Prescription Drug Monitoring Program Query Research Articles

Changes in opioid prescribing and prescription drug monitoring program utilization following electronic health record integration-Massachusetts, 2018.

In this study we explored key prescription drug monitoring program-related outcomes among clinicians from a broad cohort of Massachusetts healthcare facilities following prescription drug monitoring program (PDMP) and electronic health record (EHR) data integration. Outcomes included 7-day rolling averages of opioids prescribed, morphine milligram equivalents (MMEs) prescribed, and PDMP queries. We employed a longitudinal study design to analyze PDMP data over a 15-month study period which allowed for six and a half months of pre- and post-integration observations surrounding a two-month integration period. We used longitudinal mixed effects models to examine the effect of EHR integration on each of the key outcomes. Following EHR integration, PDMP queries increased both through the web-based portal and in total (0.037, [95% CI = 0.017, 0.057] and 0.056, [95% CI = 0.035, 0.077]). Both measures of clinician opioid prescribing declined throughout the study period; however no significant effect following EHR integration was observed. These results were consistent when our analysis was applied to a subset consisting only of continuous PDMP users. Our results support EHR integration contributing to PDMP utilization by clinicians but do not support changes in opioid prescribing behavior.

Prescription drug monitoring program (PDMP) utilization and outcomes within the West Palm Beach Veterans Affairs (VA) healthcare system.

Prescription drug monitoring programs (PDMPs) can identify patients at risk of controlled substance (CS) polypharmacy and accidental poisoning. A retrospective pre-/post-intervention review of a random sample of provider notes with documentation of PDMP outcomes was completed before and after the enactment of a Florida law mandating PDMP queries. West Palm Beach Veterans Affairs Health Care System, which provides inpatient and outpatient services. Reviewed a random sample of 10 percent of progress notes documenting PDMP outcomes between September and November 2017 and the same timeframe of 2018. Florida enacted a law in March 2018 requiring PDMP queries to be completed for all new and renewed CS prescriptions. The primary outcome was to compare PDMP utilization and prescribing decisions based on query results before and after the enactment of the law. The number of progress notes documenting PDMP queries increased by over 350 percent from 2017 to 2018. In 2017 and 2018, 30.6 percent (68/222) and 20.8 percent (164/790) of PDMP queries found non-Veterans Affairs (VA) CS prescriptions, respectively. Providers decided to avoid prescribing CS prescriptions in 23.5 percent (16/68) of patients with non-VA CS prescriptions found in 2017 and 11 percent (18/164) in 2018. Overlapping or unsafe combinations were identified in 10 percent (7/68) of queries with non-VA prescriptions found in 2017 and 14 percent (23/164) in 2018. Mandating PDMP queries resulted in an increase in the total number of queries, positive findings, and overlapping CS prescriptions. Outcomes of PDMP mandate impacted prescribing by discontinuation and avoidance of CS initiation in 10-15 percent of patients.

Effect of Integrating Access to a Prescription Drug Monitoring Program Within the Electronic Health Record on the Frequency of Queries by Primary Care Clinicians

Tools that are directly integrated with the electronic health record (EHR) workflow can reduce the hassle cost of certain guideline-concordant practices, such as querying a prescription drug monitoring program (PDMP) before prescribing opioids. To investigate the effect of integrating access to a PDMP within the EHR on the frequency of program queries by primary care clinicians. The PRINCE (Prescribing Interventions for Chronic Pain Using the Electronic Health Record) randomized trial used a factorial cluster design at the clinic level in 43 primary care clinics in Minnesota. In all, 309 clinicians participated; 161 clinicians were given EHR-integrated access to PDMP at the intervention clinics, and 148 clinicians had the usual access at the control clinics. The intervention went live on August 27, 2020, and data were collected through March 3, 2021. Single sign-on access to the Minnesota PDMP was integrated into the EHR, allowing clinicians to query a patient's controlled substance prescription and dispensing history as recorded in the Minnesota PDMP directly from the patient's EHR record without logging into a separate web portal. Additionally, the integration tool alerted clinicians and reminded them to review the PDMP if a patient had 3 or more opioid prescriptions in the past year and 1 or more in the past 6 months. Clinics in the control group did not receive access to the EHR-integrated PDMP tool; instead, these participants logged into the PDMP web portal separately. Monthly PDMP query counts for primary care clinicians, overall and by modality (EHR-based, web-based, via a clinical delegate), adjusted for clinician characteristics, including type (physician, nurse practitioner, physician assistant), sex, and years in practice. Data were analyzed from August 2021 to May 2022. Of the 43 participating clinics with 309 clinicians, 21 clinics with 161 clinicians (102 [63.4%] women; 114 [70.8%] physicians; tenure, 10.6 [4.4] years) received the PDMP integration intervention. Baseline unadjusted monthly PDMP query rates for the average clinician were 6.6 (95% CI, 4.4-9.9) vs 8.8 (95% CI, 6.0-13.1) queries in the control vs the PDMP integration group, respectively. During the intervention, PDMP query rates for the average clinician were 6.9 (95% CI, 4.7-10.3) vs 14.8 (95% CI, 10.0-22.0) queries among the control vs the PDMP integration group, respectively. Compared with the control group, the EHR-integrated PDMP tool produced a 60% greater increase in the relative change in monthly PDMP queries (95% CI, 51%-70%). An increase in PDMP queries via the EHR-integrated PDMP tool drove this increase, while web-based and delegate queries declined by 39% more among the intervention compared with the control group (95% CI, 34%-43%). This cluster randomized clinical trial found that integrating access to the PDMP in the EHR increased PDMP-querying rates, suggesting that direct access reduced hassle costs and can dramatically improve adherence to guideline-concordant care practices among primary care clinicians. ClinicalTrials.gov Identifier: NCT04601506.

