Prescription Drug Monitoring Programs:They Are Not All Created Equal

CHAIM MILLER, BA

ASIF ILYAS, MD, MBA, FACS

SUMMARY POINTS

• The PDMP remains the single most studied legislative action addressing the opioid epidemic, however defining the success of a state’s PDMP is difficult.

• PDMP characteristics that improve its effectiveness include: required provider registration, use mandate, frequently updating data, and sharing data between state lines.
  

• Legislators should continue to support and enhance PDMPs, focusing on strategies to improve it, including: robust qualities such as mandated use, regular and critical analysis of the data, consistency of implementation strategies, and sharing of data between states.

ANALYSIS

Introduction

The opioid epidemic in the United States has gained significant public attention recently and has become a true health crisis. An estimated 130 people die every day from opioid related drug overdoses and about 2 million people had an opioid use disorder in 2018.1,2 A legislative measure aimed at combatting the opioid epidemic was the Prescription Drug Monitoring Program (PDMP). PDMPs are electronic databases that collect and analyze patient prescription data regarding controlled substances and allow physicians the ability to access that information before prescribing. To date, all 50 states have operating or legislative mandates for a PDMP, but how much do we truly know about PDMPs since the first was adopted in 1939? The following paragraphs aim to present the data currently known to the medical community and outline the ways in which PDMPs can improve to reflect the inherent weaknesses within them.

The PDMP In A Nutshell

Since its inception, the PDMP has changed dramatically both in terms of its practical use, as well as its internal legislative components. The more modern implementations are more likely to be digital, and since 1999, have been changing at an incredibly fast pace. The typical PDMP now varies significantly from state to state in its makeup and required usages which as we will discuss later, lead to the discrepancy in accepted medical knowledge regarding its effect. The bare-bone PDMP is a central database with all the controlled substance prescription information for a given patient. Advances in our understanding of the opioid epidemic have led to improvements such as: a registration and use mandate, the ability to assign delegate access, information sharing across state lines, and legal consequences for not checking the PDMP when required. All of these characteristics try to target one specific aspect of the epidemic and do it with varying levels of success.

Current Understanding of the Success of the PDMP

The PDMP remains the single most studied legislative action addressing the opioid epidemic.3 Defining the success of a PDMP is difficult since it can be so multifactorial. Instead, we must look at individual data points and how they have been affected by the programs. A common theme present in the literature is that there is no clear agreement on the true effect of the PDMP. However, a general consensus exists regarding opioid prescribing patterns. Bao et al found a reduction in the prescribing of opioids of overall, which was echoed by Wen et al and Haffajee et al.4-6 However, multiple studies have shown no significant reductions in opioid-related deaths or opioid-related crime rates following implementation of a PDMP.7-9 One particular success of the PDMP has been in lowering rates of risky prescribing habits. Reifler et al and others found an association between the implementation of a PDMP and decreasing opioid abuse and misuse trends.10-12 These measures tend to include multiple prescribers, travel across state lines, and multiple prescriptions for acute pain.

PDMP Makeup

Why do such variation exist in the effect of a PDMP? The answer lies in the component of each PDMP. To this day, significant differences exist that have real implications for a PDMP’s success. Pauly et al found operational PDMPs, and specifically those with more comprehensive or robust features, were associated with lower increases in the mean rates of opioid-related poisonings (Table 1).13 This was mirrored by Whitmore et al who found states whose programs had robust characteristics—including monitoring greater numbers of drugs with abuse potential and updating their data at least weekly—had greater reductions in deaths, compared to states whose programs did not have these characteristics.14 What is therefore clear in the literature is that the more robust PDMPs are more effective at addressing the opioid problem in America than less robust ones.

PDMP Issues and How To Improve Them

Even with all the understanding of what makes a successful PDMP, there does exist room for improvement nationally. One clear weakness, namely the implementation and enforcement of PDMP use, is still low due to the significant variations in program execution and prescriber registration. For example, currently there is no universal requirement for providers to query the database before prescribing an opioid. Moreover, there is no consistent plan or mandate for states to share their prescription data across state lines, allowing opioid abusers to access opioids in different states with greater impunity.

