Where Do Prescription Drug Monitoring Programs Fit in Safe Opioid Prescribing?

NATIONAL HARBOR, Md. — Prescription pain relievers are the second most commonly used substance, behind marijuana, among first-time drug users in the United States, 2012 data from the Substance Abuse and Mental Health Services Administration indicate. 

“Controlled substances are in most Americans’ medicine cabinets,” said Brett Badgley Snodgrass, BMSN, APRN, FNP-C, director of clinical operations at LifeLinc Pain in Memphis, Tennessee. “The perception is that prescription drugs are less addictive not as dangerous as obtaining street drugs from a dealer.”

There were 16,000 prescription opioid-related deaths in 2013, according to CDC. For every one death, there are 10 treatment admissions for abuse, 32 emergency department visits for misuse or abuse, 130 people with an abuse or addiction problem, and 825 non-medical prescription-opioid users. 

In a session at the American Academy of Pain Management 2015 meeting, Ms. Snodgrass explained how healthcare providers can use controlled substance monitoring databases to help curb this problem and improve appropriate opioid prescribing. 

In April 2012, the White House announced a federal strategy to address the problem of prescription drug abuse. The Prescription Drug Prevention plan outlined several goals, including: better education for both patients and healthcare providers, increased use of prescription drug monitoring programs (PMPs), implementing and promoting prescription drug disposal programs, and better law enforcement efforts to prevent illegal prescribing. 

“A PDP is a tool for collecting, managing, and analyzing prescription drug data from a given state, territory, district or commonwealth with the goal of preventing drug abuse and diversion, without preventing access to controlled substances for patients with legitimate medical needs,” said Ms. Snodgrass.

These programs can help identify potential prescription drug misuse and abuse, enable early intervention and treatment, and more efficient law enforcement investigations.

“Prescription drug monitoring programs are an invaluable tool for patient monitoring, treatment planning, and risk management, but utilization is unacceptably low with the exception of states that have legal mandates,” said Ms. Snodgrass. 

In 2015, PMPs were operational in 49 US states, with the exception of Missouri, and one US territory, Guam. Such programs capture a considerable amount of useful information including: patient information; the Drug Enforcement Administration (DEA) registration numbers of both healthcare providers and prescription drug dispensers; the dates prescriptions are written and dispensed; and drug information including the national drug code, quantity, number of days supplied, and whether a prescription is new or a refill. 

In addition to generating patient-, prescriber-, and pharmacy-specific reports, PMP users are also able to generate specialized reports based on specific medications or geographic region. Currently prescribing clinicians, pharmacists, law enforcement officials, licensing boards, and patients are all authorized to access PMP data. 

However, several limitations exist. These include a lack of interoperability among state PMPs that makes it hard to screen prescriptions across state borders, and lag time between when prescriptions are filled and reported into the system. 

Additionally, tech-savviness varies from person to person and many providers complain there is not enough time to provide quality patient care and also deal with the administrative work involved with accessing the database.

“PMPs may require extra time or extra staff to access records,” said Ms. Snodgrass. “I’ve designated a non-clinician employee in my office to check the system on my behalf.”

This does not involve sharing a single username or password, but requesting individual authorization for assigned to staff members to access the PMP, she clarified. 

Another limitation is the potential for error when entering information into the PMP. Ms. Snodgrass recalled several instances in which pharmacists reported her DEA number as the origin of prescriptions for attention-deficit hyperactivity disorder medications written by other prescribers within her practice. These errors can be fixed, but require time and effort on the part of healthcare providers. 

Despite these challenges, compelling evidence exists that PMPs are having a beneficial effect on opioid prescribing. A 2011 Fact Sheet form the Office of National Drug Control Policy indicated that when PMP data were used in the emergency department, prescribing habits were altered in 41% of cases — with 61% of those cases resulting in fewer or no opioid medications being prescribed than originally planned and 39% of cases resulting in more opioid medications being used than was planned prior to review.

Ms. Snodgrass called for better integration of PMPs into clinical practice. She encouraged clinicians to  sign up for their state’s PMP and to become familiar with that specific system and it’s limitations. Once clinicians have access to their state’s PMP they should check the database for all new and current patients and tailor monitoring efforts based on patient risk and state requirements. She also recommended notifying patients via either a general or individualized notice and incorporating this information into the patient agreement. 

If an unexpected report occurs, healthcare practitioners should take the following steps:

Confront the patient

• Explore whether the abused medication was for the patients own use or diversion
• Question if the patient gets the prescription medication from other sources, such as out-of-state prescribers, friends, family, or a dealer
• Discuss the risks associated with misuse and diversion
• Obtain consent to contact the patient’s other prescribing clinicians
• Make appropriate referrals for substance use disorder when necessary

She encouraged practitioners to establish clear practice guidelines for how to proceed if a unexpected report occurs. 

“Our profession must come to consensus on the indications for opioid pain medication and their appropriate use in managing acute and chronic pain,” said Ms. Snodgrass. “Ultimately, PMPs are just one piece of the puzzle. Better training is needed for responsible opioid prescribing.”

Disclosures: Brett Badgley Snodgrass is on speakers’ bureaus for Astrazeneca, Depomed Pharmaceuticals, and Iroko Pharmaceuticals.

Reference

1. Snodgrass BB. “The Prescription Drug Monitoring Program: Past, Present, and Future.” Presented at: AAPM 2015; Sept. 17-20, 2015; National Harbor, Maryland.