Expand and Enhance Prescription Drug Monitoring Programs (PDMPs)

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Introductory Paragraph

Prescription Drug Monitoring Programs (PDMPs) are designed to collect, monitor, and analyze electronically transmitted prescribing and dispensing data submitted by pharmacies and dispensing practitioners. This information is used to assist prescribers, dispensers, and other health care professionals in making clinical decisions for their patients. PDMPs also have been shown to reduce adverse drug interactions and help health care professionals identify patients who may be in need of substance use treatment. Law enforcement and regulatory/licensing board officials utilize PDMP information, under appropriate circumstances, to further their investigations of suspected violations of controlled substance laws and compliance with regulatory/licensing board practice standards. Many states have begun to use PDMPs as a public health surveillance tool. PDMPs continue to be among the most promising state-level interventions to improve opioid prescribing, inform clinical practice, and protect patients at risk. [1] PDMPs allow access to timely patient-controlled substance history information by pre-registered users including: [2]

  • healthcare prescribers licensed to prescribe controlled substances
  • pharmacists authorized to dispense controlled substances
  • law enforcement
  • regulatory boards

Key Information

States are working to find ways to increase the use of PDMPs by prescribers. In some states, PDMP registration is automatic when practitioners apply for a license. There are also efforts to integrate PDMP data into electronic medical record systems, so the information is available at the point of care. [3] The main objectives of PDMPs are to:

  • Improve patient safety.
  • Build a data collection and analysis system at the state level.
  • Facilitate the exchange of collected prescription data among states.
  • Enhance existing programs' ability to analyze and use collected data.
  • Assess the efficiency and effectiveness of the programs funded under this initiative. [4]

PDMPs can alert healthcare providers to provide potentially lifesaving information and interventions, but they DO NOT dismiss patients from care. [5] PDMPs foster collaboration with patients, such as tapering to a safer dosage or consideration of Naloxone. They provide a catalyst to weigh patient goals, needs, risk and offer opportunities to discuss safety concerns and treatment options, if opioid use disorder is suspected.

Benefits

In addition to patient safety, PDMPS have the benefit of increasing communication with other providers managing the patient

  • Between the years 2010-2012, Florida implemented a PDMP and other "pill mill" policies that had a positive impact on the opioid epidemic. According to the CDC, Florida recorded a 26.1% decrease in opioid analgesic overdose deaths, after these policies were implemented. [6] The Florida Department of Health reported that from 2010 to 2013, Oxycodone overdose deaths fell from 1,516 to 534—a 65% decrease. [7]
  • New York experienced a 75% decrease in prescriptions issued through "doctor shopping" as a result of a 2012 requirement that prescribers check the PDMP before writing a prescription.
  • 74% of California physicians changed their prescribing practice as a result of patient activity reports created using the state's PDMP.
  • After establishing a PDMP, Tennessee saw a reduction in the morphine milligram equivalents dispensed, a reduction in the number of doctor and pharmacy shoppers going to multiple outlets to obtain drugs, an increase in queries to the State's Controlled Substance Monitoring Database Program by prescribers and extenders, and a change in practices, with some 41.4% less likely to prescribe certain controlled substances

