Keeping Patients Safe by Keeping Track of Drugs

Pain Management, June 2010, Volume 3, Issue 4

Just how well do you know your patients? Every day physicians across the country treat patients from all different walks of life-some they've known for years, others they see once or twice a year, and some are new patients whom they know little about other than what they've read off initial forms.

Just how well do you know your patients? Every day physicians across the country treat patients from all different walks of life—some they’ve known for years, others they see once or twice a year, and some are new patients whom they know little about other than what they’ve read off initial forms.

The role of the physician is to evaluate, diagnose, and offer treatment to individuals needing medical attention; but increasingly, that role now seems to require an additional component: to grill patients about their medication history. Doing so provides an added measure of safety— not only for the patient, but for the physician as well. The reason for this shift is because more and more, patients are turning to a variety of sources to obtain medications, such as multiple doctors and pill farms, and are even crossing borders to obtain prescription drugs.

One example is Leslie Cooper, a patient who became addicted to painkillers “after a particularly tough surgery,” as reported in USA Today. The addiction continued for a decade. Cooper, 34, visited several doctors and pain clinics in southern Ohio until overdosing after traveling two hours to fill a prescription (http://hcp.lv/9Mbqqb).

According to a report issued by the CDC on June 18, “Emergency department visits for nonmedical use of opioid analgesics increased 111% during 2004-2008” (http://hcp.lv/cwndxz). That is why organizations like the National Alliance for Model State Drug Laws (NAMSDL; www.namsdl.org) and doctors across the country are pushing for prescription drug monitoring programs (PDMPs) to be the standard in every state.

State Prescription Drug Monitoring Programs

PDMPs are statewide electronic databases that collect data on dispensed narcotic substances and distribute it to individuals authorized under state law to receive it for purposes of their profession (http://hcp.lv/aXhnka). PDMPs, which are usually overseen by a statewide regulatory, administrative, or law enforcement agency, gather information on the prescription drug habits of patients and the prescribing patterns of physicians, tracking data such as how often a patient receives prescriptions, for which conditions they receive prescriptions, and from how many doctors they receive prescriptions.

According to the NAMSDL, the five main benefits of PDMPs are their ability to:

• Support access to legitimate medical use of controlled substances

• Identify and deter, or prevent, drug abuse and diversion

• Facilitate and encourage the identification, intervention with, and treatment of persons

addicted to prescription drugs

• Inform public health initiatives through outlining of use and abuse trends

• Educate individuals about abuse and diversion of and addiction to prescription drugs (http://hcp.lv/ aK9q1Y)

Many supporters generally believe that tracking this kind of information can help prevent the misuse of prescription drugs and curb abuse. According to Dr. John F. Dombrowski, a board member of the American Society of Interventional Pain Physicians

(ASIPP; www.asipp.org), not only could this be a crucial step in controlling the availability of illegal prescription drugs on the street, but by its very nature it can help curb healthcare costs.

“With respect to these medications, obviously they have a lot of risks in terms of addiction, abuse, perhaps even death, but they also cost money,” Dombrowski says. “So, if we can then limit all those drugs that are out there then we can also limit the cost of all those drugs being out there. And once that system gets up and running, you can have costcontainment.”

Spreading across the country

Currently, there are 33 operational state PDMPS across the county. These PDMPs actively collect prescription data and release it upon request to the appropriate parties. Overall, 42 states have currently enacted laws to create and utilize PDMPs as of June 1, according to research from the NAMSDL (http://hcp.lv/ceDD9z).

However, not all state PDMPs are created equally. For example, some programs may only include schedule II drugs, while others may only include schedule IV-V drugs. The groups that have access to the databases can also vary, as can the methods of access. States typically fall into two categories: those with proactive PDMPs and those with reactive PDMPs. Proactive PDMPs “identify and investigate cases, generating unsolicited reports whenever suspicious behavior is detected,” and also “tend to be law-enforcement oriented.” On the other hand, reactive PDMPs “generate specific reports only in response to a specific inquiry” (http://hcp.lv/bJHZiT). In 2004, the NAMSDL developed criteria for building strong and effective PDMPs, recommending that programs:

• Include drugs that demonstrate a potential for abuse, especially as indicated by law officials and addiction treatment professionals

• Proactively provide information to law enforcement, occupational licensing officials, and other appropriate individuals.

