ATrain Education

 

Continuing Education for Health Professionals

Alcohol Use Disorders and Opioid Dependence Treated in Primary Care

Module 8

PDMPs and Federal Support

Prescription drug monitoring programs (PDMPs) often referred to as PMPs are state housed data systems that collect controlled substance prescription drug dispensing information as dictated by their state legislation. PDMPs were historically set up as law enforcement tools to monitor drug diversion and fraud but have evolved over the years to also serve as a clinical decision making tool to ensure the appropriateness of medication therapy as well as identifying individuals who may need further assessment or treatment.

Information typically available from a PDMP report include

  • patient information (i.e., name, address, date of birth, gender, and patient identifier),
  • prescriber information (i.e., name, address, DEA number, and phone number),
  • pharmacy information (i.e., pharmacy name, address),
  • and drug information (i.e., date drug was dispensed, drug quantity, drug strength, and source of payment in some states).

However, there is some variability with what information is available because of the state laws that govern each of the PDMPs. Most states collect controlled schedules II–IV prescription medications and specific states collect nonscheduled drugs, such as tramadol. PDMPs are used by healthcare professionals, licensing and regulatory boards, law enforcement for drug investigations, state medical examiners or coroners, and/or research organizations for analysis and research [91].

Many primary care providers take advantage of existing systems that allow for delegates in some states to check PDMPs under the supervision of a physician. If that option is unavailable, providers may want to consider triaging and checking the PDMP only when prescribing controlled substances or when they suspect their patient is diverting, misusing, or abusing medications. Another option when limited by time is to run the PDMP reports for new patients or patients who travel long distances to attain treatment at their practice setting.

Important aspects of the report for the primary care provider are the drugs dispensed, quantity, dates, prescribers, and pharmacies, as well as determining suspicious patterns, if any. In a case study, a medical director from an opioid treatment program found that most of the patients were forthcoming in their medication history reports [92]. It was only a small number of patients who fell outside of the norm. Once the physician became familiar with their PDMP, it took about twenty seconds to check a patient’s history and some additional time if they found prescriptions in the report. The study suggests informing patients that the PDMP is being monitored in advance rather than after the report is run so that patients-provider relationship is not damaged, since it is likely that not all of the patients will be receptive to the monitoring.

However, while the PDMP report offers an opportunity for conversations to take place about potential drug-drug interactions and therapeutic duplications, physicians have often expressed that this is a difficult conversation to have. Many primary care providers are untrained to deal with prescription drug misuse and abuse and according to a survey done in Oregon (http://www.acumentra.org/assets/PDMP-Presentation_Survey_Focus-Groups.pdf) are likely to discharge their patients or have their patient leave their practice “quietly” based on PDMP findings, instead of working with the patient to develop a comprehensive care plan for their addiction while continuing to serve as their primary care provider. Other options providers should consider including developing an ongoing relationship with an addiction specialist. The Oregon researchers conclude that there does not appear to be a need for training on how to use the PDMP but more importantly, training on how to respond to the information, especially resources on how to manage substance use disorders. Other barriers to accessing PDMP data include a lack of a seamless transaction that exists in the current clinical workflow, requiring the provider to log into one health information technology (HIT) system, only to turn around and access yet another one using a different user identification. Thus, despite the large repository of data in these systems, use in general has been reported to be suboptimal. The Department of Health and Human Services is supporting multiple programs to integrate PDMPs into HIT systems to allow for this valuable data source to be within reach to healthcare professionals. Instead of creating new systems, the thought is to use already existing HIT systems to connect with PDMPs and deliver this valuable information to healthcare professionals, such as prescribers and dispensers. The Office of the National Coordinator for Health Information Technology (ONC) along with SAMHSA supported a project called the Enhancing Access to PDMP using HIT to form workgroups to define barriers and recommend solutions to increase the use of PDMPs. This project also conducted pilots across the country to test the use of HIT to access PDMPs. The pilots allowed providers to receive certain critical information that was not available prior to their participation in the pilots. Some examples include having “person of interest” alerts provided on a weekly basis when “at risk” threshold of prescription drugs was met and integration of a patient’s controlled substance prescription history information with prescription information available on e-prescribing software. Immediate improvement to patient care access was achieved and user workflows were streamlined and improved [93].

SAMHSA also supports programs that expand on the work done in the “Enhancing Access” project by providing funding to 17 states over two years to integrate their PDMPs in various HIT systems. The goal, like the Enhancing Access project, is to integrate PDMPs into three clinical settings: the provider practice, pharmacy, and emergency department.

When used optimally, PDMPs can be a useful clinical resource for primary care providers. Primary care providers not utilizing this resource miss an opportunity to consult with their patients to address a potential substance use disorder, discuss treatment services, or clarify a mistake taken place inadvertently by a pharmacy, or identify cases of identity theft important to the patient.

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