PDMPs have sprung up nationwide over the past decade with much fanfare. Sadly, their impact hasn’t lived up to their hype in decreasing opioid prescriptions, especially when looking at data from states that instituted mandates. According to a study from Brandeis University, after adopting mandates, Kentucky, New York, and Tennessee had decreases in opioid prescriptions rates ranging from 7 percent to 11.6 percent for commonly prescribed opiates.11 When taking into consideration that at the same time nationwide opioid prescribing decreased by 4.6 percent, there is even less association between PDMPs and prescribing behavior. Over a similar time frame, Florida launched a PDMP that was not mandatory and had similar results as the states in which it was mandated—the rate of Schedule II opiates dropped by 12.5 percent and total pain prescriptions dropped by 7.1 percent.12
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ACEP Now: Vol 35 – No 07 – July 2016The trouble largely lies in theory versus practice. Initially, I heard some rumblings around our department about the new alert popping up on our electronic medical record log-in screen. As with all alarms, it soon faded into the background noise of irrelevant red boxes that clogged the screen.
Connecticut’s experience does not appear to be isolated. In California, only 9.8 percent of prescribers and pharmacists registered to use its PDMP in 2014.13 While one study in Annals of Emergency Medicine found a change in prescribing behavior after viewing a PDMP query, this finding is suspect. In that study, 17 physicians had research assistants running their queries.14 Funny, I can’t seem to find my research assistants.
For busy ED providers, time spent accessing a multistep website distracts from real patient care. Just as we don’t blindly check troponins on every patient with chest pain, it makes as little sense to check the PDMP for every patient with pain who may receive opioids. Moreover, emergency physicians only write 5 percent of all opioid prescriptions despite handling 28 percent of all acute care visits.15 Without sufficient outcomes to justify its burden in the ED, PDMP appears to be little more than a shiny new toy for politicians to pay lip service to a social epidemic while vilifying physicians for overprescribing.
While our new law does not specifically punish doctors for noncompliance, physicians not following the mandates may be at risk for liability. The state statute is under the controlled substance section of the law, which carries serious penalties for noncompliance if imposed.
Recently, a doctor in Texas was investigated after his patient (to whom he had prescribed controlled substances) caused a deadly motor vehicle crash. The police were able to seek a search warrant for the clinic, citing the doctor failed to follow the state medical boards rules for treating chronic pain including a pain management agreement.16 Ultimately, he was found guilty of fraudulent actions, but the case shines light on the potential for legal repercussions of opioid prescribing.
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2 Responses to “Prescription Drug Monitoring Programs: Regulatory Burden or an Emergency Physician Function?”
July 28, 2016
Scott WeinerThank you for the insightful article. PDMPs have been proven to be helpful tools (see recent articles by Patrick and Bao in Health Affairs), but they are important to consider in terms of their limitations – they do not detect medication misuse in patients who are diverting meds, for example. However, the best policy is not to treat everyone as “guilty until proven innocent” or even a policy of selective look-ups as clinician gestalt is not great. Simply, consider the PDMP as supplmentary information that should be reviewed prior to any opioid prescription you write. Look it up for EVERY patient for whom you are writing a prescription; don’t allow your biases to assume someone doesn’t have an opioid misuse disorder. You’ll find that if you do it routinely, you’ll be able to obtain the information in <30 seconds. Better yet, technology is making PDMPs integrated into our EMRs, so that the information will eventually be automatically and seamlessly presented. That day isn't here yet, though, but it will come.
August 3, 2016
Rich Greiner, MDRachel, nice article.
I agree, emergency physicians don’t appreciate and don’t need to be told by legislators how to do our job. None of us needs more regulations.
It would be more efficient if the PMP was integrated into the EMR and took only one click to reveal the patient’s controlled substance prescriptions, but requiring that we check a state run website which adds more time, on the order of 2 to 3 minutes, to each patient encounter, is not negligible. Some EMRs can give us a lot of this information, though usually not quickly.
Overall, I appreciate having access to this database, and I use it daily. Anecdotally, I feel like the PMP changes my management in about 1 in 4 cases. It does make me feel like I have a tool to help me not judge the patient. It is somewhat like the pregnancy test: we use it every day, it is quick and cheap, enables us not to judge or always have to believe our patients, and a positive result changes our management.
The well-intentioned three day rule makes it unlikely that I would be compelled to check the database, since I very rarely would prescribe more than three days worth (12-24 tabs) of a controlled substance in the ER. I typically only prescribe 6-12 tabs, to be used when all non-narcotic options have been maximized.
I’m the first one to agree that I don’t like to be told what to do, especially by those who don’t know anything about medicine like the government, but I also feel like the PMP is an excellent tool to help us reduce the risk of prescription (and other) narcotic abuse.
When considering controlled substance abuse potential in the ED, I wouldn’t necessarily consider every patient initially guilty, but a good OB doctor once taught me that every female is pregnant until proven otherwise.