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An in-depth look at the effects of PDMPs, which are electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients.
Prescription drug abuse is an epidemic across the U.S., with an average of 44 people dying every day as a result of prescription opioid overdoses, according to the Centers for Disease Control and Prevention (CDC).
Nearly 2 million Americans abuse or are dependent on opioids, and abuse of these drugs costs the U.S. almost $56 billion each year in lost productivity, healthcare costs, and criminal justice costs, according to the CDC.
As the nation’s opioid epidemic continues to intensify, consider joining trailblazers from health plans, pharmacies and healthcare companies at CBI’s inaugural Prescription Drug Monitoring Programs. This summit will focus on the crucial elements of managing how drugs are prescribed, dispensed and reimbursed.
Diversion is another major problem. Fifty five percent of people who abuse prescription medications get them from friends or relatives, while only 17.3% abuse their own prescription, according to the CDC. The rest of abusers obtain medications by theft or illegal purchase.
There are many ways politicians and healthcare providers are working to combat these abuses, and the epidemic has even caught the attention of the White House, with President Barack Obama pledging $500 million in his 2017 budget to fight prescription drug abuse. A portion of those funds could go to helping states expand their prescription drug monitoring programs (PDMP).
PDMPs, which are already in use in some capacity in 49 states and are electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients, can be very effective, especially when used with other interventions, says Heather Gray, legislative director of the National Alliance for Model State Drug Laws.
“Not only can these programs help identify potential doctor shoppers (individuals receiving multiple prescriptions from multiple providers) they can also help healthcare providers identify patients who may be at risk of developing a substance use disorder or even overdose,” Gray says. “It is difficult to quantify the impact that these programs have had on the prescription drug abuse problem as oftentimes the enacting state legislation was passed as part of an overall revision of prescription drug laws; however, no one doubts that they have an important role to play in the fight against prescription drug abuse.”
PDMPs are primarily used by physicians and pharmacists to ensure that their patients are not receiving duplicate prescriptions or showing any other signs of abuse, misuse, or diversion. If abuse is suspected, the hope is that the physician will refer the patient for treatment or further evaluation.
Many state guidelines strongly suggest that if a physician suspects a patient is abusing prescription drugs, the physician should refer the patient for evaluation and treatment.
PDMPs also help identify any potential drug interactions that could be harmful to a patient. For example, if a patient is receiving benzodiazepines from one physician and opioids from another, the physician checking the PDMP will be alerted to that and may choose to reduce the dosage of opioids prescribed or might change to another pain reliever because of the high risk of overdose for patients taking both types of drugs.
The success of a state’s PDMP depends on the particulars of the program, but states with strong participation requirements seems to have robust positive results.
Woody McMillin, of the Tennessee Department of Health, says the state’s Controlled Substance Monitoring Database Program (CSMD) became mandatory in 2013, and appears to be helping.
“We have seen positive changes, including 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 CSMD by prescribers and extenders, and a change in practices, with some 41.4% less likely to prescribe certain controlled substances,” McMillin says.
Research from various organizations also points to promising results. In Florida, deaths related to oxycodone overdose dropped 25% after Florida implemented its PDMP in late 2011, according to a team of University of Florida Health researchers. 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, according to the PDMP Center of Excellence at Brandeis University. Also according to the PDMP Center of Excellence, 74% of California physicians reportedly changed their prescribing practice as a result of patient activity reports created using the state’s PDMP.
The only state that hasn’t adopted a PDMP is Missouri. Sen. Robert Schaaf is a long-time opponent of such a system.
“The people of Missouri do not want one,” Schaaf says. “There have been polls taken and I’ve had many people express concern about their right to privacy of their medical information. People don’t want their private medical information on a government database.”
Schaaf doesn’t believe that PDMPs have not been shown to reduce deaths from opioids, only from diversion, and there were even mixed results on that front. “The problem is that in states that have passed and PDMP, the usage of heroin has been known to increase,” Schaaf says.
In 2014, the CDC showed that overdose deaths related to opioid pain relievers quadrupled since 1999 and were at a historic high. The problem began, according to CDC, in the 1990s when opioid pain relievers were increasingly prescribed to treat what was believed to be a widespread problem of undertreated pain. As prescriptions for opioids climbed, so did overdose deaths.