Challenges

  • Increased drug diversion activities in contiguous states. When states begin to monitor drugs, drug diversion activities tend to spill across boundaries to non-PDMP states. One example was provided by Kentucky, which shares a boundary with seven states, only two of which had PDMPs at the time -- Indiana and Illinois. As drug diverters became aware of Kentucky PDMP's ability to trace their drug histories, they tended to move their diversion activities to nearby non-monitored states. OxyContin diversion problems worsened in Tennessee, West Virginia, and Virginia -- all contiguous non-PDMP states -- because of the presence of Kentucky's PDMP, according to a joint federal, state, and local drug diversion report. [8]
  • Insufficient Resources. Providers lack the time within their practice to perform all activities (not staffed sufficiently, not reimbursed, not value-added). Virtually every knowledge and use survey for PDMPs, for example, shows only half of physicians use the PDMP and the reasons cited for not using it are "it's too time consuming" and "it's too difficult to use." ("I need to see a patient every 12 minutes to make ends meet, I do not have the time or capacity to do all of this work.")
  • Patient-Provider Relationship. The design of many programs tends to compromise the trust between patients and physicians because the providers are required to police their patients, and this is not something physicians see as part of their role as care providers. ("I did not go to medical school for this. I need a trusting relationship with the patient, which is not possible when I ask to count their pills.")
  • Data Management. There is no automation support for any of this activity today, no field within the EMR to enter the risk-adjusted monitoring protocols or schedule patient activities according to risk levels. There is no place to store the results of a pill count or PDMP check or alert the physician when a treatment agreement needs to be updated.
  • Consistency. Whether it is patients within a practice, practices within a network, or health systems within the state -- getting everyone to establish and adhere to protocols consistently is a challenge, yet inconsistent application of protocols is one of the greatest liabilities for any provider.

Funding

Currently PDMP funding is available through:

  • Federal grants
  • Private/Non-federal grants
  • General revenue funds
  • Controlled substance registration fees
  • Professional licensing fees
  • Regulatory board funds

Potential additional funding sources include: [9]

  • PDMP licensing fees
  • Health insurance licensing fees
  • Private donations
  • Medicaid fraud settlements
  • Assessed fines
  • Asset Forfeiture
  • Drug manufacturers' assessment
  • Prescription fees
  • Private third-party payers or health insurers
  • PDMP authorized users

Relevant Research

  • The CDC has performed a detailed literature review of clinical research. [10]
  • The Pew Charitable Trust published a report "Evidence-Based Practices to Optimize Use of PDMPs." [11]

Impactful Federal, State, and Local Policies

The Prescription Drug Monitoring Program was created by the FY 2002 U.S. Department of Justice Appropriations Act (Public Law 107-77).

The Comprehensive Opioid, Stimulant, and Substance Use Program (COSSUP), formerly the Comprehensive Opioid Abuse Program (COAP), was developed as part of the Comprehensive Addiction and Recovery Act (CARA) legislation. COSSUP is managed through the Bureau of Justice Assistance (BJA) within the US Department of Justice. COSSUP’s purpose is to provide financial and technical assistance to states, units of local government, and Indian tribal governments to develop, implement, or expand comprehensive efforts to identify, respond to, treat, and support those impacted by illicit opioids, stimulants and other drugs.[12] PDMPs are an integral component of this mission.

The National Alliance for Model State Drug Laws (NAMSDL) began in 1993 as the President’s Commission on Model State Drug Laws. [13] NAMSDL provides examples of PDMP laws and documents from states with PDMPs. It also provides information on:

  • Administration of PDMPs
  • Data reporting and retention
  • Types of authorized recipients
  • Access and registration
  • PDMPs and privacy

Most states have developed drug-tracking systems to allow physicians and pharmacists to check patients’ prescription drug use, including opioid painkillers, to determine whether they may be receiving too many pills, at too high a dose or in dangerous combination with other medications such as sedatives and muscle relaxants. However, few prescribers took advantage of the systems. Until states began requiring physicians to use PDMPs, fewer than 35 percent of medical professionals used the tracking systems to identify patients who may be at risk for addiction and overdose. Now, in states that require doctors to consult PDMPs, physician usage rates exceed 90 percent. [14] Overall opioid prescribing has declined in those states as well, as have drug-related hospitalizations and overdose deaths. States also are seeing a rise in addiction treatment as more doctors refer patients to treatment after discovering they are taking painkillers from multiple sources and are likely addicted.

