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Prescription drug monitoring programs improve, but challenges remain


 

When Wisconsin introduced its first prescription drug monitoring program (PDMP) system in 2013, doctors found the system clunky and cumbersome to navigate, recalled Noel Deep, MD, an Antigo, Wis.–based internist and president of the Wisconsin Medical Society.

Physicians had to click through several screens and were then directed to log into another website to enter patient information and scan records.

The state’s PDMP is much improved today, Dr. Deep said. The Wisconsin Department of Safety and Professional Services launched an enhanced version of the PDMP in January, giving doctors time to learn the new system before its use became mandatory for prescribers in April. The system takes fewer clicks and communicates with practices’ electronic medical record.

Dr. Noel Deep


“It is very easy, compared with what it was before,” Dr. Deep said in an interview. “I was one of those people who were skeptical, but I’ve been happy with the PDMP. It’s extremely quick. I know it’s a few more clicks, but it has also shown that, in Wisconsin, this has significantly decreased the use of prescription [opioid] medications.”

Across the country, physicians are experiencing similar ups and downs with state PDMPs as they work to manage the systems, juggle patient caseloads, and make the best prescribing decisions. Currently, 49 states, the District of Columbia, and Guam have operational PDMPs. Most databases generally require that Schedule II, III, and IV prescriptions be reported, explained Natalia Mazina, a San Francisco–based attorney who specializes in health and pharmacy law.

“Some states also require Schedule V, and some states even require certain noncontrolled substances to be reported,” she said in an interview. “That’s the biggest difference. There are also different agencies responsible for enforcement.”

States differ in the time allowed for prescribers and dispensers to report data, Ms. Mazina added. States such as New York and Utah, for instance, require real-time reporting, while Alabama and Louisiana require daily PDMP reporting. South Dakota requires reporting within 7 days of a prescription, while Alaska allows for monthly reporting. Training hours required for PDMP participation also vary by state.
Natalia Mazina, a San Francisco-based attorney who specializes in health and pharmacy law
Natalia Mazina


More states are moving toward mandatory rather than voluntary PDMP systems. At least 34 states now specify circumstances in which prescribers, dispensers, or both must access a patient’s PDMP prescription history, according to a summary by the National Alliance for Model State Drug Laws. For doctors, the push toward mandated PDMPs has generated mixed feelings and led to legislative battles in some states.

“From a safety standpoint, [PDMPs are] a good thing,” Dr. Deep said. “From a physician standpoint, [some] people feel this is restricting the physician-patient relationship and dictating how much we can prescribe, when we can prescribe, and what we can do. That’s one of the downsides.”
 

Beneficial or burdensome?

When Georgia legislators proposed a law earlier this year that would tighten reporting requirements for their state’s PDMP, physician leaders fought back against what they viewed as excessive regulations.

An initial bill included reporting requirements not only for standard controlled substances but for stimulants such as Adderall, Vyvanse, Focalin, and Ritalin, and all other nonopioid controlled drugs. The early version of the bill also recommended civil and criminal penalties for physicians who violated the regulations.

The American College of Physicians Georgia Chapter and the Medical Association of Georgia successfully advocated for the two provisions to be removed from the bill’s final version, said W. Cody McClatchey, MD, chair of the ACP Georgia Chapter’s health and public policy committee.

“We are in the midst of an opioid epidemic,” Dr. McClatchey said in an interview. “It would have been unreasonable and costly for state government to mandate that prescribers check PDMP for controlled drugs not related to the opioid epidemic. [In addition], I felt strongly that prescribers should not be subject to criminal penalties for not checking the PDMP. We are already subject to civil and criminal penalties for intentionally or knowingly overprescribing controlled drugs. That is adequate protection for patients.”

Georgia’s law, signed in May, requires physicians and up to two certified staff to seek and review information from the PDMP every 90 days for any prescription outlined in the law that exceeds 3 days/26 pills for medical care, or 10 days/40 pills for surgical care. In addition, physicians must make a notation in the patient’s medical record stating the date and time upon which such inquiry was made, among other requirements.

Dr. W. Cody McClatchey ACP Georgia
Dr. W. Cody McClatchey


The new requirements mean it will take longer to manage patients with chronic pain, anxiety, and depression who may need opioids and benzodiazepines because of the time necessary to access the PDMP, document that it was reviewed, and properly counsel the patient, Dr. McClatchey said. However, he noted that the additional time may allow physicians to charge a higher level of evaluation and management services. Doctors can minimize the impact of the rules by delegating many of the tasks to certified medical assistants and using “smartphrases” to document completion, he said.

“In my opinion, the final version of HB 249 strikes a fair balance between the needs of patients and the administrative burden on physicians,” he said. “Most physicians do not prescribe opioids and benzodiazepines on a continuing basis to many patients. Physicians who prescribe chronic opioids or benzodiazepines now have the ability to more accurately know when patients may be abusing opioids and benzodiazepines, which can be a matter of life or death.”
 
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