers - for a bona fide drug 

iinvestigation i i – certified ifi d bby iinvestigator i and d supervisor i 

• Medicaid – for a recipient 

• Grand Juries - by subpoena 

• Practitioners - for medical treatment, and Pharmacists - 

for pharmaceutical p 

treatment 

• A judge or probation or parole officer administering a 

drug diversion or probation program 


Who Uses KASPER? 

KASPER Report Requests 2006 


Goals of KASPER 

• KASPER was designed as a tool to help 

address the problem with prescription drug 

abuse and diversion by providing: 

– A source of information for health care 

professionals. 

– An investigative tool for law enforcement. 

• KASPER was not designed to: 

– Prevent people from getting prescription drugs drugs. 

– Decrease the number of doses dispensed. 


A National Perspective 

• Kentucky is the recognized leader in Prescription 

Monitoring Program implementation. 

St State t visits i it by b Alabama, Al b Florida, Fl id Ohio, Ohi SSouth th 

Carolina, Virginia, and many others. 

KASPER KASPER program highlighted at National 

Conference of State PMPs, April 2006. 

• Kentucky y used as the model for NASPER legislation g to 

provide funding for enhancements related to sharing 

PMP information with other states. 

• KASPER satisfaction i f i survey results l and d other h program 

information utilized by other states to foster their efforts 

to implement and expand PMPs PMPs. 


Planned Enhancements 

• Contract with a vendor to provide most controlled 

substance prescription data within 24 hours of 

dispensing. 

• Participate in a Cabinet ePrescribing pilot program. 

• Work with federal government to support efforts to 

share PMP data among the states. 

– Participate on Bureau of Justice Assistance sponsored PMP 

Committee. 

– Participate in a pilot project to share PMP data (KY, MI, MS, 

NY and OH). OH) 

• Further develop KASPER data analysis capabilities. 


KASPER DData t AAnalysis l i

Data Analysis and Trend Reporting 

• KRS 218A.240 (7) (a) 

– The Cabinet for Health and Family Services shall use the 

data compiled in the electronic system created in KRS 

218A.202 for investigations, research, statistical analysis, 

and educational purposes purposes, and shall proactively identify 

trends in controlled substance usage and other potential 

problem areas. 

– OOnly l cabinet bi t personnel l who h hhave undergone d ttraining i i ffor th the 

electronic system and who have been approved to use the 

system shall be authorized access to the data and reports 

under d thi this subsection. b ti 

– No reports shall identify an individual prescriber, dispenser 

or patient. p 


KASPER Trend Reporting 

The KASPER legislation required the Cabinet to 

develop p trend reporting p g criteria and ppublish 

trend 

reports quarterly. 

• Criteria developed in collaboration with: 

– Licensure Boards. 

– Law enforcement focus group. 

• Utilizing geographic information system (GIS) 

software to provide graphical representation 

of the data and to conduct “hot spot” analysis. 


Goal of Trend Reporting 

• To allow the professional licensure boards and 

law enforcement officials to have the tools 

needed to identify potential “hot spots” and 

possible diverters under their scrutiny. 

• The original mandate was to provide 

“spreadsheet” spreadsheet type tools tools. 

• By working with our epidemiologist we 

expanded d d th the concept t tto include i l d GIS mapping i 

and analysis. 


Overview of Today’s Trend Reports 

• Based on patient residence zip code data. 

• Excludes county boundaries on published 

maps. 

– To minimize legislative and media scrutiny scrutiny. 

• Trend maps being published on KASPER 

WWeb b site. it 

• Spreadsheets and all trend maps available to 

the boards. 


The Next Level of Data Analysis 

• Recent database changes allow analysis based 

upon prescriber and dispenser addresses as 

well. 

• Implement changes to allow breakdown by 

prescriber type (MD, DO, DMD, ARNP, etc). 

– Licensure boards seeking g identification of 

licensees prescribing/dispensing in excess of the 

“norm” for their specialty. 

• Analysis of KASPER data and crime data may 

provide predictive tool for law enforcement. 


Data Analysis Collaboration Process 

• Research team submits formal request to the CHFS/Office of 

the Inspector General (OIG) for KASPER data. 

– Identify organization, organization purpose of research, research proposed 

methodology to be employed and publication plan. 

• On a case by case basis, CHFS/OIG reviews request and 

obtains additional information as needed needed. 

• CHFS/OIG and research team agree upon collaboration plan. 

– Schedule 

– Methods 

– Analysis 

– RReporting ti 

– Publication 

• CHFS/OIG approves request. 


Data Analysis Constraints 

• Statutory limitations. 

– KRS 218A.202 

– KRS 218A.240 

• Database a abase limitations. a o s 

– Non-normalized database 

– Accuracy y of data 

• Staffing limitations. 

– Number of staff members available with 

needed query knowledge 


KASPER TTrend d RReporting ti

Trends Analysis 

Tools

• ArcView 9.1 

– ArcTool Box 

• Spatial p Autocorrelation 

• Hot Spot Analysis 

– Spatial Analyst Extension 

• Point density analysis 

• VENN Diagramming 

• Data Sources 

– KASPER extracts 

– U.S. Census 2000 

• Geographic Levels 

– County 

– ZIP code 

– U.S. Census Block 


Tools 

• Focus Group 

Development 

– Licensure Boards 

– Law Enforcement 

• KASPER Satisfaction 

Surveys 

– 2004 

– 2006

VENN Diagramming 

Crime 

Activity 

C 

Crime 

A A1 A A2 Prescriber Written 

Dispensed Pharmacy 

# by ZIP 

# by Co. 


A∩B∩C 

Filled 

B 

Patient 

Per capita ZIP 

Per capita Co. 