Effect of Prescription Drug Monitoring Programs on Testosterone Prescriptions

ABSTRACT Introduction Symptoms of testosterone deficiency are increasingly prevalent in the aging male population. Oftentimes, this is managed medically with exogenous testosterone supplementation. Pharmacologic testosterone is classified as a schedule III controlled substance by the Food and Drug Administration. In recent years, many states have implemented prescription drug monitoring programs (PDMP) to help track the prescribing and dispensing of controlled substances in an effort to curb the opioid epidemic. Many states also require a provider query of an online system prior to prescribing controlled medications, which has led to a reduction in opioid prescriptions. Objectives We sought to determine if the implementation of a state mandated query of PDMP prior to prescribing testosterone impacted provider prescribing behavior. Methods State PDMP requirements were determined by examining state regulatory websites. Only states who had recently implemented PDMP query mandates (since 2016) for testosterone were included. Using an insurance claims database, we evaluated all men aged 40-70 in each state who were enrolled for at least 1 year and did not move to another state during follow up. From this, a sub-cohort of men who enrolled within 3 and 6 months before and after the start date of their respective state's mandate in attempt to identify any immediate effect. Men were also stratified by race/ethnicity (White, Black, Hispanic, Asian) to observe any demographic trend. In a similar fashion, the total number of men who ever or never filled prescriptions for testosterone were identified. Rates before and after mandate implementation were compared using the generalized estimating equations test. Results 11 states (AK, CA, FL, HI, MI, NM, NV, PA, SC, WI, WY) were identified has having recent PDMP mandates for testosterone. A total of 2,297,290 men who met enrollment criteria were identified. Rates of testosterone prescriptions varied around the country (from 5.02 to 32.80 per 1000 person years). Moreover, there were no consistent changes in the rates of testosterone prescriptions after mandate implementation, regardless of the timeframe evaluated. Testosterone prescriptions increased in a majority of the states after implementation of a PDMP mandate (6 of 11 states, p<0.05) or showed no change (3 states). South Carolina and Wisconsin showed a decrease in the number of prescriptions after mandate implementation (p<0.05). While differences in the rates of testosterone prescriptions existed between races, the association with PDMP mandates were similar to the statewide analyses. Conclusion The implementation of state mandated PDMP query prior to prescribing testosterone does not appear to have a reliable effect on testosterone prescription patterns. Men with symptomatic hypogonadism do not appear to be negatively affected by new regulatory controls largely meant to curb opioid prescriptions. Disclosure No

Effects of State Opioid Prescribing Laws on Use of Opioid and Other Pain Treatments Among Commercially Insured U.S. Adults.

