A Healthesystems publication

Spring 2013

PDMP: The Game Changer?

Prescription drug abuse could be monitored and prevented if PDMPs are given the funding and attention they deserve.

Prescription Drug Monitoring Programs (PDMPs) have the potential to offer a real-time glimpse into controlled substance prescribing patterns and patient drug-seeking behavior. That is, if these state-sponsored programs are appropriately utilized, mandated and funded. As it stands, plans are being developed to improve PDMPs, but as is the case with many interstate projects, time and cost are hindering factors. Regardless, the potential remains for PDMPs to be a serious contender in the fight against prescription drug abuse.

A Clinical Perspective: PDMPs Offer Promise

The opportunity to impact the trajectory of the opioid epidemic is within our reach, but as a nation, we can’t seem to keep a hold of it. Prescription Drug Monitoring Programs could be an effective tool to help overcome prescription drug abuse.

A PDMP is a statewide, electronic database created to monitor the prescribing and dispensing of controlled substances. These databases are secured and access is authorized only to relevant parties, such as health care practitioners, pharmacists, law enforcement officers and other regulatory agencies.

The ultimate purpose of a PDMP is to encourage and facilitate legitimate medical use of controlled substances, and to discourage drug abuse, misuse, diversion and doctor-shopping. There are many advantages to a PDMP – but the limited funding, interstate variability, lack of third-party access, and lack of communication between states restricts the potential.

Most States Have an Active PDMP

Currently, 49 states, the District of Columbia, and one U.S. territory have passed legislation enacting a PDMP and 43 states have a PDMP that is actively collecting and reporting data. The Drug Enforcement Agency (DEA) plays no role in overseeing states PDMPs, but a variety of other regulatory bodies do oversee and administer state PDMPs, including law enforcement agencies, Boards of Pharmacy, Departments of Health, professional licensing agencies and substance abuse agencies. [See map below]

For updated PDMP Maps and Tables click here.

All states with PDMPs monitor Schedule II controlled substances, which include certain opioids, stimulants, and depressant drugs with very high abuse potential. Some examples of Schedule II drugs include morphine, oxycodone, codeine, methylphenidate, dextroamphetamine and some barbituates. In New York, due to the recent iSTOP legislation, hydrocodone is now considered a Schedule II controlled substance with stricter prescribing limits.

Many states also monitor Schedules II-V drugs, and some states expand their focus to include other drugs of possible abuse, such as tramadol and carisoprodol. On January 12, 2012, carisoprodol became a schedule IV substance in all states.

Each state determines who is authorized to access the PDMP for that state, however, most states grant authority to prescribers and pharmacists, as this information relates to the treatment of a specific patient.

States may also provide PDMP data to other entities, such as state medical examiners, law enforcement, other state PDMPs, licensing/regulatory boards, or research organizations for data analysis. Typically, law enforcement does not gain access to patient-specific PDMP data unless requested as part of an ongoing investigation. A few states even allow patient access to the PDMP and may grant patients a report of their own record if requested, but patients are not allowed direct access to the database.

PDMPs Are Underutilized

Although more research on the effectiveness of PDMPs is warranted, current data suggests that the benefits of a using a PDMP may reduce doctor-shopping, alter prescribing behavior, and curb rates of opioid abuse.1,2

A recent study, published in September 2012 by researchers at the Heller School for Social Policy and Management, assessed the role of PDMPs and offered recommendations for improving PDMP effectiveness, such as offering proactive reports, mandating prescriber use, and improving data quality through timeliness, completeness and consistency.3

However, several issues currently stand out as being barriers to immediately realizing the full impact of PDMPs. Wide variability exists among states in how data is contained and reported, and since PDMPs are not active in all states, no uniformity presently exists on data sharing and interstate operability. This concept is not yet widely embraced, although a handful of states have begun to take the step towards data sharing. The fact is that injured workers do travel between states, cross state lines to visit doctors, and use pharmacies in neighboring states. Historically, there has not been a widely adopted vehicle in place to share prescription drug monitoring information across states, except between Kentucky and Ohio. These two states currently have interchange of data in place. Interstate operability is one of the keys to early intervention and abuse avoidance.

There is movement to change this. The Prescription Monitoring Information Xchange (PMIX) architecture, sponsored by the Alliance of States with Prescription Monitoring Programs, is one ongoing attempt to facilitate the sharing of encrypted PDMP data across state lines. Its goal is to implement a standardized, secure, scalable approach for the exchange of electronic PDMP data among states. Each state can participate in the PMIX program by passing its own legislation to share realtime information with other defined partnering states.4

The National Association of Boards of Pharmacy (NABP) has expanded on the concept with additional technology to facilitate ease of data sharing. This technology platform, InterConnect, will be compatible with the PMIX architecture. It is estimated that 25 states will be using the NABP software for data sharing by early to mid-2013.5 Currently, 15 states participate in the InterConnect program. See the interactive map in the RxInformer App version of this publication to view the participating states.