Conclusion

Going forward, we advocate for the use of PDMPs, but also recommend more robust qualities such as mandated use, regular and critical analysis of the data, consistency of implementation strategies, and sharing of data between states. Using scientific rigor and collaborative strategies will optimize the effectiveness of a PDMP to combat the opioid epidemic.

REFERENCES:

1. NCHS National Vital Statistics System.

2. 2019 National Surey on Drug use and Health. Mortality in the United States, 2016.

3. Schuler MS, Heins SE, Smart R, et al. The state of the science in opioid policy research. Drug Alcohol Depend. 2020;214:108137. doi:10.1016/j.drugalcdep.2020.108137

4. Bao Y, Pan Y, Taylor A, et al. Prescription Drug Monitoring Programs Are Associated With Sustained Reductions In Opioid Prescribing By Physicians. Health Aff (Millwood). 2016;35(6):1045-1051. doi:10.1377/hlthaff.2015.1673

5. Zeiner AL, Burak MA, O'Sullivan DM, Laskey D. Effect of a Law Requiring Prescription Drug Monitoring Program Use on Emergency Department Opioid Prescribing: A Single-Center Analysis [published online ahead of print, 2020 Apr 15]. J Pharm Pract. 2020;897190020918096. doi:10.1177/0897190020918096

6. Haffajee RL, Mello MM, Zhang F, Zaslavsky AM, Larochelle MR, Wharam JF. Four States With Robust Prescription Drug Monitoring Programs Reduced Opioid Dosages. Health Aff (Millwood). 2018;37(6):964-974. doi:10.1377/hlthaff.2017.1321

7. Li G, Brady JE, Lang BH, Giglio J, Wunsch H, DiMaggio C. Prescription drug monitoring and drug overdose mortality. Inj Epidemiol. 2014;1(1):9. doi:10.1186/2197-1714-1-9

8. Paulozzi LJ, Kilbourne EM, Desai HA. Prescription drug monitoring programs and death rates from drug overdose. Pain Med. 2011;12(5):747-754. doi:10.1111/j.1526-4637.2011.01062.x

9. Mallatt J. The Effect of Prescription Drug Monitoring Programs on Opioid Prescriptions and Heroin Crime Rates. 2017.

10. Reifler LM, Droz D, Bailey JE, et al. Do prescription monitoring programs impact state trends in opioid abuse/misuse?. Pain Med. 2012;13(3):434-442. doi:10.1111/j.1526-4637.2012.01327.x

11. Surratt HL, Grady CO, Kurtz SP, Stivers Y, Cicero TJ, Dart RC, et al. Reductions in prescription opioid diversion following recent legislative interventions in Florida. Pharmacoepidemiol Drug Saf. 2014;23:314–320. doi: 10.1002/pds.3553.

12. Buchmueller TC, Carey CM, Meille G. How well do doctors know their patients? Evidence from a mandatory access prescription drug monitoring program. Health Econ. 2020;29(9):957-974. doi:10.1002/hec.4020

13. Pauly NJ, Slavova S, Delcher C, Freeman PR, Talbert J. Features of prescription drug monitoring programs associated with reduced rates of prescription opioid-related poisonings. Drug Alcohol Depend. 2018 Mar 1;184:26-32. doi: 10.1016/j.drugalcdep.2017.12.002. Epub 2018 Jan 11. PMID: 29402676; PMCID: PMC5854200.

14. Whitmore CC, White MN, Buntin MB, Fry CE, Calamari K, Patrick SW. State laws and policies to reduce opioid-related harm: A qualitative assessment of PDMPs and naloxone programs in ten U.S. States. Prev Med Rep. 2018 Dec 30;13:249-255. doi: 10.1016/j.pmedr.2018.12.014. PMID: 30705812; PMCID: PMC6348390.