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How to monitor prescription drugs

June 24, 2015
by Brian Albright
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Driven by a dramatic increase in prescription drug overdoses and misuse over the past decade, state prescription monitoring programs (PMPs) have gradually rolled out in 49 states. Twenty-four of those states mandate the use of PMPs by prescribers.

The lone hold out is Missouri. But earlier this year, after years of opposition and delays, the state senate finally brought forth a compromise bill that would establish a PMP. If it passes, Missouri prescribers and pharmacists would be able to use the PMP database to more quickly identify potential prescription abuse in the state.

Initially conceived as a way to prevent diversion, PMPs have slowly evolved into a healthcare tool, leveraging data from pharmacies to help physicians identify potential prescription drug abuse among their patients. The tool can flag individuals who have filled an unusual number of prescriptions for opioids, for example.

But the transition from database to point-of-care prevention tool has not always been a smooth one.

Prescribers have historically pushed back against PMP prechecks because they consider them an administrative burden and because of logistical flaws. It can be cumbersome to access the PMP, and the data is typically not well integrated into existing workflows. Data within the PMP may also be difficult to interpret, incomplete or even provide information on multiple patients with similar names, which the prescriber has to further distill.

Programs vary

The lack of adoption has led to inconsistent monitoring.

Research firm Abt Associates analyzed 146.1 million opioid prescription records and identified a small group (0.7 percent) that purchased a disproportionate 2 percent of all such prescriptions and 4 percent of the total amount of opioid drugs, if measured by weight. On average, these outliers obtained 32 opioid prescriptions from 10 different doctors in a 10-month period. They were able to do so because physicians inconsistently checked the PMP database, and in many cases, were not able to access information from other state PMPs.

“Initially, a lot of the data was out of date because most pharmacies were only required to report twice a month or monthly, but that has changed so that the information is updated weekly or daily,” says Heather Gray, legislative director at the National Alliance for Model State Drug Laws (NAMSDL). “Access has been a challenge, but that is getting easier, and a lot of states now allow the use of delegates, so nurses can pull PMP reports for the physicians.”

More improvements could be on the way. The Centers for Disease Control and Prevention received $20 million in 2015 for its Prescription Drug Overdose Prevention for States program to target states with high levels of prescription drug overdose issues. Part of that funding will include enhancements to PMPs for states that apply for the grants. There are also efforts underway to make it easier for PMPs to share data across state lines.

PMP structures vary by state in terms of how they are accessed, how integrated the data is with healthcare systems, and how they are implemented. While nearly half of states now mandate use by prescribers, how that works at the practical level also varies quite a bit.

“In 2015, we’re seeing additional state legislatures proposing mandates now,” says Sherry Green, CEO and manager of Sherry L. Green & Associates and a consultant with the National Association of State Controlled Substances Authorities (NASCSA). “But there’s no real uniformity in terms of the circumstances of that mandate.”

For example, in New York, doctors have to check the PMP every time they prescribe a Schedule II, III or IV substance (with some specific exceptions). In New Mexico, physicians check on new patients being prescribed Schedule II, III or IV substances for more than 10 days. Generally, mandates result in more queries of the database and a reduction in opioid prescription rates.

Are PMPs worthwhile?

Mandated or not, use of PMPs can curtail doctor shopping, which is why pressure has mounted on Missouri to establish a program. Studies conducted in multiple states have shown that PMPs with active physician and pharmacy participation can reduce the overall rate of opioid prescriptions, alter physician prescribing practices, and in some instances, reduce the number of prescription opioid-related overdoses.

For example, in the first year after the inception of the PMP in Florida, the state reported that doctor shopping declined by 35 percent, while overall drug deaths fell by 6.3 percent. Deaths attributable to oxycodone overdose fell by 18 percent.

A handful of lawmakers in the Show Me State, led by state Senator (and physician) Rob Schaaf, have routinely blocked PMP legislation. Schaaf generally cites privacy concerns as the source of his opposition, along with a general disregard for those who have addictions.

“If they overdose and kill themselves, it just removes them from the gene pool,” Schaaf reportedly said during his 2012 filibuster.

Missouri’s now unique position has made it a destination for people from neighboring states hoping to fill prescriptions with no oversight. That reality has local law enforcement, pharmacists, state medical associations, and even the White House insisting that Missouri get on board with a PMP.

“Over the past 20 years, as states have begun to adopt PMPs, we can see the impact on neighboring states,” Green says. “Pharmacists in Missouri are reporting that people come from other states to get those prescriptions filled there, and there is more criminal activity on the borders with those other states.”

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I certainly agree that PMP's have a significant place in the treatment compliance for non-malignant pain management patients. Compliance by providers is virtually a universal issue given the meager resources in the daily administration of medical services, but given the national epidemic, it is a necessary or ought to become necessary component of pain management treatment protocols.

Of additional concern is the trending per patient in a pain management setting as to understanding the treatment plan and willingness to explore other options open to the patient for pain amelioration. Follow ups on additional treatment plan components are just as necessary to drive home the global plan of care, such as compliance with physical therapy, home exercises, mental health improvements, and family "by-in" to the patient's care.

That is the rational behind the Pain Patient Compliance scale

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