There is concern that state laws to curb opioid prescribing may adversely affect patients with chronic noncancer pain, but the laws' effects are unclear because of challenges in disentangling multiple laws implemented around the same time. To study the association between state opioid prescribing cap laws, pill mill laws, and mandatory prescription drug monitoring program query or enrollment laws and trends in opioid and guideline-concordant nonopioid pain treatment among commercially insured adults, including a subgroup with chronic noncancer pain conditions. Thirteen treatment states that implemented a single law of interest in a 4-year period and unique groups of control states for each treatment state were identified. Augmented synthetic control analyses were used to estimate the association between each state law and outcomes. United States, 2008 to 2019. 7694514 commercially insured adults aged 18 years or older, including 1976355 diagnosed with arthritis, low back pain, headache, fibromyalgia, and/or neuropathic pain. Proportion of patients receiving any opioid prescription or guideline-concordant nonopioid pain treatment per month, and mean days' supply and morphine milligram equivalents (MME) of prescribed opioids per day, per patient, per month. Laws were associated with small-in-magnitude and non-statistically significant changes in outcomes, although CIs around some estimates were wide. For adults overall and those with chronic noncancer pain, the 13 state laws were each associated with a change of less than 1 percentage point in the proportion of patients receiving any opioid prescription and a change of less than 2 percentage points in the proportion receiving any guideline-concordant nonopioid treatment, per month. The laws were associated with a change of less than 1 in days' supply of opioid prescriptions and a change of less than 4 in average monthly MME per day per patient prescribed opioids. Results may not be generalizable to non-commercially insured populations and were imprecise for some estimates. Use of claims data precluded assessment of the clinical appropriateness of pain treatments. This study did not identify changes in opioid prescribing or nonopioid pain treatment attributable to state laws. National Institute on Drug Abuse.

Factors Related to Prescription Drug Monitoring Program Queries for Veterans Receiving Long-Term Opioid Therapy.

State prescription drug monitoring programs (PDMPs) identify controlled medications dispensed across providers and systems. Department of Veterans Affairs (VA) policy requires electronic health record documentation of PDMP queries at least annually for VA patients receiving controlled medications; however, queries are not uniformly conducted. We examined factors associated with PDMP queries for veterans receiving long-term opioid therapy. Veterans with a VA provider who received long-term opioid therapy between August 2015 and August 2016 within a four-state region were identified; 9,879 were due for a PDMP query between August 2016 and February 2017. Likelihood of veterans' PDMP queries during this follow-up period was modeled as a function of patient, provider, and facility characteristics of interest in mixed-effects modified Poisson models estimating relative risk and 95% confidence intervals. Multivariable models controlled for potential confounders identified through the use of directed acyclic graphs. PDMP queries were documented for 62.1% of veterans that were due for a PDMP query. Veterans were more likely to be queried if they were Hispanic or if they received methadone, had average daily milligram morphine equivalents >20, or received urine drug screening during the studied period. Veterans were less likely to be queried if they had a rural address, mail order medication, or cancer diagnosis. Likelihood of PDMP queries was also lower for veterans whose opioid-prescribing provider was an oncologist or working in a low-complexity facility. Adherence to PDMP query policy within the VA varied by patient, clinician, and facility factors. Mechanisms to standardize the conduct of PDMP queries may be needed.

Opioid Prescribing and Opioid Risk Mitigation Strategies in the Veterans Health Administration.

The Veterans Health Administration (VHA) has taken a multifaceted approach to addressing opioid safety and promoting system-wide opioid stewardship. To provide a comprehensive evaluation of current opioid prescribing practices and implementation of risk mitigation strategies in VHA. VHA is the largest integrated health care system in the United States. VHA prescribing data in conjunction with implementation of opioid risk mitigation strategies are routinely tracked and reviewed by VHA's Pharmacy Benefits Management Services (including Academic Detailing Service) and the Pain Management Program Office. Additional data are derived from the Partnered Evidence-Based Policy Resource Center (PEPReC) and from a 2019 survey of interdisciplinary pain management teams at VHA facilities. Prescribing data are reported quarterly until first quarter fiscal year 2020 (Q1FY2020), ending December 31, 2019. VHA opioid dispensing peaked in 2012 with 679,376 Veterans receiving an opioid prescription, and when including tramadol, in 2013 with 869,956 Veterans. Since 2012, the number of Veterans dispensed an opioid decreased 56% and co-prescribed opioid/benzodiazepine decreased 83%. Veterans with high-dose opioids (≥ 100 mg morphine equivalent daily dose) decreased 77%. In Q1FY2020, among Veterans on long-term opioid therapy (LTOT), 91.1% had written informed consent, 90.8% had a urine drug screen, and 89.0% had a prescription drug monitoring program query. Naloxone was issued to 217,469 Veterans and resulted in > 1,000 documented overdose reversals. In 2019, interdisciplinary pain management teams were fully designated at 68%, partially designated at 28%, and not available at 4% of 140 VA parent facilities. Fifty percent of Veterans on opioids at very high risk for overdose/suicide received interdisciplinary team reviews. VHA clinicians have greatly reduced their volume of opioid prescribing for pain management and expanded implementation of opioid risk mitigation strategies. VHA's integrated health care system provides a model for opioid stewardship and interdisciplinary pain care.

