Tools
Prescription Drug Monitoring Program
Introduction
Opioids, benzodiazepines, stimulants, and other controlled substances are widely prescribed in medical practice. However, these medications are also susceptible to misuse and diversion for nonmedical purposes.[1][2] The United States Centers for Disease Control and Prevention (CDC) reported that opioid use—both prescription and illicit—was involved in 42,249 deaths in 2016, a 5-fold increase since 1999. A contributing factor to this statistic is the rise in the number of opioid prescriptions issued. Notably, although opioid sales in the United States quadrupled between 1999 and 2014, there was no corresponding reduction in the overall level of pain reported by Americans.[3][4][5]
The Prescription Drug Monitoring Program (PDMP) was established to reduce prescription misuse and diversion while monitoring and analyzing prescription and dispensing data for controlled substances. The PDMP consists of independent statewide electronic databases that track prescriptions for controlled substances. Health authorities can use this data to obtain timely information on prescribing practices and patient behaviors. The concept of the PDMP dates back to 1918 in New York, while California has operated the oldest continuously running program since 1939.[6] Oklahoma became the first state to implement a modern PDMP with electronic prescription data collection and distribution in 1991.[7] Although the concept has existed for over a century, many states have established PDMPs only within the past 2 decades.
Function
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Function
PDMPs have been implemented in the United States in 49 of 50 states, the District of Columbia, and 1 territory (Guam).[8] PDMPs require pharmacies statewide to report medication data at scheduled intervals, including the drug name, dose, dispense date, and information about the patient, prescriber, and pharmacy, covering the past year. Typically, oversight generally extends to all controlled substances, including Drug Enforcement Agency (DEA) Schedule II to V drugs, as well as non-opioids such as stimulants (eg, methylphenidate) and unscheduled medications (eg, muscle relaxants).[9] Both individual patient reports and population-level reports can be generated, providing insights into epidemiological trends within and across regions. Law enforcement organizations can use this information to detect fraudulent prescriptions and the illegal diversion of controlled substances.[10]
One model operates on a nonmandatory basis, allowing prescribers and dispensers to access the database voluntarily. Another model involves proactive reporting, where, in addition to voluntarily checking the database, prescribers and dispensers receive unsolicited reports about patients obtaining dangerous doses or combinations of controlled substances or acquiring prescriptions from multiple providers. Finally, a mandated use model is gaining attention due to preliminary studies demonstrating a reduction in opioid prescribing and a decline in "doctor shopping."[11] Early implementations of this mandated model have occurred in Kentucky, Tennessee, New York, and Ohio, where prescribers must review PDMP data before prescribing controlled substances.[7]
The CDC has outlined key features of effective and resourceful PDMPs, emphasizing the importance of requiring providers to check a state PDMP report before prescribing controlled substances; this is the mandated model. These features include providing real-time data on controlled substance dispensing and allowing access for state health departments to analyze opioid epidemic trends and evaluate intervention effectiveness [Drug Overdose Data, CDC].
Access to PDMP data varies with state law, but healthcare prescribers and pharmacists can typically obtain reports for patients under their care. Some states also provide access to law enforcement agencies, state Medicaid programs, licensing and regulatory boards, medical examiners, and research initiatives.[12]
Issues of Concern
Significant deficiencies exist within the currently deployed PDMPs.[13] Firstly, certain information is inadequately collected across various states, such as the method of payment and the identity of the person filling the prescription. In addition, no states track data on prescribers’ deaths or their disciplinary status, including license suspensions.
Secondly, the data provided by PDMPs are not always effectively utilized in clinical practice. Many states do not require prescribers or pharmacists to check a PDMP report before prescribing or dispensing controlled substances. Additionally, there is often a lag in data updates, and tools for analyzing the comprehensive data generated by the PDMP are frequently lacking. Thirdly, limited interstate data sharing may hinder the effective monitoring of patients who cross state boundaries to obtain medications. Finally, regulatory agencies often do not utilize the data adequately, and some states have legal protections that restrict law enforcement's access to these reports.[12]
Clinical Significance
The evidence supporting the positive impact of statewide PDMPs remains mixed. A review by Finley et al in 2017 assessed the outcomes of PDMP implementation across 4 key domains—opioid prescribing, opioid diversion and supply, opioid misuse, and opioid-related morbidity and mortality.[6] Although the evidence revealed a reduction in opioid prescriptions in certain states, such as Florida and New York, these associations were not observed when results from multiple PDMP states were combined.[14][15][16]
In terms of illicit drug diversion and overall supply, states with a PDMP experienced reduced shipments of oxycodone; there was no overall reduction in total shipments of opioids.[17] Only one study evaluated the impact on opioid misuse, finding that while the presence of a PDMP slowed the rate of increase in misuse, there was no observed absolute reduction in misuse.[18] Importantly, studies have shown that opioid-specific mortality rates were lower in certain states with a PDMP, such as California, Texas, New York, and Florida.[19] However, this trend was not observed when data from all PDMP states were combined.[20]
Other Issues
Similar to all electronic databases, PDMPs may encounter several challenges, including difficulties with obtaining login access, inability to use the database when systems are under maintenance or during downtime, lack of integration of comprehensive information into clinical workflows, and the presence of incomplete data.[9][21] Furthermore, limited professional guidance may exist to assist providers in accessing and interpreting query results correctly.[21]
The development of certain guidelines has faced resistance from primary care clinicians due to concerns about undermining patient-provider trust. For example, some guidelines recommend the use of written agreements or pain contracts and urine drug screening, which some patients may interpret as a confrontational approach, thereby introducing a source of mistrust.[9][22]
Each PDMP has been developed at the individual state level, resulting in significant variation in policies, query generation, and data reporting. This inconsistency in data collection and lack of standardization across states complicate the interpretation of results for providers who need to access to multiple state-specific PDMPs.[23] These deficiencies are likely to have hindered clinical outcomes research.[6]
Enhancing Healthcare Team Outcomes
All healthcare workers who prescribe medications should be familiar with the PDMP, which has been implemented in 49 states, the District of Columbia, and 1 US territory (Guam).[8] This program mandates that pharmacies report medication data at scheduled intervals, including drug name, dose, dispense date, and information about the patient, prescriber, and pharmacy for the past year. Typically, oversight covers all controlled substances, including DEA Schedule II to V drugs, as well as non-opioids such as stimulants (eg, methylphenidate) and unscheduled medications such as muscle relaxants.[9]
Both individual patient reports and broader population-level reports can be generated, highlighting epidemiological trends within and across geographic regions. Law enforcement organizations can use this information to identify fraudulent prescription activities and illegal diversion of controlled substances.[10] More importantly, the PDMP is also utilized to analyze the prescribing habits of physicians, nurse practitioners, and physician assistants, particularly concerning controlled substances, and to identify outliers.
References
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