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Prescription Drug Monitoring Programs (PDMDs) are a cornerstone of the government’s platform to combat the opioid epidemic and have demonstrated to be highly effective in many facets of the United States’ healthcare system.(1-2) However, there are key aspects of modern PDMPs that have fallen short of their aims and require drastic improvements moving forward. Of primary concern is the fact that PDMPs lack the ability to compile comprehensive patient profiles for analyzing and identifying troublesome prescription behavior.(3-4) If they are to be efficacious in reducing “doctor shopping” behaviors in the target population, PDMPs require continuously updated patient data in order to assist physicians in better identifying these patterns of behavior. This problem is confounded by the fact that since unique PDMPs are implemented by each state, they lack standards in collecting and reporting data thus fatally limiting the interoperability of patient data between clinics and physicians even in neighboring states.(5-6) Moreover, PDMPs have come to be perceived as a major impediment to clinical workflow and physicians have voiced concerns of legal repercussions if they are not properly implemented and utilized.(7-11) Altogether, PDMPs have demonstrated massive potential at both the state and federal levels to curb opioid abuse, but the aforementioned impediments and limitations necessitate significant improvements across every state if they are to ever reach their full potential.
PDMPs excel at increasing accountability among, in particular high-volume, prescribers and patients. Implementation of a PDMP is associated with a decrease in controlled substance prescriptions, without an increase in illicitly obtained narcotics use.(12-15) Not only do PDMPs drive down the amount of opioids, measured in morphine milligram equivalence (MME), prescribed, but also help curb doctor and pharmacy shopping significantly.(16)
Although the abuse and over prescription of opioids and controlled substances affects an alarmingly high number of patients annually, it is believed the vast majority of fraudulent or otherwise malicious prescribing of the drugs is facilitated by a relatively a small number of doctors.(17-18) This is has been clearly depicted most recently by the arrests of thirty-two medical professionals in Tennessee at the beginning of April 2019 that were improperly prescribing opioids, sometimes in dangerous combination with other drugs.(19) While it is commendable that these healthcare workers were stopped, if indeed they are guilty of what they are accused, Tennessee has a robust PDMP and amongst the most stringent prescribing guidelines, so how did it happen in the first place?(20) This malpractice fell through the cracks, in part, because of a lack of interoperability between data already shared on the system. The state’s PDMP collects all the prescription data, and provides it upon request, but it does not actively send alerts or create unsolicited profiles of doctors and pharmacies and their respective prescribing habits.(21)
In Tennessee not only is it required to report to the state monitored PDMP every controlled substance prescribed, but the PDMP must be checked before any patient is prescribed a controlled substance. This is a commendable first step as such requirements have been found to make these programs far more effective.(22-23) The law, however, does not provide any guidance on verifying that a patient’s PDMP data was queried prior to a prescription being written. Including auditing software built into the system doctors use to access PDMP data is crucial for both validating that the law is being followed and providing documentation of good practice for doctors who have already been following the letter of the law.
Requiring the PDMP to be consulted before any patient is prescribed a controlled substance helps to remove unintentional biases from the prescribing process as well as general human error. In a recent study, physicians expressed confidence in their ability to spot a substance use disorder (SUD) in their respective patient populations.(24) However, when provided with more context surrounding patients’ drug history, many of these doctors were surprised by who presented with a SUD.(25) Research has shown that substance abuse training utilizing actors in primary care settings can help doctors recognize and treat SUDs.(26)
This study also cast light on a disturbing trend among prescribers: upon discovery of a patient’s SUD, doctors who were not waivered to prescribe buprenorphine were likely to discontinue care for the patient, even in the face of Health and Human Services and Center for Disease Control guidelines explicitly advocating the opposite approach.(27) This cuts the patient off from not only SUD intervention, but also all other primary care they would receive from their doctor. In contrast the primary care physicians waivered to prescribe buprenorphine, who received further addiction centric education, advocate that addiction treatment can, and in light of the scale of addiction in the country often should, be performed at the primary care level.(28) Governmental bodies need to incentivize doctors, monetarily or otherwise, to treat those with SUDs to combat the stigma, both perceived and real, surrounding patients with addiction.
As doctors scramble to comply with new PDMP reporting requirements and attempt to implement their new duties into their existing work routine, they will be faced with major disruptions.(29) Additionally there is fear among physicians that any oversight at all could result in criminal prosecution, especially when faced with a nationwide crackdown on opioid prescribing.(30) Doctors harbor concerns that outside of making consultations take longer, PDMP usage lowered their patient satisfaction scores by refocusing their attention from patient pain management to opioid reduction.(31) By increasing the accessibility of patient data to doctors, and carefully monitoring who accesses the data and when, healthcare providers can feel more confident they have the records to prove they are following the strictures of their state’s laws.