Prescription drug monitoring programs in community pharmacy: An exploration of pharmacist time requirements and labor cost

ObjectiveTo (1) measure the average time community pharmacists require to query prescription drug monitoring program (PDMP) reports, and (2) estimate pharmacist labor costs associated with PDMP use. DesignThis exploratory project consisted of an observational time study followed by analysis of existing PDMP data sets. Data collected included time spent by pharmacists in Final Verification of controlled substance prescriptions (CSPs), and whether or not they queried the PDMP. Zip code level PDMP query rates and prescription volume of opioid and benzodiazepines (O&BZD) were linked to time-study results to calculate cost estimates of pharmacist labor. Setting and participantsCommunity pharmacists in Connecticut were observed and timed in their usual pharmacy setting as they verified CSPs. Deidentified PDMP data were obtained from the Connecticut Prescription Monitoring and Reporting System. Outcome measures(1) The time required by community pharmacists to query their PDMP in prescription filling workflow, and (2) the estimated labor costs associated with variable PDMP utilization rates. ResultsBetween November 2018 and January 2019, 9 pharmacists in 4 independent community pharmacies were observed verifying 53 CSPs. Pharmacists spent more time verifying CSPs when they queried the PDMP versus when they did not query the PDMP (106 ± 66 seconds vs. 28 ± 27 seconds; p < 0.01). Between June 2016 and May 2017, community pharmacists in 24 community pharmacies in 4 represented zip codes queried the PDMP for 11% (n = 19,074) of CSPs dispensed, costing an estimated $24,769 in pharmacist labor. To meet a 100% PDMP query rate for O&BZDs alone, an additional 3735 hours of pharmacist labor ($224,100) would be required. ConclusionPharmacists require considerably more time to verify CSPs when they query PDMPs. This extra time requirement may challenge community pharmacy operating costs, and also impose time pressures on community pharmacists.

Examining the Effect of a Whole Health Primary Care Pain Education and Opioid Monitoring Program on Implementation of VA/DoD-Recommended Guidelines for Long-term Opioid Therapy in a Primary Care Chronic Pain Population.

To describe the core elements of a Whole Health Primary Care Pain Education and Opioid Monitoring Program (PC-POP) and examine its effectiveness at increasing adherence to six of the Veteran Affairs/Department of Defense (VA/DoD) recommended guidelines for long-term opioid therapy (LOT) among chronic noncancer patients seen in primary care (i.e., urine drug screens [UDS], prescription drug monitoring program [PDMP] queries, informed consent, naloxone education/prescriptions, morphine equivalent daily dose [MEDD], and referrals to nonpharmacological pain interventions). A within-subjects comparison of outcomes was conducted between pre- and post-PC-POP enrollees (N = 25), as was a a between-subjects comparison to a comparison group (N = 25) utilizing a six-month range post-index date of 10/1/2018 (i.e., between-subjects comparison at Time 2). A convenience sample of adult veterans with chronic noncancer pain receiving opioid therapy consecutively for the past three months in primary care. Results showed increased concordance with VA/DoD guidelines among those enrolled in the PC-POP, characterized by increased documentation of urine drug screens, prescription drug monitoring program queries, informed consent, naloxone education/prescriptions, and a decrease in MEDD among patients enrolled in the PC-POP. The PC-POP shows promise for increasing guideline-concordant care for providers working in primary care.

Implementation and enforcement of state opioid prescribing laws

BackgroundIn response to the role overprescribing has played in the U.S. opioid crisis, in the past decade states have enacted four main types of laws to curb opioid prescribing: mandatory prescription drug monitoring program (PDMP) enrollment laws requiring clinicians to register with a PDMP; mandatory PDMP query laws requiring clinicians to check a PDMP prior to prescribing opioids; pill mill laws regulating pain management clinics; and opioid prescribing cap laws limiting the dose/duration of opioid prescriptions. While 47 states now have one or more of these laws in place, little is known about implementation and enforcement strategies, facilitators, and barriers. MethodsFrom November 2017 to February 2019, we interviewed 114 professionals involved in state opioid prescribing law implementation and enforcement in 20 states and identified common themes. ResultsImplementation efforts focused on awareness campaigns and targeted training of key front-line implementers. Enforcement strategies included active, complaint-based, and automated strategies. Collaboration across agencies and stakeholders, particularly health agencies and law enforcement, was identified as an important facilitator of implementation and enforcement. Two key interrelated barriers were identified: the complexity of state opioid prescribing laws in terms of which providers, patients, and prescriptions they applied to, and IT infrastructure. ConclusionDespite differing approaches, our findings suggest similar barriers to implementation and enforcement across state opioid prescribing laws. Strategies are needed to ease implementation and enforcement of laws that apply only to specific sub-sets of providers, patients, or prescriptions and address issues of access and data utilization of the PDMP.

