All but one state has established a prescription drug monitoring program (PDMP), with California being the first in 1939, and Missouri remaining the lone holdout. Such databases have indeed made it more difficult for individuals to go doctor shopping for prescription medication, but research is still ongoing as to what type of impact PDMPs are having on reducing opioid overdose deaths and improving interventions.
There is evidence that they are valuable. Overall, PDMPs have helped reduce instances of doctor shopping, reduced the overall number of opioid prescriptions being written and helped physicians intervene earlier when it appears patients may be abusing or diverting pain medication. And there is some tentative evidence that they are reducing overdose deaths as well.
However, without access to comprehensive treatment services or standard protocol for what physicians should do once they identify a patient that may have a substance use problem, states have not adequately addressed the crux of the opioid crisis: Denied access to prescription opioids, many individuals often turn to diverted sources or illicit opioids like heroin.
While prescription-opioid-related deaths are beginning to level off or even decline in some regions, heroin overdose deaths increased by 39% between 2012 and 2013, and rose 20.6% between 2014 and 2015, according to the Centers for Disease Control and Prevention (CDC). A 2014 study published in JAMA Psychiatry found that 75% of more recent heroin users began opioid use via prescription drugs.
However, there is still significant work to be done when it comes to effectively using PDMPs as clinical tools to help identify and treat those with addiction.
“We have to be realistic,” says Sherry L. Green, president of the National Alliance for Model State Drug Laws (NAMSDL). “The PDMP helps identify people whose pattern of behavior suggests an abuse or addiction problem. It’s an identification tool for prescribers. But we can’t just stop there. If we are going to refer someone, we need to make sure we follow through that process systematically and not only refer them but have the resources to make sure we’re getting them the help they need. That piece is not getting as much focus in this country as it should be.”
While doctors have often voiced complaints about using PDMPs—particularly when mandates are in effect—resistance to them is not nearly what it was earlier in the decade.
“I don’t think there are really any more general objections to the concept of the program, but there are still legitimate concerns being raised about transforming these PDMPs into better healthcare tools,” Green says.
More states have shifted to automated registration to make the databases easier for physicians in their daily workflow. There are also efforts to better integrate PDMP queries with existing clinical systems and to allow other staff to make those queries, to help make the process more efficient.
“We’re seeing efforts to fit the PDMP into the workflow,” says Cynthia Reilly, director of the Pew Charitable Trusts’ substance use prevention and treatment initiative. “In some cases, they can integrate the PDMP into other health IT systems. In New Jersey, there is a mobile app. There are a lot of strategies to decrease the burden on prescribers.”
There’s also a second challenge facing physicians in that most are not trained to have discussions about addiction with their patients.
“Having the data from the PDMP can actually help them have that conversation because they can point to that data,” says Peter Kreiner, principal investigator at the Prescription Drug Monitoring Program Training and Technical Assistance Center (PDMP TTAC) at Brandeis University. “But often there is a lack of treatment resources, or the doctor or practice may not have the information about what sort of treatment resources are available.”
Measuring PDMP effectiveness
PDMPs are being studied both at the state and federal level using a number of different measures to gauge effectiveness. In general, the most common data involve the opioid prescribing rate and the number of multi-provider incidents (doctor shopping) that occur. There are some limits to these outcomes, given that prior to PDMP, implementation there is little or no data to compare.
More research is coming, experts say.
“I can tell you based on the calls we get that there is an increase in the number of researchers who are trying to assess the impacts of these programs,” Green says.
According Reilly, assessments vary from state to state. In some cases, there are large formal projects in conjunction with local universities; in others, the data is collected by state health departments and might not be as widely publicized.
“They are looking at intermediate or proxy measures, such as the impact on prescriptions dispensed or multi-provider episodes,” Reilly says. “Generally, analyses are showing that if prescribers see this information, it increases their awareness that other providers are engaged in patient care, and it helps them make more informed prescription decisions.”