We should be willing to accept some responsibility for the epidemic, but so should the general community. Patient education has a role to play. For example, in New York City and in California, governing bodies issued voluntary ED guidelines and created posters for educating patients on opioid restrictions.17 Temple University Hospital in Philadelphia saw a 20 percent decrease in opioid prescriptions for chronic pain after introducing voluntary guidelines; this reduction was sustained over a year later. All 31 eligible prescribing physicians completed a survey, and 100 percent supported the use of those guidelines.18
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ACEP Now: Vol 35 – No 07 – July 2016PDMPs may yet prove their worth in the fight against the opioid epidemic. Targeting and integrating alerts into electronic medical records would seem useful. Although at least 31 states have the authority to send such alerts, relatively few states do. Massachusetts piloted unsolicited targeted electronic alerts and found that 82 percent of providers did not realize their patients were inappropriately receiving prescriptions from multiple prescribers. After six months, detected doctor shopping activity was reduced by 50 percent.19
We must not deny that physician behavior is part of the opioid problem, and we can be a part of the solution. However, our maximum impact is unlikely to be realized if we act merely as automatons of states’ ineffectual policing. With government cooperation improving PDMPs, developing initiatives to decrease pressure to prescribe potentially harmful drugs, and providing increased patient support, we should see improvements in curbing addiction. This can be accomplished while retaining the right to rationally prescribe without viewing our patients as guilty until proven innocent.
Dr. Solnick is an emergency medicine resident at the Yale Emergency Medicine Program in New Haven, Connecticut.
References
- Shelton J. Forum: How to stop an epidemic? Support Connecticut bill on opiate abuse. New Haven Register website..
- Today’s heroin epidemic. CDC website.
- Why heroin has made a comeback in America. The Economist website.
- Report of the International Narcotics Control Board for 2008. INCB website.
- Mularski RA, White-Chu F, Overbay D, et al. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006;21(6):607-612.
- Gounder C. Who is responsible for the pain-pill epidemic? The New Yorker website.
- The DAWN report: highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Substance Abuse and Mental Health Services Administration website.
- Drug overdose deaths hit record numbers in 2014. CDC website.
- Substitute for Governor’s H.B. 6856 Session Year 2015. Connecticut General Assembly website.
- Gov. Malloy hails final legislative passage of bill combating substance abuse and opioid overdoses. Connecticut State website.
- Mandating PDMP participation by medical providers: current status and experience in selected states. PDMP Center of Excellence website.
- 2012-2013 Prescription Drug Monitoring Program annual report. Florida Health website.
- Kim T, Small M, Hwang C, et al. Controlled substance utilization review and evaluation system: a tool for judicious prescribing. LA County Department of Public Health website.
- Baehren DF, Marco CA, Droz DE, et al. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010;56(1):19-23.e1-3.
- Safe prescribing. California ACEP website.
- Berlin J. Revised TMB rules target nefarious prescribers, but physicians say the rules are a burden. Tex Med. 2016;112(1):28-35.
- New ER guidelines to prevent opioid prescription painkiller abuse. Mike Bloomberg website.
- del Portal DA, Healy ME, Satz WA, et al. Impact of an opioid prescribing guideline in the acute care setting. J Emerg Med. 2016;50(1):21-27.
- Electronic alerts for prescribers: Massachusetts Prescription Monitoring Program experience. PDMP Center of Excellence website.
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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.