Beyond requiring mandatory reporting to PDMPs, states should move towards PDMP systems that utilize unsolicited reporting techniques to alert prescribers, pharmacists, and if needed the pharmacy board or law enforcement, to any unusual prescription activity. Studies indicate that unsolicited reports are associated with more positive patient outcomes.(32) PDMP agencies should also strive for more interagency cooperation, both in terms of data sharing, and to share effective techniques they have developed.(33)
The burgeoning field of distributed ledger technology offers novel approaches to data sharing that, if implemented, would provide unparalleled data inter and intra-operability. Within a distributed ledger network each entity owns the data they create and share that data through automatic transactions with other credentialed users. These automatic transactions rely on a layer of code called ‘chaincode’, or colloquially ‘smart contracts’, that verify that every submitted transaction follows a preset, and pre-agreed-upon, set of rules. Smart contracts eliminate the need for a third party to verify each transaction, opening the door for a nationwide PDMP that can share data easily between states while automatically staying compliant with varying state privacy laws.
Accurately applying data across prescribers treating patients with varying needs is difficult and could benefit from modern data analytics.(34) In the future PDMPs should focus on increasing transparency of operation and involving patients and the community in its implementation.(35) Mind also needs to be paid to those with chronic pain and disabilities who are often left behind as regulations sweep through opioid prescribing.(36) It would seem doctors would be more inclined to use a system that minimized disruptions to their workflow and/or time with patients, while automatically documenting prescriber use of a PDMP to help ease fear of legal repercussions.(37) This would help strike a balance between assuaging doctors’ concerns surrounding legal culpability while still empowering them to be mindful of
the quantity of highly addictive opioids they are prescribing.
1. Bachhuber, M. A., et al. (2019). "Impact of a prescription drug monitoring program use mandate on potentially problematic patterns of opioid analgesic prescriptions in New York City." Pharmacoepidemiol Drug Saf 28(5): 734-739.
2. Ali MM, Dowd WN, Classen T, Mutter R, Novak SP. Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: Evidence from the National Survey of Drug Use and Health. Addict Behav. 2017;69:65-77.
3. Chang HY, Lyapustina T, Rutkow L, et al. Impact of prescription drug monitoring programs and pill mill laws on high-risk opioid prescribers: A comparative interrupted time series analysis. Drug Alcohol Depend. 2016;165:1-8.
4. Grecu AM, Dave DM, Saffer H. Mandatory Access Prescription Drug Monitoring Programs and Prescription Drug Abuse. Journal of policy analysis and management : [the journal of the Association for Public Policy Analysis and Management]. 2019;38(1):181-209.
5. Griggs CA, Weiner SG, Feldman JA. Prescription drug monitoring programs: examining
limitations and future approaches. The western journal of emergency medicine. 2015;16(1):67-70.
6. Radomski TR, Bixler FR, Zickmund SL, et al. Physicians' Perspectives Regarding Prescription Drug Monitoring Program Use Within the Department of Veterans Affairs: a Multi-State Qualitative Study. Journal of general internal medicine. 2018;33(8):1253-1259.
7. Griggs CA, Weiner SG, Feldman JA. Prescription drug monitoring programs: examining
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8. Irvine JM, Hallvik SE, Hildebran C, Marino M, Beran T, Deyo RA. Who uses a prescription drug monitoring program and how? Insights from a statewide survey of Oregon clinicians. J Pain. 2014;15(7):747-755. (Islam et al 2014)
9. Islam MM, McRae IS. An inevitable wave of prescription drug monitoring programs in the
context of prescription opioids: pros, cons and tensions. BMC pharmacology & toxicology. 2014;15:46.
10. Radomski TR, Bixler FR, Zickmund SL, et al. Physicians' Perspectives Regarding Prescription Drug Monitoring Program Use Within the Department of Veterans Affairs: a Multi-State Qualitative Study. Journal of general internal medicine. 2018;33(8):1253-1259.
11. Greenwood-Ericksen MB, Poon SJ, Nelson LS, Weiner SG, Schuur JD. Best Practices for Prescription Drug Monitoring Programs in the Emergency Department Setting: Results of an Expert Panel. Ann Emerg Med. 2016;67(6):755-764.e754.
12. Ali MM, Dowd WN, Classen T, Mutter R, Novak SP. Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: Evidence from the National Survey of Drug Use and Health. Addict Behav. 2017;69:65-77.
13. Brady JE, Wunsch H, DiMaggio C, Lang BH, Giglio J, Li G. Prescription drug monitoring and dispensing of prescription opioids. Public health reports (Washington, DC : 1974).