# by ZIP 

# by Co..

Trends Analysis 

Methods

Fixxed 

Distance Loweer 

Higher 

Trends Analysis Using ArcGIS and Spatial Statistics 

Kentucky’s Prescription Monitoring Program 

(*individual slides of maps available in separate slideshow) 

All Controlled 

SSubstances bstances Hd Hydrocodone d OOxycodone d MMethadone th d MMorphine hi VValium li XXanax 

Map project created by Neal L. Rosenblatt, Project Epidemiologist, CHFS OIT HSAD, 275 E. Main Street, LL W-1, Frankfort, KY 40601, (502) 564-0105 ext. 10460 

04/25/06. Updated June 20, 2006. 

Average Number of Prescriptions 

Dispensed 

2003-2005 

Average % Increase/Decrease 

Per 1,000 Resident Population, 2003-2005 

Total % Increase/Decrease 

Per 1,000 Resident Population, 2003-2005 

Spatial Autocorrelation/Hot Spot Analysis 

• Identifying spatial clusters of statistically 

significant high or low values 

• Total % increase/decrease per 1,000 resident 

population, 2003-2005 

Hot spots are depicted in dark red; that is, values that are 

higher g e tthan a tthe e mean ea for o the t e study aare e where e e tthese ese high g values a ues 

have been found to be near each other. Low values (cool 

spots), shown in yellow, indicate areas that are lower than the 

mean for the study area where they are found together. 

Directional Distribution Analysis 

• Measuring whether a distribution of features 

exhibits a directional trend 

• Total % increase/decrease per 1,000 resident 

population, 2003-2005

Average Prescriptions Dispensed By County 






Partnership Development 

Operation UNITE


LONDON 

HAZARD 

PRESTONBURG

Investigating Arrest Activities 

Partnering with Operation UNITE 


Field Office Locations 


UNITE Service Area 

Field Office Locations

Arrest Activity 2004-June 2006 


Apparent Activity Clustering 


Unit of Analysis: U.S. Census Block

Zooming In – Further Assessment 


Observing Possible Corridor Activity 


n=21

Examining Case Level Activities 


Crime Activity – Arrest Status 


Crime Activity – Arrest Status 


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Using spatial autocorrelation, hot spot 

analysis, and point-density analysis 

Confirming activity clusters and significance 

Operation UNITE

Spatial Autocorrelation Determination 

Z-score 

Z-scores at defined fixed distances (feet) 

30 27.1 Plug into Hot Spot Tool… 

25 

20 

15 

10 

5 

0 

50000 100000 150000 200000 250000 300000 350000 


Fixed Distance (feet)

Identifying “Hot Spots” 



Confirming Hot Spots with 

Point Density Analysis


Further Confirmation with 

Choropleth Mapping 

Count per Block

Final Confirmation 

PPoint i Density D i & &AArrest CCount OOverlay l 

By U.S. Census Block 



Treating Outliers

Directional Distribution – Hot Spot Area 


2005 2006 2004

Directional Distribution - Cumberland 


Directional Distribution – Big Sandy 


Concept Development 

Partnership 

Data Use 

Technical 

Development

Partnership Vision 

Crime 

Activities 

For Use By DEPPB 

Investigative 

C 

Reporting Only Reporting 

Crime 

Activity/ 

Arrest 

Status 

Report 

A B 

# Crimes 

Crime Location 

Clusters/Corridors 

Case Open/Close Status 

Case Status Location 

Providers 


A∩B∩C 

For Use By DEPPB 

Investigative 

Reporting Only Onl 

User 

Shoppers 

Diverting 

Provider/ 

Shopper 

Report 

List of Potential 

Diverting Providers 

Or Shoppers

Methods Summary 

Getting from here to there and from who to where where…

METHODS – Phase I: Geographic Targeting 

Prescriber 

# by ZIP 

A∩B 

Pharmacy 

# by ZIP 

#byCo. # by Co. Written Dispensed #byCo. # by Co. 

%↑ 

Filled 

Patient 

Per capita ZIP 


Aggregate Level 


Concept Data Development Analysis

METHODS – Phase II: Case Level Reporting 

Who? 

Where? 


Concept 

Prescriber 

Activity (%↑) 

Dispenser 


Crime 


Prescriber 

# by ZIP 

A 

B 

C 

A∩B∩C 

C Case L Level l Reporting R ti 

“Hot List” 

of Top 10 

%↑ 

Prediction Reporting 

Who? Where? 

Diverting 

Provider 

Crime 

Shopper 

Activity 

Report 

Crime 

Written Dispensed 

Pharmacy 

# by ZIP 

# by Co. # by Co. 

Filled 

Patient 

Per capita p ZIP 


Potential 

Data Development Where? Analysis 

List of Potential 

Diverting 

Prescribers, 

Dispensers, and/or 

Shoppers 

Crime 

Activity 

Report 

List of Locations 

Potential 

Clusters/Corridors 

Case Status 

Potential 

Who?

Thank You! 

KASPER Web site: 

http://www.chfs.ky.gov/KASPER

Kentucky All Schedule Prescription Electronic Reporting (KASPER)

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