Margaret B. Greenwood-Ericksen, MD MPH
Sabrina J. Poon, MD

Brigham and Women’s Hospital
Massachusetts General Hospital
Harvard-Affiliated Emergency Medicine Residency

Background
The United States is currently facing an epidemic of opioid analgesic-related addiction, overdose, and death. Opioid prescriptions quadrupled between 1999 and 2013 with overdose deaths increasing in parallel.^1,2 In response, states have implemented Prescription Drug Monitoring Programs (PDMPs) to track prescriptions of controlled substances. PDMPs are statewide electronic databases that collect data from pharmacies regarding dispensed controlled substances. While they were first designed for use by law enforcement and regulatory agencies, PDMPs have been identified as a critical tool in identifying patients at risk for opioid overdose, abuse or diversion. As such, all state PDMPs now allow authorized health care providers to access this database to evaluate a patient’s controlled substance prescription history. There is evidence to suggest that PDMPs are a useful tool in reducing opioid-related addiction, diversion, and overdose.^3,4 The role of state PDMPs in addressing this epidemic has been highlighted in recent publications,^5–7 including the White House Office of National Drug Control Policy’s Prescription Drug Abuse Prevention Plan.⁸

PDMPs in the Emergency Department
There has been increasing emphasis on the role of Emergency Medicine in the prescription opioid epidemic, and leaders in the field have begun to advocate for safer prescribing practices.⁹ One example is the implementation of prescribing guidelines for Emergency Physicians (EPs), which have now been developed in many jurisdictions including Washington State and New York City.^10,11 Integral to these guidelines is the evaluation of the patient’s prescription history by use of PDMPs, especially since EPs lack continuity of care for and knowledge about the medical history of the patients under their care.

Barriers to routine PDMP use in the ED
At present, PDMPs are generally underutilized due to state regulations and PDMP design that are at odds with the core operational factors of an ED.^12,13 PDMPs are not routinely used by EPs due to several limitations, including complex procedures for physician enrollment, lack of timeliness in reporting by pharmacies, and stand-alone PDMP websites that require additional log-in procedures (i.e. not integrated with existing EHRs).^12,14 Because each state has developed its own PDMP independently, they are also not standardized, and there has been limited opportunity to optimize best practices.¹⁵ Some of these limitations are more pronounced in the ED setting.¹³ For example, accessing the database for patient care typically requires a significant time investment, which is especially problematic for EPs who face increased pressure to maintain patient throughput as EDs become more crowded, and who lack consistently available staff to check the PMDP on behalf of the EP.

Future Directions
As the prescription opioid epidemic continues, and a heroin epidemic has emerged, leaders and organizations across all fields – medical, government, and others – are committed to addressing this growing problem. It is clear that a multifaceted approach is needed, including the optimization of PDMPs. Several features of PDMPs as they exist currently are outlined in the figure below, accompanied by a proposed ideal alternative. Continued research and advocacy are critical to improving PDMP use and effectiveness.


Model of Ideal PDMP



References

1. Mack KA, Centers for Disease Control and Prevention (CDC). Drug-induced deaths - United States, 1999-2010. Morb Mortal Wkly Rep Surveill Summ Wash DC 2002. 2013;62 Suppl 3:161-163.
2. Centers for Disease Control and Prevention. 2015. http://www.cdc.gov/nchs/deaths.htm. Accessed April 8, 2015.
3. Reifler LM, Droz D, Bailey JE, et al. Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Med Malden Mass. 2012;13(3):434-442. doi:10.1111/j.1526-4637.2012.01327.x.
4. Haegerich TM, Paulozzi LJ, Manns BJ, Jones CM. What we know, and don’t know, about the impact of state policy and systems-level interventions on prescription drug overdose. Drug Alcohol Depend. 2014;145:34-47. doi:10.1016/j.drugalcdep.2014.10.001.
5. Morgan L, Weaver M, Sayeed Z, Orr R. The Use of Prescription Monitoring Programs to Reduce Opioid Diversion and Improve Patient Safety. J Pain Palliat Care Pharmacother. 2012;27(1):4-9. doi:10.3109/15360288.2012.738288.
6. Johnson H, Paulozzi L, Porucznik C, Mack K, Herter B, Hal Johnson Consulting and Division of Disease Control and Health Promotion, Florida Department of Health. Decline in drug overdose deaths after state policy changes - Florida, 2010-2012. MMWR Morb Mortal Wkly Rep. 2014;63(26):569-574.
7. Baehren DF, Marco CA, Droz DE, Sinha S, Callan EM, Akpunonu P. A Statewide Prescription Monitoring Program Affects Emergency Department Prescribing Behaviors. Ann Emerg Med. 2010;56(1):19-23.e3. doi:10.1016/j.annemergmed.2009.12.011.
8. Office of National Drug Control Policy. Epidemic: responding to America’s prescription drug abuse crisis. thewhitehouse.gov. http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/rx_abuse_plan.pdf. Accessed August 1, 2013.
9. Weiner SG, Perrone J, Nelson LS. Centering the Pendulum: The Evolution of Emergency Medicine Opioid Prescribing Guidelines. Ann Emerg Med. 2013;62(3):241-243. doi:10.1016/j.annemergmed.2013.02.028.
10. Neven DE, Sabel JC, Howell DN, Carlisle RJ. The development of the Washington State emergency department opioid prescribing guidelines. J Med Toxicol Off J Am Coll Med Toxicol. 2012;8(4):353-359. doi:10.1007/s13181-012-0267-6.
11. New York City Department of Health and Mental Hygiene. Mayor Bloomberg, Deputy Mayor Gibbs and Chief Policy Advisor Feinblatt announce new emergency room guidelines to prevent opioid prescription painkiller abuse. http://www.nyc.gov.
12. Perrone J, DeRoos F, Nelson L. Prescribing Practices, Knowledge, and Use of Prescription Drug Monitoring Programs (PDMP) by a National Sample of Medical Toxicologists, 2012. J Med Toxicol.1-12. doi:10.1007/s13181-012-0250-2.\
13. Griggs CA, Weiner SG, Feldman JA. Prescription drug monitoring programs: examining limitations and future approaches. West J Emerg Med. 2015;16(1):67-70. doi:10.5811/westjem.2014.10.24197.
14. Passik SD. PMPs and Rx Drug Abuse—Encouraging Signs but Is It Every Man for Himself? Pain Med. 2012;13(3):355-356. doi:10.1111/j.1526-4637.2012.01337.x.
15. Gugelmann HM, Perrone J. Can prescription drug monitoring programs help limit opioid abuse? JAMA J Am Med Assoc. 2011;306(20):2258-2259. doi:10.1001/jama.2011.1712.