  • In 2010, Colorado, Delaware, Louisiana, Nevada and Oklahoma were the first states to require doctors and other prescribers to search patients’ drug histories before prescribing opioid painkillers, sedatives or other potentially harmful and addictive drugs. By December 2016, at least 31 states were requiring prescriber use of PDMPs.
  • In 2017, eight more states — Alabama, Alaska, California, Florida, Michigan, South Carolina, Texas and Wisconsin — implemented policies requiring doctors to not only log in to the state’s prescription drug-tracking system before prescribing a controlled substance, but also to analyze each patient’s history of drug use, and if necessary, limit prescription renewals for opioids and other potentially addictive or dangerous medications.[15]

Available Tools & Resources

SAFE Project:

  • See the wiki titled "Improve Prescribing Practices" for more detailed information on how healthcare professionals can can help prevent dependence on pain medications by improving education, regulating pharmaceutical advertising, and limiting industry influence on prescribing practices.[16]

The Bureau of Justice Assistance (BJA) manages the Harold Rogers PDMP which a major source of federal funding for PDMP projects. It enhances the capacity of regulatory and law enforcement agencies and public health officials to collect and analyze controlled substance prescription data and other scheduled chemical products through a centralized database administered by an authorized agency. This program assists state, local, and tribal efforts to break the cycle of substance abuse and misuse by reducing the demand for, use, and illegal trafficking of controlled substances. [17]

PDMP TTAC (Training Technical Assistance Center) at Brandeis University, in partnership with the BJA, provides services, support, resources, and strategies to improve the effectiveness of state PDMPs. [18]

The CDC provides general guidance on PDMPs. [19]

American Association of Nurse Practitioners provides an index of state PDMPS. [20]

Prescription Drug Monitoring Information Exchange (PMIX). This enables nationwide information sharing by the use of free, open, and consensus-based solutions. PMIX provides common formatting of shared data, security and privacy protocols to protect sensitive information, and preserves the state choice of interstate sharing solutions. [21]

Promising Practices

  • The CDC recommends that state-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. [22] It has highlighted several states with promising PDMP programs. Oregon was recognized for its successful PDMP implementation, its use of the Core State Violence and Injury Prevention Program, and training collaborative for physicians and allied health care professionals on safe and effective pain care. [23] While PDMPs are now available in all 50 states, requirements vary from state to state. [24]
  • Arizona. The State Board of Pharmacy Controlled Substances Prescription Monitoring Program (CSPMP) allows practitioners and pharmacists to look up, view, and print controlled substance dispensing information on their specific patients directly via username and password. [25] Quarterly report cards are prepared and distributed by the state's PDMP. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.
  • California. CURES is the name of the California PDMP. [26]
  • Florida's PDMP has been in effect since 2010 [27] with annual reports available for each year. [28] The website also includes a list of its funding sources. [29]
  • Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.
  • Ohio's PDMP created a "Practice Insight Report" providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: (a) top 25 patients by number of other prescribers visited in past 12 months, (b) top 25 patients by MME, (c) top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, and (d) a listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months. Ohio also developed the "safety checkpoints" approach to minimize inappropriate prescriptions but still allow people who need them to be able to get them--with some added precautions. [30]
  • Oregon and Washington use the Emergency Department Information Exchange (EDIE) system. This technology allows ED practitioners to identify patients with more than five ER visits in a one-year period or those with complex care needs who can be directed to appropriate care. This system allows for alerts to hospitals as soon as a patient visits the ER. [31]
  • West Virginia doctors are ranked based on how much they prescribe.

Sources

 

