The New Seatbelt – Prescription Drug Monitoring Programs

Jeffrey J. Pothof, MD, Robert I. Broida, MD, FACEP, Drew C. Fuller, MD, FACEP

Throughout the early 2000’s, unintentional deaths were largely attributed to motor vehicle collisions.  Significant multifactorial advancements were made, including vehicles construction, the development of educational campaigns and even legislation that de-incentivized risk-taking behavior by requiring seatbelt use.

A startling fact that still remains relatively unknown is that since 2007, motor vehicles are no longer the leading cause of unintentional deaths in the United States.  Poisonings have surpassed motor vehicle collisions and continue to do so at an alarming rate.1 Even more concerning is the fact that physicians are involved in access to the leading poison, prescription pain killers (opioids). Physicians prescribed 69 tons of oxycodone and 42 tons of hydrocodone annually in the United States.2 We as Emergency Medicine physicians are a part of this growing problem.

In recent years, states began to pass legislation that enables the collection of prescription pain killer prescription data on individual patients.  This data is then contained in a database that is accessible to providers along with other groups of individuals. Currently, there are 49 states with legislation that has approved the creation of such programs.  Missouri is the only state that has yet to create the framework to allow such a program.  Of the states with legislation in place, 46 have operational programs providing physician access. Georgia, New Hampshire, and Maryland are currently developing their programs.4

Prescription Drug Monitoring Programs (PDMP) have the potential to provide many benefits to the EM provider including:

  1. Assessing patients for aberrant behavior or doctor shopping;
  2. Identifying the specific substance in an overdose;
  3. Obtaining a self-assessment of your prescribing history.5

There is very little literature that evaluates the effectiveness of PDMP as it pertains to EM providers.  One small study found that the availability of a patient prescription report altered prescribing in 41% of 179 cases, with the decision to decrease or not administer opioid pain medication 61% of the time.6 A separate study revealed a decrease in the rate of opiate abuse in three states that had PDMP in effect.7 Another study found a decrease in the number of intentional opioid ingestions reported to poison centers in states with PDMP.8 

The American College of Emergency Physicians (ACEP) has endorsed the use of PDMP in a 2012 clinical policy titled “Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department.”9

Barriers to physician use of PDMP have included:

  1. Provider uncertainty over how to use the data.
  2. Incomplete or stale data
  3. Concerns regarding perceived increased liability.
  4. Inability to delegate authority to other members of the care team.
  5. Current web portals that do not adequately integrate into clinician workflows.2

Further work should be performed to better understand the effectiveness of these now nearly ubiquitous programs on provider prescribing habits as well as prescription drug abuse rates.  In addition, further process improvement should be dedicated to improving the use PDMP and integrating them as clinical decision support into electronic medical records.

References

  1. National Center for Health Statistics. NCHS Data on Drug Poisoning Deaths. National Vital Statistics System, 2010. http://www.cdc.gov/nchs/data/factsheets/factsheet_drug_poisoning.pdf
  2. Hammer, Jeffrey.  Enhancing Access to Prescription Drug Monitoring Programs
    A national effort to reduce prescription drug abuse and overdose through technology and policy. Powerpoint Presentation. Given in Scottsdale Arizona at the National Association of State Controlled Substances Authorities Conference.
  3. Prescription Drug Abuse, Addiction, and Diversion: Overview of State Legislative and Policy Initiatives. State Prescription Drug Monitoring Programs. The National Alliance for Model State Drug Laws and the National Safety Council. 2013
  4. Alliance of States with Prescription Drug Monitoring. State/Territory/Districts Updates. Powerpoint Presentation. Given June 4th 2012 in Washington DC at the Alliance of States with Prescription Drug Monitoring Conference.
  5. "Questions & Answers - State Prescription Drug Monitoring Programs." Questions & Answers - State Prescription Drug Monitoring Programs. US Department of Justice. Website. 16 Aug. 2013. http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm
  6. Baehren DF et al: A statewide prescription monitoring program affects emergency department prescribing. Ann Emerg Med 2010 56:24-26.
  7. Paulozzi, Leonard J., Edwin M. Kilbourne, and Hema A. Desai. "Prescription Drug Monitoring Programs and Death Rates from Drug Overdose." Pain Medicine 2011; 12: 747–754
  8. Reifler LM, Droz D, Bailey JE, Schnoll SH, Fant R, Dart RC, Bucher Bartelson B.  Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Med. 2012 Mar;13(3):434-42
  9. Cantrill SV, Brown MD, Carlisle RJ, Delaney KA, Hays DP, Nelson LS, O'Connor RE, Papa A, Sporer KA, Todd KH, Whitson RR; American College of Emergency Physicians Opioid Guideline Writing Panel. Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med. 2012 Oct;60(4):499-525.

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