Changes in Opioid Prescribing Patterns: A Survey of the Florida Society of Plastic Surgeons.

With thousands of people in the United States dying of opioid overdose each month, the opioid epidemic has become a serious public health concern. Legislators have attempted to address this problem at various levels of the government. Evaluation of outcomes of these measures is a necessary part of resolving the epidemic. Our survey was designed to evaluate the impact of measures enacted in Florida State in 2018 upon prescribing practices of plastic surgeons. The survey was prepared electronically using the online Qualtrics platform. Survey questions were multiple choice and inquired regarding changes in prescribing practices after enactment of mandatory query of the prescription drug monitoring program database and prescribing limits in Florida. The survey was distributed by e-mail 1 year after these laws took effect. Two survey reminder e-mails were sent at 2-week intervals after the initial message. Results were collected for an additional 3 weeks after the final correspondence. Thirty-two survey responses were received after distribution to the 156 members of the Florida Society of Plastic Surgeons, for a response rate of 20.5%. Twenty-two respondents reported changing their prescribing practices. The most common change reported was decreased number of tablets prescribed. Most respondents reported they believe that mandatory prescription drug monitoring program query and prescribing limits will be effective. This included 17 (53.1%) and 18 (56.3%) respondents, respectively. Results from our survey indicate that Florida plastic surgeons have adjusted their prescribing practices in response to recently enacted legislation. Most plastic surgeons reported decreased number of tablets of opioids prescribed. Many also reported incorporating nonopioid analgesics. Further study will be necessary to determine the impact of these changes on rates of opioid overdose.

Prescription drug monitoring program use and utility by Washington State pharmacists: A mixed-methods study

ObjectivesTo explore factors and situations that influence pharmacists to use the prescription drug monitoring program (PDMP) and to characterize actions taken by pharmacists after alarming scenarios from a PDMP query. DesignExplanatory sequential 2-phase mixed-methods design: (1) cross-sectional Web-based survey of Washington State pharmacists followed by (2) interviews with purposefully selected respondents to explore statistically significant quantitative findings. Setting and participantsThe study was conducted in Washington State from September 2018 to February 2019. A total of 967 Washington State pharmacists from various practice settings, including inpatient and outpatient pharmacies, participated. Ten outpatient pharmacists were interviewed in the second phase. Outcome measuresThe pharmacists reported the frequency of PDMP use, opinion on the usefulness of PDMP, and action(s) taken after a concerning PDMP report. ResultsThe usable response rate for pharmacists with a PDMP account was 17.6% (818/4659), and usable response rate for all pharmacists was 10.4% (967/9263). PDMP use varied by race, practice setting, and employer policy on PDMP use. Among the 818 PDMP users, 396 (48%) used the database at least once during a shift. Frequent PDMP users were more likely to recommend naloxone compared with less frequent users (adjusted odds ratio 1.70 [95% CI 1.09–2.65], P = 0.02). The following 3 interview themes were identified: time, company policy, and red flags. ConclusionPDMP has value to pharmacists of all practice settings studied. Frequent PDMP use may facilitate more pharmacist interventions, such as a naloxone prescription.

Order From Chaos: An Initiative to Improve Opioid Prescribing in Rheumatology Using Lean A3.

ObjectiveUse an established quality improvement method, Lean A3, to improve the process of opioid prescribing in an academic rheumatology ambulatory clinic.MethodsThis retrospective pre‐postintervention analysis of rheumatology records included patients prescribed opioids at least once during the study period. Lean A3 was used to develop a Controlled Substance Visit Protocol to standardize eight recommended elements of the opioid prescribing workflow. Analyses included changes in the recommended workflow elements and changes in opioid prescribing volume.ResultsImprovements were observed in seven of the eight recommended elements. Patient education, including treatment agreements and consent forms (39% completion for both preimplementation) increased to 78% and 80%, respectively (P < 0.001 for both). Risk assessment, as measured by the Current Opioid Misuse Measure, increased from 0.5% to 76% (P < 0.001). Best practices in prescribing, including prescribing in multiples of seven to avoid weekend refill requests, increased from 1% to 79% (P < 0.001). Monitoring parameters, including standardized functional assessment (0% vs. 86%), prescription drug monitoring program queries (49% vs. 84%), and urine testing (1% vs. 32%) all increased (P < 0.001). Visits scheduled at least quarterly for patients on chronic opioids did not change (P = 0.18). Overall, the number of patients prescribed opioids (185 vs. 160; P < 0.001) and annual prescription opioid morphine milligram equivalents (MMEs) (1 933 585 MME vs. 1 386 368 MME; P < 0.001) decreased.ConclusionThe Lean A3 method is a successful quality improvement tool for improving and sustaining opioid prescribing within a single academic rheumatology clinic. This method has potential applicability to similar clinics interested in improving opioid prescribing.