  1. ↑ Comprehensive Opioid Abuse Site-based Program FY 2017 Competitive Grant Announcement, U.S. Department Of Justice, Office of Justice Programs, Bureau of Justice Assistance, Retrieved from https://bja.ojp.gov/library/publications/comprehensive-opioid-abuse-site-based-program-fy-2017-competitive-grant
  2. ↑ PDMP/CURES. (n.d.). Retrieved November 24, 2019, from https://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/PDMP-CURES.html
  3. ↑ Psychiatry & Behavioral Health Learning Network. (n.d.). Retrieved November 24, 2019, from https://www.psychcongress.com/article/how-monitor-prescription-drugs
  4. ↑ Bureau of Justice Assistance—Comprehensive Opioid Abuse Program (COAP). (n.d.). Retrieved November 24, 2019, from https://www.bja.gov/ProgramDetails.aspx?Program_ID=72#horizontalTab1
  5. ↑ https://www.cdc.gov/opioids/healthcare-professionals/pdmps.html
  6. ↑ Decline in Drug Overdose Deaths After State Policy Changes—Florida, 2010–2012. (n.d.). Retrieved November 24, 2019, from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a3.htm
  7. ↑ Rutkow, L., Chang, H.-Y., Daubresse, M., Webster, D. W., Stuart, E. A., & Alexander, G. C. (2015). Effect of Florida’s Prescription Drug Monitoring Program and Pill Mill Laws on Opioid Prescribing and Use. JAMA Internal Medicine, 175(10), 1642–1649. https://doi.org/10.1001/jamainternmed.2015.3931
  8. ↑ Diversion of Prescription Drugs. (n.d.). Retrieved November 24, 2019, from Drug War Facts website: https://www.drugwarfacts.org/chapter/diversion
  9. ↑ Technical Assistance Guide, No.04-13, Prescription Drug Monitoring Program Training and Technical Assistance Center, Brandeis University, July 3, 2013. Retrieved from https://www.pdmpassist.org
  10. ↑ https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
  11. ↑ http://www.pewtrusts.org/en/research-and-analysis/reports/2016/12/prescription-drug-monitoring-programs
  12. ↑ Bureau of Justice Assistance—Comprehensive Opioid Abuse Program (COAP). (n.d.). Retrieved November 24, 2019, from https://www.bja.gov/ProgramDetails.aspx?Program_ID=72#horizontalTab1
  13. ↑ https://namsdl.org/model-laws/
  14. ↑ In Opioid Epidemic, States Intensify Prescription Drug Monitoring. (n.d.). Retrieved November 24, 2019, from https://www.govtech.com/policy/In-Opioid-Epidemic-States-Intensify-Prescription-Drug-Monitoring.html
  15. ↑ In Opioid Epidemic, States Intensify Prescription Drug Monitoring. (n.d.). Retrieved November 24, 2019, from https://www.govtech.com/policy/In-Opioid-Epidemic-States-Intensify-Prescription-Drug-Monitoring.html
  16. ↑ https://www.yoursafesolutions.us/wiki/Improve_Prescribing_Practices
  17. ↑ https://bja.ojp.gov/funding/opportunities/o-bja-2022-171290
  18. ↑ http://www.pdmpassist.org/
  19. ↑ https://www.cdc.gov/drugoverdose/pdmp/
  20. ↑ https://www.aanp.org/advocacy/advocacy-resource/policy-briefs/issues-at-a-glance-prescription-drug-monitoring-programs-pdmp
  21. ↑ [20]Prescription Drug Monitoring Programs: Critical Information Sharing Enabled by National Standards, Retrieved from https://bja.ojp.gov/sites/g/files/xyckuh186/files/media/document/PMIXArchitecture.pdf
  22. ↑ https://www.cdc.gov/drugoverdose/pdmp/
  23. ↑ https://www.cdc.gov/drugoverdose/policy/successes.html
  24. ↑ https://www.aanp.org/advocacy/advocacy-resource/policy-briefs/issues-at-a-glance-prescription-drug-monitoring-programs-pdmp
  25. ↑ https://pharmacypmp.az.gov/
  26. ↑ https://oag.ca.gov/cures/faqs
  27. ↑ http://www.floridahealth.gov/statistics-and-data/e-forcse/
  28. ↑ http://www.floridahealth.gov/statistics-and-data/e-forcse/news-reports/index.html
  29. ↑ http://www.floridahealth.gov/statistics-and-data/e-forcse/funding/index.html
  30. ↑ https://www.pharmacy.ohio.gov/Documents/Pubs/Newsletter/2019/State%20Board%20Newsletter%20(February%202019).pdf
  31. ↑ https://www.hcinnovationgroup.com/policy-value-based-care/medicare-medicaid/blog/13022596/improving-emergency-department-information-flow-in-the-pacific-northwest
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