Then, in recent years, heroin use began to climb as well, more than doubling from 2007 to 2012, according to the Substance Abuse and Mental Health Services Administration. Many healthcare providers attribute the rise in heroin addiction to opioid abuse, particularly when the prescription pipeline is shut off or becomes too costly.
“CDC’s analysis has found that more than three out of four people who reported both past-year opioid abuse and heroin use said they used opioids non-medically-that is, without a prescription or for the feeling or experience the drugs cause-prior to heroin initiation,” said Daniel Sosin, MD, MPH, FACP, acting director of the National Center for Injury Prevention and Control at CDC in his 2014 testimony on prescription drug and heroin abuse before the House Energy and Commerce Subcommittee on Oversight and Investigations. “In addition, more than seven out of 10 people who reported past-year heroin use also reported using opioids non-medically in the past year. From 2002 to 2011, first-time heroin use was 19 times higher among those reporting prior non-medical opioid use than among those who did not report using opioids non-medically.”
While concerning, Sosin noted that that the portion of heroin users who turned to the drug after using opioids is small-less than 4%.
Schaaf says he has offered to end his PDMP opposition if legislators would put the issue to a public vote and implement his alternative system that would deliver information to physicians about an individual’s prescription history on request, rather than provide them with an open database of patient medical records.
Schaaf says his proposal would create a state database that physician could access via a request on a patient’s status. An electronic reply would be returned from the state agency responsible for maintaining the database within seconds alerting the physician to any prescribing issues, he says.
“I know exactly what it’s like having someone looking up data on a monitor in a doctor’s office and how easy it would be to get the username and password of one of the people who have access to that database,” says Schaaf. “If we’re going to be asked to give up our liberty because other people are picking the law, it ought to at least be shown to be effective. The big problem isn’t people doctor shopping, it’s people getting a prescription and then selling it. The PDMP does nothing to stop that problem of people going to get their own prescription for their own medical problem.”
Missouri Rep. Holly Rehder, who introduced a House Bill to initiate a PDMP that has passed in the House for the last two years but stalled in the Senate, said in an editorial in the Springfield News-Leader, that numerous states have found success in their PDMPs. Her bill, which was expected to move along to the Senate for consideration in mid-February, never made it to the House floor-although a separate bill approving increased public access to naloxone (Narcan) was passed in the House by a vote of 154-2 and will move to the Senate. Narcan reverses the dangerous effects of opioids, including respiratory depression, and is a first-line emergency treatment for opioid abuse.
The Missouri Hospital Association (MHA) showed in a special report last year that inpatient or emergency department encounters related to opioid abuse increased by 137% in Missouri between 2005 and 2015. The report also suggests that as many as 3 out of 4 opioid abusers will eventually turn to heroin as a less-expensive option. MHA has issued its own recommendations for interventions to combat opioid use.
While the PDMP battle remains unsettled in Missouri, the Centers for Medicare & Medicaid Services (CMS) is taking action. CMS proposed late last year that it was considering adding a review of patient information on a state PDMP as part of revised discharge requirements, but the nearly 300 comments on the proposal were largely negative, with many raising questions about the standards in PDMP across the country.
“PDMP information is often incomplete, out of date and hard to access,” the Federation of American Hospitals wrote in a statement to CMS, and the American Medical Association (AMA) says the information in state databases can be misleading and be the result of uncoordinated care or legitimate prescriptions.
“We urge caution when looking at a data point rather than trying to understand the full scope of a patient's experience,” AMA wrote to CMS.
Other commenters pointed out that some states allow only physicians and pharmacists to access the databases, not nurses, making checking the PDMP before discharge a potential nightmare. Additionally, not many states are set up to share information with other states, and to do so would require considerable investment.
Several groups, such as the National Association of Psychiatric Health Systems and Johns Hopkins asked CMS to consider allowing physicians to keep searching patient information in the PDMP at their own discretion so as not to overwhelm the current work flow.
At press time, CMS had not yet posted any updates on the possible new rule following the closure of the comment period in early January.
Rachael Zimlich is a writer in Columbia Station, Ohio.