Utilization of prescription drug monitoring programs for prescribing and dispensing decisions: Results from a multi-site qualitative study.

Prescription drug monitoring programs (PDMPs) track the dispensing of prescription-controlled substances with the goal of mitigating misuse and diversion. Authorized users query the PDMP for controlled substance prescription histories at the point of care. Despite widespread implementation of PDMPs, there is much not known about how PDMPs influence prescribing and dispensing decisions. The objective of this study was to investigate how primary care providers (PCPs) and pharmacists utilize PDMPs when making prescribing and dispensing decisions. Data from in-depth, qualitative interviews with PCPs (n = 48) and community pharmacists (n = 60) across four states- Arkansas, Idaho, Kentucky, and Washington were analyzed for themes around PDMP use. Both PCPs and pharmacists reported that PDMPs are key tools for aiding prescribing and dispensing decisions. PCPs reported variable use of PDMPs with most querying the PDMP when there are "red flags" and fewer reporting having clinic policies that direct PDMP use. Primary care providers in Kentucky reported more consistent and routine use of the PDMP as a result of a state law that mandates query prior to the initial prescribing of Schedule II controlled substances. Community pharmacists practicing in chain pharmacies reported formal policies requiring PDMP query prior to dispensing opioids, while utilization of PDMPs by pharmacists practicing in independently-owned pharmacies was more variable. Pharmacists and PCPs reported barriers to PDMP use, such as having to "log in on a separate machine" and perceived that PDMP utility could be improved by integrating it within pharmacy dispensing systems and electronic health records. Pharmacists and PCPs reported the importance of PDMP information to aid their prescribing and dispensing decisions. Efforts to enhance state PDMP programs should consider processes that seamlessly integrate all available controlled substance prescription history for a given patient at the point of care so that PDMP utility for prescribing and dispensing decisions is maximized.

Association of the Use of a Mandatory Prescription Drug Monitoring Program With Prescribing Practices for Patients Undergoing Elective Surgery

ImportanceMost states have adopted the routine use of a prescription drug monitoring program (PDMP) to curb overprescribing of opioids. The American College of Surgeons promotes the use of these programs as a “guiding principle to curb the opioid epidemic.” However, there is a paucity of data on the effects of the use of these programs for surgical patient populations.ObjectiveTo determine the association of the mandatory use of a PDMP with the opioid prescribing practices for patients undergoing general surgery.Design, Setting, and ParticipantsA prospective observational cohort study was conducted at an academic hospital in New Hampshire among 1057 patients undergoing representative elective general surgical procedures from July 1, 2016, to June 30, 2017.ExposuresNew state legislation mandated the use of a PDMP and opioid risk-assessment tool for all patients receiving an outpatient opioid prescription in New Hampshire beginning January 1, 2017. The electronic medical prescribing system was modified to facilitate and support compliance with the new requirements.Main Outcomes and MeasuresChange in opioid prescribing practices after January 1, 2017, and time to complete PDMP requirements.ResultsAmong the 1057 patients (569 women [53.8%] and 488 men [46.2%]; mean [SD] age, 56.8 [15.4] years), the percentage of patients prescribed opioids after surgery did not decrease significantly (429 of 536 [80.0%] before the new requirements vs 401 of 521 [77.0%] after the requirements; P = .29). The mean number of opioid pills prescribed decreased from 30.8 to 24.0 (22.1%) in the 6 months prior to the mandatory PDMP requirement; the rate of decrease was actually less (from 22.8 to 21.9 pills [3.9%]) in the 6 months after the legislation. These new requirements did not identify any high-risk patients who subsequently were not prescribed opioids. The query and opioid abuse risk calculator together took a median time of 7 minutes (range, 2-17 minutes) to complete.Conclusions and RelevanceA mandatory PDMP query requirement was not significantly associated with the overall rate of opioid prescribing or the mean number of pills prescribed for patients undergoing general surgical procedures. In no cases was a high-risk patient identified, leading to avoidance of an opioid prescription. A PDMP can be a useful adjunct in certain settings, but this study found that it did not have the intended effect in a population undergoing elective surgical procedures. Legislative efforts to mandate PDMP use should be targeted to populations in which benefit can be demonstrated.

