WASHINGTON – The prescription drug–monitoring programs that exist in every state are not going to make a dent in opioid abuse unless physicians use them.
Because each state governs its own prescription drug–monitoring program (PDMP), the efficiency and effectiveness of each varies widely from the others. In the ideal, a PDMP collects information on which prescriptions are being filled by what patients as well as which physicians are prescribing the drugs. Information from the databases is used to help determine which patients might be doctor shopping for opioids as well as identify physicians who might be operating “pill mills” and contributing to the availability of narcotic pain medication that is used for other than clinical purposes.
Data from several studies have shown that in many instances, doctors do not realize the detail and usefulness of data from PDMPs, Allan Coukell, senior director for drugs and medical devices at Pew Charitable Trusts, Washington, said at a panel discussion on prescription drug abuse hosted by the Alliance for Health Reform and the Pharmaceutical Care Management Association, the industry lobby for pharmacy benefit managers.
When shown data on a specific patient, a physician was often “surprised to know how many other physicians that patient was seeing, and having that information changed their prescribing,” Mr. Coukell said, noting that in some cases, the information led to physicians refusing to prescribe pain medication and in others, it eased fears that a patient might be doctor shopping, giving the physician some peace of mind about writing a prescription for a narcotic.
Panelist Dr. Sarah Chouinard, medical director of Community Care of West Virginia, noted that physicians often are surprised when presented with data collected by PDMPs about their own individual prescribing habits.
“Eight out of 10 people were very surprised at the number of hydrocodone prescriptions they had written in the last 3 months,” Dr. Chouinard said.
In addition, the culture of administering pain medicine has gone through a shift in the last 10 years that is contributing to the problem of how many pills are available.
“About 10 years ago, there were doctors wandering around with buttons that said ‘No Pain’ with a red circle and a line through it because we were accused of under treating pain,” she observed. “Now, the pendulum has swung in the opposite direction. They used to say, ‘Hey, we’ll get sued if we don’t write pain medicine for these people,’ and now it’s, ‘Gosh, don’t write anything, or we will be a pill mill.’ I think the real answer is getting back to the middle and allowing the word to be out there that you don’t have to use a narcotic for every bump.”
To that end, Dr. Chouinard shared a solution her community organization has implemented. She said that “none of the [family physicians] are equipped, myself included, to treat chronic pain. Chronic pain is a specialty. ... It requires special training. The training that we as family doctors get now, after residency, is a mandatory 3 hours every 2 years.”
So Community Health of West Virgina hired an anesthetist who is not interested in family medicine but rather has a special interest in addictions medicine and outpatient pain medicine.
“Every one of our patients who has chronic pain [is sent] to this physician first,” Dr. Chouinard explained. “He does the work-up. He looks to see if the patients are amenable to any kind of alternatives and then sends those patients back to us as primary care doctors.”
After that, every patient gets a pain contract that essentially provides consent to have urine tested on a regular basis to track adherence, as well as provide pill counts and office visits as required by the doctors. The physicians also are required to regularly check the PDMP database.
Patients who need this kind of treatment do not complain that the requirements are burdensome, said Dr. Chouinard, who described the program as successful overall. She said 30% have stayed properly adherent to their prescription narcotics and are living within the agreements of their contracts, while another 20% were taken off their medication because they were able to be placed on alternate, nonopioid therapies. About 30% ended up recommended for or enrolled in an addiction program, while 20% failed to maintain their contracts, and thus were unable to get their prescriptions.
Dr. Chouinard said a program like this could easily be rolled out across the country to help address the opioid abuse problem, as well as help remove primary care doctors from the prescribing loop.
“None of these people went into medicine because they had an interest in treating chronic pain,” she said.
In keeping with the overall message of getting doctors to use PDMPs more, Mr. Coukell said that getting this information integrated into electronic health records is “the Holy Grail,” though he added that getting practice alerts are a good short-term fix. He also said that getting consistency of reporting practice uniform across states and getting more states to trade information also was key, as is getting rules in place to allow someone in the office other than the doctor to have access to the PDMP databases (which some states do allow).
Centers for Disease Control and Prevention Director of the Division of Unintentional Injury Prevention Grant Baldwin, Ph.D., concurred.
“Providers have a limited amount of time to see patients,” Dr. Baldwin said. “Integrating all of these fixes will not necessarily extend the amount of time, but it actually makes it easier for the health care team to do their job in an efficient manner in that same 10-15 minute time."