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14. Moyo P, Simoni-Wastila L, Griffin BA, et al. Impact of prescription drug monitoring programs (PDMPs) on opioid utilization among Medicare beneficiaries in 10 US States. Addiction. 2017;112(10):1784-1796.
15. Moyo P, Simoni-Wastila L, Griffin BA, et al. Impact of prescription drug monitoring programs (PDMPs) on opioid utilization among Medicare beneficiaries in 10 US States. Addiction. 2017;112(10):1784-1796.
16. Bachhuber, M. A., et al. (2019). "Impact of a prescription drug monitoring program use mandate on potentially problematic patterns of opioid analgesic prescriptions in New York City." Pharmacoepidemiol Drug Saf 28(5): 734-739.
17. Chang HY, Lyapustina T, Rutkow L, et al. Impact of prescription drug monitoring programs and pill mill laws on high-risk opioid prescribers: A comparative interrupted time series analysis. Drug Alcohol Depend. 2016;165:1-8.
18. Lin HC, Wang Z, Boyd C, Simoni-Wastila L, Buu A. Associations between statewide prescription drug monitoring program (PDMP) requirement and physician patterns of prescribing opioid analgesics for patients with non-cancer chronic pain. Addict Behav. 2018;76:348– 354.
19. https://www.tennessean.com/story/news/health/2019/04/17/opioids-32-tennessee-doctors-nurses-medical-professionals-charged-takedown/3496172002/
20. https://www.tn.gov/opioids/education-and-prevention/laws-and-policies.html
21. https://www.tn.gov/health/health-program-areas/health-professional-boards/csmd-board/csmd-board/faq.html
22. Ayres I, Jalal A. The Impact of Prescription Drug Monitoring Programs on U.S. Opioid
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23. Allen, B., Harocopos, A., & Chernick, R. (2019). Substance Use Stigma, Primary Care, and the New York State Prescription Drug Monitoring Program. Behavioral Medicine, 1–11.
24. Allen, B., Harocopos, A., & Chernick, R. (2019). Substance Use Stigma, Primary Care, and the New York State Prescription Drug Monitoring Program. Behavioral Medicine, 1–11.
25. Parish SJ, Ramaswamy M, Stein MR, Kachur EK, Arnsten JH. Teaching about substance abuse with objective structured clinical exams. J Gen Intern Med. 2006;21(5):453–459.
26. Centers for Disease Control and Prevention. Checking the PDMP: An Important Step to Improving Opioid Prescribing Practices. cdc.gov. https://www.cdc.gov/ drugoverdose/pdf/pdmp_factsheet-a.pdf. Updated August 30, 2017.
27. Allen, B., Harocopos, A., & Chernick, R. (2019). Substance Use Stigma, Primary Care, and the New York State Prescription Drug Monitoring Program. Behavioral Medicine, 1–11.
28. Lowry R. Using drug monitoring programs to optimize pain management for elective surgery
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29. Griggs CA, Weiner SG, Feldman JA. Prescription drug monitoring programs: examining
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30. Islam MM, McRae IS. An inevitable wave of prescription drug monitoring programs in the
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31. Penm J, MacKinnon NJ, Connelly C, et al. Emergency Physicians' Perception of Barriers and Facilitators for Adopting an Opioid Prescribing Guideline in Ohio: A Qualitative Interview Study. J Emerg Med. 2019;56(1):15-22.
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33. Rutkow, L., et al. (2017). "Prescription drug monitoring program design and function: A qualitative analysis." Drug Alcohol Depend 180: 395-400.
34. Penm J, MacKinnon NJ, Connelly C, et al. Emergency Physicians' Perception of Barriers and Facilitators for Adopting an Opioid Prescribing Guideline in Ohio: A Qualitative Interview Study. J Emerg Med. 2019;56(1):15-22.
35. Yuanhong Lai A, Smith KC, Vernick JS, Davis CS, Caleb Alexander G, Rutkow L. Perceived Unintended Consequences of Prescription Drug Monitoring Programs. Substance use & misuse. 2019;54(2):345-349.
36. Radomski TR, Bixler FR, Zickmund SL, et al. Physicians' Perspectives Regarding Prescription Drug Monitoring Program Use Within the Department of Veterans Affairs: a Multi-State Qualitative Study. Journal of general internal medicine. 2018;33(8):1253-1259.
37. Chang HY, Lyapustina T, Rutkow L, et al. Impact of prescription drug monitoring programs and pill mill laws on high-risk opioid prescribers: A comparative interrupted time series analysis. Drug Alcohol Depend. 2016;165:1-8.