Variations in prescription drug monitoring program use by prescriber specialty

BackgroundAlthough prescription drug monitoring programs (PDMPs) have been widely implemented to potentially reduce abuse of prescription opioids, there is limited data on variations in PDMP use by prescriber specialty. Such knowledge may guide targeted interventions to improve PDMP use. MethodsUsing data from Washington state Medicaid program, we performed a retrospective cohort study of opioid prescribers and their PDMP queries between Nov 1, 2013 and Oct 31, 2014. PDMP registration was mandatory for emergency physicians, but not for other providers. The unit of analysis was the prescriber. The primary outcome was any prescriber queries of the PDMP. We used multivariate regression models to identify variations in PDMP queries by prescriber specialty, as well as to explore explanatory pathways for observed variations. ResultsWe studied 17,390 providers who prescribed opioids, including 8718 (50%) who were not registered with PDMP, 4767 (27%) who were registered but had no recorded use of the PDMP, and 3905 (23%) PDMP users (queries/user: median 18, IQR 5–64). Compared to general medicine physicians, PDMP use was higher for emergency physicians (OR 1.4, 95%CI: 1.2–1.7), and lower for surgical specialists (OR 0.1, 95%CI: 0.08–0.1), obstetrician-gynecologists (OR 0.2, 95%CI: 0.1–0.2) and dentists (OR 0.4, 95%CI: 0.4–0.5). Higher use by emergency physicians appeared to be mediated by higher registration rates, rather than by provider level predilection to use the PDMP. ConclusionsA minority of opioid prescribers to Medicaid beneficiaries used the PDMP. We identified variations in PDMP use by prescriber specialty. Interventions to increase PDMP queries should target both PDMP registration and PDMP use after registration, as well as specialties with current low use rates.

Physicians' Perspectives Regarding Prescription Drug Monitoring Program Use Within the Department of Veterans Affairs: a Multi-State Qualitative Study.

The Department of Veterans Affairs (VA) has implemented robust strategies to monitor prescription opioid dispensing, but these strategies have not accounted for opioids prescribed by non-VA providers. State-based prescription drug monitoring programs (PDMPs) are a potential tool to identify VA patients' receipt of opioids from non-VA prescribers, and recent legislation requires their use within VA. To evaluate VA physicians' perspectives and experiences regarding use of PDMPs to monitor Veterans' receipt of opioids from non-VA prescribers. Qualitative study using semi-structured interviews. Forty-two VA primary care physicians who prescribed opioids to 15 or more Veterans in 2015. We sampled physicians from two states with PDMPs (Massachusetts and Illinois) and one without prescriber access to a PDMP at the time of the interviews (Pennsylvania). From February to August 2016, we conducted semi-structured telephone interviews that addressed the following topics regarding PDMPs: overall experiences, barriers to optimal use, and facilitators to improve use. VA physicians broadly supported use of PDMPs or desired access to one, while exhibiting varying patterns of PDMP use dictated by state laws and their clinical judgment. Physicians noted administrative burdens and incomplete or unavailable prescribing data as key barriers to PDMP use. To facilitate use, physicians endorsed (1) linking PDMPs with the VA electronic health record, (2) using templated notes to document PDMP use, and (3) delegating routine PDMP queries to ancillary staff. Despite the time and administrative burdens associated with their use, VA physicians in our study broadly supported PDMPs. The application of our findings to ongoing PDMP implementation efforts may strengthen PDMP use both within and outside VA and improve the safe prescribing of opioids.

Assessment of outcomes following high-dose opioid tapering in a Veterans Healthcare System.

To assess the impact of tapering of chronic high dose opioid therapy in veterans prompted by the implementation of the Opioid Safety Initiative in 2013. IRB and VA Office of Research and Development-approved retrospective, observational chart review. North Florida/South Georgia Veterans Health System Patients: Veterans on high dose opioid therapy (≥300 mg of morphine equivalents per day) for chronic non-cancer pain as of 1/1/2012 with an opioid agreement discontinuation note documented in the medical record were included. Veterans treated for cancer pain or under palliative care were excluded. Descriptive outcomes include rate of opioid discontinuation, average duration of tapering, and rate of relapse. Differences before and after discontinuation assessed include healthcare utilization, monitoring via urine drug screens and state prescription drug monitoring program (PDMP) queries, non-opioid analgesics, benzodiazepines, and non-pharmacologic modalities. Forty-three patients were included. The mean duration of therapy was 7.8 years and 81.4 percent were on methadone prior to tapering. Opioids were tapered to discontinuation in 28 patients (65 percent) with long-term abstinence in 71 percent. The mean duration of tapering was 81 days and the median/mode was 30 days. Statistically significant differences after tapering include decreased PDMP queries, increased non-opioid analgesics, decreased benzodiazepine prescriptions, and increased use of mental health services (p < 0.05). There were zero adverse outcomes identified in those tapered and one death in the group who sought non-VA care for continuation. This study suggests that moderate speed tapering in high-risk veterans on chronic high-dose opioid therapy can be achieved, but caution is warranted in ensuring adequate follow-up and monitoring. Clinical pharmacy services may improve tapering outcomes by providing more frequent follow-up, monitoring via state PDMP queries to identify patients who have relapsed, and dispensing naloxone for increased safety.