The National Council for Prescription Drug Programs (NCPDP), the organization that provides national coding standards for the insurance industry, recently published recommendations for improving PDMPs. NCPDP proposes improving standardization of data by requiring a minimum data set and standard transaction format across all states, enacting real-time reporting leveraging current electronic prescribing capability, and the inclusion of a central data repository to provide multistate access to comprehensive data.6

Currently, states may not report data in a real-time fashion, and pharmacy submission requirements vary from daily, weekly, bi-weekly, to monthly. States may retrospectively analyze and report information contained in the database. Available research suggests that issuing reports proactively – to prescribers or pharmacies when suspicious trends are identified – may have a more significant impact on curbing abuse.7

Furthermore, not all states mandate that prescribers consult the PDMP database before issuing a script for a controlled substance. However, in 2012, four states (Kentucky, Massachusetts, New York, and Tennessee) passed legislation mandating that prescribers consult the state PDMP before issuing a script, and Florida currently has proposed similar legislation as well.8

New York’s recently enacted iSTOP legislation requires enhancement and modernization of the existing Department of Health’s secure prescription monitoring program registry, to include information about dispensed controlled substances reported by pharmacies on a “real time” basis, to curb abuse and diversion. The legislation, in most cases, requires health care practitioners to consult the PMP Registry before prescribing or dispensing certain controlled substances prone to abuse and diversion. In addition, the law mandates electronic prescribing for all controlled substances, with limited exceptions.

The Kentucky All Schedule Prescription Electronic Reporting (KASPER) System tracks controlled substance prescriptions dispensed within the state. This PDMP, which has documented success, reports all scheduled prescriptions for an individual over a specified time period, the prescriber and the dispenser. Practitioners, pharmacist and law enforcement have access to the KASPER system.

Future Considerations

It is known that chronic opioid use may predict lengthened disability, and long term use of opioids is associated with extended disability and less successful outcomes9,10,11 as well as higher medical costs and more costly claims.12 Third-party payer access by entities with a significant stake in curtailing opioid misuse and abuse is the next logical step in the evolution of state PDMPs.

A report released by the California Workers’ Compensation Institute (CWCI) claimed that payer access to the California state PDMP, Controlled Substance Utilization Review and Evaluation System (CURES), could have cut California workers’ compensation claim costs by an estimated $57.2 million – by identifying inappropriate opioid prescribing not recommended by evidence-based medical literature or the Medical Treatment Utilization Schedule.13

However, none of these benefits may be realized if the databases are not operational, which remains a serious problem looming over many states plagued by lack of funds. Currently, a mix of grants, licensing fees, general revenue, and board funds constitute funding for state PDMPs, none of which is a reliable source of sustainable income. While state PDMPs offer the potential to champion the fight against prescription drug abuse, they will not gain the advantage unless funding and access is provided.

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SOURCES

1 -Julie Worley, “Prescription Drug Monitoring Programs, a Response to Doctor Shopping: Purpose, Effectiveness, and Directions for Future Research,” Issues in Mental Health Nursing, vol. 33, no. 5 (2012), pp. 319-328.
2 -Liza M. Reifler et al., “Do Prescription Monitoring Programs Impact State Trends in Opioid Abuse/Misuse,” Pain Medicine, no. 13 (2012), pp. 434-442.
3 -Thomas Clark et al, Prescription Drug Monitoring Programs: An Assessment of the Evidence for Best Practices, 6 (2012).
4 -Alliance of States with Prescription Drug Monitoring Programs. Available at: http://www.pmpalliance.org/. Accessed January March 14, 2013.
5 -National Association of State Boards of Pharmacy (NABP), NABP PMP InterConnect, 2012, http://www.nabp.net/ programs/pmp-interconnect/nabp-pmp-interconnect.
6 -National Council for Prescription Drug Programs (NCPDP), NCPDP Recommendations for Improving Prescription Drug Monitoring Programs (PDMP), 2013, Available at: www.ncpdp.org. Accessed March 14, 2013.
7 -Ronald Simeone and Lynn Holland, An Evaluation of Prescription Drug Monitoring Programs, Simeone Associates, Inc., No. 2005PMBXK189, September 1, 2006. Sponsored by the U.S. Department of Justice (DOJ), Office of Justice Programs (OJP), Bureau of Justice Assistance (BJA).
8 -Thomas Clark et al, Prescription Drug Monitoring Programs: An Assessment of the Evidence for Best Practices,6 (2012).
9 -Franklin GM, Stover BD, Turner JA, et al; Disability Risk Identification Study Cohort. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine (Phila Pa 1976) 2008;33(2):199-204.
10 -Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery, and late opioid use. Spine (Phila Pa 1976) 2007; 32:2127-2132.
11 -Kidner CL, Mayer TG, Gatchel RJ. Higher opioid doses predict poorer functional outcome in patients with chronic disabling occupational musculoskeletal disorders. J Bone Joint Surg Am. 2009;91(4):919-27.
12 -Leider HL, Dhaliwal J, Davis EJ, et al. Healthcare costs and nonadherence among chronic opioid users. Am J Manag Care. 2011;17(1):32-40.
13 -Alex Swedlow and John Ireland. Estimated Savings from Enhanced Opioid Management Controls Through Third Party Payer Access to CURES. January 2013. California Workers’ Compensation Institute (CWCI).
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