Prescription drug monitoring programs PDMPs continue to be among the most promising state-level interventions to improve opioid prescribing, inform clinical practice, and protect patients at risk. Although findings are mixed, evaluations of PDMPs have illustrated changes in prescribing behaviors, use of multiple providers by patients, and decreased substance abuse treatment admissions.
States have implemented a range of ways to make PDMPs easier to use and access, and these changes have significant potential for ensuring that the utility and promise of PDMPs are realized.
A prescription drug monitoring program PDMP is an electronic database that tracks controlled substance prescriptions in a state. PDMPs can provide health authorities timely information about prescribing and patient behaviors that contribute to the epidemic and facilitate a nimble and targeted response. However, a PDMP is only useful to health care providers if they check the system before prescribing. Some states have implemented polices that require providers to check a state PDMP prior to prescribing certain controlled substances and in certain circumstances, and these policies have significant potential for ensuring that the utility and promise of PDMPs are maximized.
When pharmacists dispense controlled substances to patients, they have to enter the prescription into the state PDMP. PDMPs are more than just passive databases. Use of PDMPs by providers prior to writing a prescription for opioids may be mandatory or optional, and states vary in the responsibility they place upon providers for any negative outcomes associated with misuse or abuse by their patients [ 5 ].
PDMPs also vary in the frequency with which data is reported to them by participating pharmacies, the ease of accessing necessary information, the types of providers allowed to register, the information available, the amount of training providers receive in use of PDMPs, and by which state agencies they are administered [ 5 ].
As a result, the timeliness and accuracy of PDMP data varies considerably across states, as does the frequency and consistency of use by providers. It was unsurprising to find two studies examining the impact of PDMP implementation on opioid diversion, given the important role played by the Bureau of Justice Assistance in supporting PDMP implementation [ 8 ]. However, reviewing the evidence makes it clear that more nuanced investigation of the impact of specific characteristics of PDMP legislation and implementation will be necessary to firmly establish the policy features and strategies associated with PDMPs that are successful in reducing negative outcomes as intended.
Even within the limitations of the current evidence, however, it has already become clear that PDMPs may also be associated with impacts beyond those generally hypothesized, both potential benefits and harms.
Studies have reported that many clinicians find PDMPs useful as a tool for communication and interaction with patients [ 19 , 20 ]. What happens when providers re-evaluate their opioid prescribing has proven to be a critical question, although relatively few studies have yet provided data to answer it.
Of the studies examined in this review, Rasubula et al. Paulozzi et al. More troublingly, there is also evidence that patients, when faced with reduced ability to access licit opioids, may turn to illicit heroin, morphine, or fentanyl as alternatives, with studies indicating an increase in related mortality in some PDMP states [ 17 , 22 , 23 ].
There are several limitations to this review. Because the PDMP literature remains small and study outcomes and design vary, we were unable to conduct a traditional systematic review or meta-analysis, thus limiting our ability to conduct statistical analysis of the cumulative evidence.
Because we described state-administered PDMP programs exclusively, findings may not extend to other prescription monitoring approaches in the U. Nonetheless, this scoping review may inform other monitoring efforts, particularly by underscoring the importance of having clearly defined target outcomes e. Drawing upon PubMed as the core search database may have resulted in identifying more literature emphasizing healthcare policy rather than law enforcement impacts of PDMPs.
In addition, this review was limited to published data; additional analyses may be available in unpublished reports from state or other sources, and should be considered for inclusion in future systematic reviews. We believe the conceptual framework and synthesis of findings presented here offer valuable tools for evaluating the body of knowledge around PDMPs as policy and research in this area continue to progress.
Establishing a conceptual framework for PDMP evaluation is helpful in clarifying areas of relative strength and weakness in the literature. Moreover, evaluating the literature available along each step of the conceptual framework makes it clear how poorly we yet understand the real-time consequences of PDMP implementation, or the nuances of how specific characteristics of PDMP policy or implementation may impact downstream effects.
More sophisticated analysis of specific components of PDMPs will be required to fully understand widely varying impacts across states.
We offer a call to action to engage in rigorous examination of PDMP impacts across the range of domains identified here, and particularly with regard to opioid misuse, and to do so with a careful eye to understanding features of PDMP legislation and implementation associated with positive outcomes. This call comes at a time when the field of PDMP evaluation is rapidly maturing and more information is becoming available through data sharing and linking with electronic medical records.
The increased analytic capacity enabled by such growth should directly facilitate the examination of algorithms for identifying opioid prescribing, misuse, and abuse that are so much a part of the promise of PDMPs, but which have not yet achieved their full potential in mitigating opioid-related harms for individuals and populations.
Center for Behavioral Health Statistics and Quality. Prescription drug monitoring and dispensing of prescription opioids. Public Health Rep. Pain Medicine. Zibbell, and R. Matthew Gladden. Morbidity and Mortality Weekly Report 64, no. Clark et al. Clark, J. Eadie, P. Kreiner, G. Accessed An inevitable wave of prescription drug monitoring programs in the context of prescription opioids: pros, cons and tensions.
BMC Pharmacol Toxicol. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. ISSN — Synthesising research evidence. Methods for studying the delivery and organisation of health services.
London: Routledge; Google Scholar. The use of a prescription drug monitoring program to develop algorithms to identify providers with unusual prescribing practices for controlled substances. J Prim Prev. Article PubMed Google Scholar. Prescription opioid usage and abuse relationships: an evaluation of state prescription drug monitoring program efficacy.
Subst Abus. Freeman J. Iowa Med. Perrone J, Nelson LS. However, as with any tool it needs to be used with caution. Not every patient who gets an opioid is misusing it, and there are many for whom opioids mean the difference between suffering and being able to manage pain. There is certainly a lot of room for prescribers to do a better job addressing pain, discussing both drug and nondrug options as well as early referral to pain clinics. Prescribers, policy makers, and the public need to ensure that these medications are available to the people who truly need them, for the short or long term.
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A concern I have as a long-term tramadol patient is that this hypervigilence will eventually be applied to this medication as well. Not once have I ever felt narcotic effects. I transferred to a different pharmacy and have had no problems since. Tramadol is a prodrug, which means it has to get bioactivated to produce the narcotic active metabolite. The other method of action is via SNRI effects which do not need this bioactivation. That said though, insurance carriers will not cover the genetic testing to find out if this is the case.
I am betting, however, that if a crackdown happens, they will be right there saying that this medication that I have used for years without ANY sort of misuse is suddenly not covered.
The irony here is an FDA-approved option for diabetic neuropathy is tapentadol, which was created from tramadol with the intent of making it not need bioactivation and removing the serotonin inhibition. Tapentadol is, of course, a brand drug vs. You fail to mention other problems about all these databases. First, this constant monitoring is making physicians afraid to prescribe opioids at all — even when they might be the best option. Second, how safe are these databases from hackers? Third, what about patient privacy, the patient.
In that same category, I had an interesting experience at our county health center. The nurse pulled up a screen and went through various medications that I had been prescribed over time that is, some were current, others not and asked me about them. When I asked where she was getting the information, I was told that the state had the database which included any medication that had been received through mail order. I think the danger to the privacy of law abiding, non-addicted medication users is huge.
Thoughts on this topic? Thank you for this important and well written article on a very important subject. Well balanced discussion about PMP is necessary to address each aspect of a very complicated problem.
Well done.
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