Protocol: mixed-methods study to evaluate implementation, enforcement, and outcomes of U.S. state laws intended to curb high-risk opioid prescribing

BackgroundThe U.S. opioid epidemic has been driven by the high volume of opioids prescribed by healthcare providers. U.S. states have recently enacted four types of laws designed to curb high-risk prescribing practices, such as high-dose and long-term opioid prescribing, associated with opioid-related mortality: (1) mandatory Prescription Drug Monitoring Program (PDMP) enrollment laws, which require prescribers to enroll in their state’s PDMP, an electronic database of patients’ controlled substance prescriptions, (2) mandatory PDMP query laws, which require prescribers to query the PDMP prior to prescribing an opioid, (3) opioid prescribing cap laws, which limit the dose and/or duration of opioid prescriptions, and (4) pill mill laws, which strictly regulate pain clinics to prevent nonmedical opioid prescribing. Some pain experts have expressed concern that these laws could negatively affect pain management among patients with chronic non-cancer pain. This paper describes the protocol for a mixed-methods study analyzing the independent effects of these four types of laws on opioid prescribing patterns and chronic non-cancer pain treatment, accounting for variation in implementation and enforcement of laws across states.MethodsMany states have enacted multiple opioid prescribing laws at or around the same time. To overcome this issue, our study focuses on 18 treatment states that each enacted a single law of interest, and no other potentially confounding laws, over a 4-year period (2 years pre-/post-law). Qualitative interviews with key leaders in each of the 18 treatment states will characterize the timing, scope, and strength of each state law’s implementation and enforcement. This information will inform the design and interpretation of synthetic control models analyzing the effects of each of the two types of laws on two sets of outcomes: measures of (1) high-risk opioid prescribing and (2) non-opioid treatments for chronic non-cancer pain.DiscussionStudy of mandatory PDMP enrollment, mandatory PDMP query, opioid prescribing cap, and pill mill laws is timely given a dynamic policy environment in which numerous states pass, revise, implement, and enforce varied laws to address opioid prescribing each year. Findings will inform enactment, implementation, and enforcement of these laws in additional states.

Effect of Automated Prescription Drug Monitoring Program Queries on Emergency Department Opioid Prescribing

We assess whether an automated prescription drug monitoring program intervention in emergency department (ED) settings is associated with reductions in opioid prescribing and quantities. We performed a retrospective cohort study of ED visits by Medicaid beneficiaries. We assessed the staggered implementation (pre-post) of automated prescription drug monitoring program queries at 86 EDs in Washington State from January 1, 2013, to September 30, 2015. The outcomes included any opioid prescribed within 1 day of the index ED visit and total dispensed morphine milligram equivalents. The exposure was the automated prescription drug monitoring program query intervention. We assessed program effects stratified by previous high-risk opioid use. We performed multiple sensitivity analyses, including restriction to pain-related visits, restriction to visits with a confirmed prescription drug monitoring program query, and assessment of 6 specific opioid high-risk indicators. The study included 1,187,237 qualifying ED visits (898,162 preintervention; 289,075 postintervention). Compared with the preintervention period, automated prescription drug monitoring program queries were not significantly associated with reductions in the proportion of visits with opioid prescribing (5.8 per 1,000 encounters; 95% confidence interval [CI] -0.11 to 11.8) or the amount of prescribed morphine milligram equivalents (difference 2.66; 95% CI -0.15 to 5.48). There was no evidence of selective reduction in patients with previous high-risk opioid use (1.2 per 1,000 encounters, 95% CI -9.5 to 12.0; morphine milligram equivalents 1.22, 95% CI -3.39 to 5.82). The lack of a selective reduction in high-risk patients was robust to all sensitivity analyses. An automated prescription drug monitoring program query intervention was not associated with reductionsin ED opioid prescribing or quantities, even in patients with previous high-risk opioid use.