• Allow dispenser and prescribers, law enforcement officials, and occupational licensing officials to request specific information from the databases

• Attempt to address interstate misuse and abuse of prescription drugs

The next steps

The NAMSDL, in a 2006 follow-up evaluation of PDMPs nationwide, found that proactive programs “may be more effective” than reactive programs “in reducing the per capita supply of prescription pain relievers and stimulants.” (http://hcp.lv/bJHZiT)

Among the states frequently mentioned as having effective programs in place are Nevada, Kentucky, Ohio, Maine, and Vermont, according to Sherry Green, chief executive officer, NAMSDL. “There are now over 20 states that are allowed to provide some type of unsolicited report,” Green says. “Some states are allowed to send pertinent information to professional licensing or occupancy boards or law enforcement if, in reviewing the PMP [prescription monitor program] data, there is reason to believe that a violation of law or a breach of an occupational standard has occurred. Some states are allowed to send information to prescribers if there is reason to believe there has been misuse or abuse of prescription medications.”

Getting information into the hands of knowledgeable health professionals who are able to most effectively address the issue is the ongoing focus, she says. “This suggests to me that PMP officials are striving to use their programs for early intervention and early identification of potential problems as much as possible.”

Today, many of the recommendations made by the NAMSDL for establishing effective programs are still valid and are being utilized across the country, says Green. “Our components were based on those successful elements common to most programs at the time we developed the document. I’m glad to say that as more and more states have established PMP programs, they have generally incorporated the same successful elements.” The burgeoning nationwide initiative to establish PDMPs is clearly having an effect; next up is getting users familiar and comfortable with the programs. Since 2006, PMP officials have been intent on identifying ways to improve the effectiveness of the programs as information tools for professionals, Green says. “To this end, states have been creating 24/7 access through secure Web portals for prescribers to access the PMP data at the times most useful to them in terms of assessing treatment plans for their patients.”

Protecting data is also of concern, and attention is also being placed on “upgrading various technical security measures,” she adds. “Additionally, over the last several years, we’ve seen a strong effort among PMPs to educate authorized users of the data on how to use the PMP system, the value of the PMP data to their professional responsibilities, and the appropriate uses of the data.”

Going national?

While establishing PDMPs at the state level may be useful, the problem of doctor-shopping and pharmacy-hopping across state lines has some supporters—including members of ASIPP—calling for a national prescription monitoring program. A strong PDMP supporter, ASIPP has helped lobby Congress to offer aid to individual states to create their own databases through the signing of the National All Schedules Prescription Electronic Reporting Act in 2005 (www.nasper.org). Behind the creation of the bill is another initiative headed by the ASIPP to eventually establish a national database that is accessible by physicians across the country (http://hcp.lv/cq1dPB).

Opening up database information to neighboring states, or even creating a national database accessible to all physicians, is believed by many to be an even better way to achieve the goals that are associated with state prescription monitoring program databases (http://hcp.lv/casJs9).

While the NAMSDL does not have an official statement on the concept of a national PMP, Green says she is aware of “several interstate sharing initiatives” that the group is tracking. For example, Green mentions that the IJIS Institute is currently working with states such as Kentucky and Ohio, along with several PMP officials, on the “development of a technological infrastructure which would allow multiple state PMPs to securely transmit PMP data to other state PMPs.” Similarly, Green says that the Council of State Governments’ National Center on Interstate Compacts is drafting “an interstate compact on PMP data sharing” that “would be considered by all state legislatures,” and if adopted, “would allow that state’s PMP to share PMP data with other PMPs in states that have also adopted the compact.”