Modern PDMPs reduce prescription drug abuse and related harms
In April, House Bill 317 moved out of the Pennsylvania House and Human Services Committee and is now ready for a vote on the house floor. It represents Pennsylvania’s current effort to create a widely accessible Prescription Drug Monitoring Program (PDMP) that gathers information about patterns of prescribing and dispensing prescription drugs within the state.
Currently, Pennsylvania’s database is one of the most limited in the US—it tracks only Schedule II controlled substances, data is updated monthly, and access is limited to law enforcement officers.
HB 317 would require reporting from all dispensers in the Commonwealth, including mail order and Internet sales of pharmaceuticals. It would expand database access to all “practitioners,” defined as pharmacists, physicians, dentists, nurse practitioners, veterinarians, and others. And it would require “dispensers” (primarily pharmacists) to report information to the system within seven days to keep data updated to near-real-time.
The use of an updated PDMP in Pennsylvania would reach into several important realms. It would reduce drug diversion and overdose, improve quality of care, and offer real-time state and local datasets about drug use trends.
One hundred people die of drug overdoses every day in the United States, leading the CDC to term prescription drug abuse a national “epidemic.” In Allegheny County, drug overdoses have surpassed motor vehicle accidents as the leading cause of death and recent numbers show that drugs cause a third of all accidental deaths. Neighboring Westmoreland County has also been hit hard.
PDMPs have been hailed as elegant and relatively inexpensive means through which practitioners and dispensers can understand and prevent prescription drug abuse, overdose, and diversion. They are one of the CDC’s top five policy recommendations for preventing prescription drug overdoses and have been widely adopted across the nation.
One of the PDMP’s most shining successes is in Kentucky. Since the introduction of a PDMP—the Kentucky All Schedule Prescription Electronic Reporting (KASPER) System, now considered a “gold-standard” for PDMPs—Kentucky has seen its ranking among states with the highest nonmedical use of prescription painkillers drop from second to thirty-first place—a drop that officials attribute largely to its monitoring program.
How do PDMPs work?
Currently, 42 states have operational PDMPs. Funding, infrastructure, and reporting vary widely from state to state, but their general workings are similar.
Each PDMP is housed by an entity that can support electronic data collection, whether by state IT systems, a system sponsored by the National Association of Boards of Pharmacy (NABP), or maintained by a private company. The PDMP collects prescribing and dispensing data for controlled substances from pharmacists and prescribing physicians (and in some states, veterinarians) in a time frame varying from 24 hours to a month, depending on state regulations.
Data is then monitored and analyzed for patterns that indicate abuse or diversion. Medical providers and pharmacists can access the data (which is between a day and a month old) before writing a prescription or dispensing a controlled substance.
For example, if an individual obtains prescriptions for controlled substances (such as Vicodin or OxyContin) from multiple dispensers in a 24-48 hour period (a practice known as “doctor shopping”), it may indicate a pattern of substance use disorder or drug diversion. PDMPs relay this information to prescribers and dispensers (in some states, law enforcement can also access this data) who can intervene, perhaps preventing future overdose.
How do PDMPs improve quality of care?
It might seem that PDMPs are set up in the interest of criminalization: to punish fraud and diversion. But what states and practitioners have found is that PDMPs help identify substance abuse and misuse earlier. This information is essential to providing individuals with early interventions and preventative care.
PDMPs also help practitioners and researchers understand patterns in prescriptions to treat patients with pain more effectively. As a study by the University of Toledo indicates, use of PDMP data by physicians helped them distinguish between doctor shoppers and patients legitimately in pain. Physicians originally planning to prescribe less medication because of fears about diversion and substance abuse were able to prescribe more medication to patients in need of pain management.
What else do PDMPs do?
PDMPs can help curb the overdose epidemic. Overdoses happen for various reasons, including drug-drug interactions, overmedication, and illicit use of prescription drugs. PDMPs are built to address all three of these situations. According to the CDC, populations most vulnerable to prescription drug overdose include people who take high daily dosages of prescription painkillers and those who misuse multiple abuse-prone prescription drugs, low-income people and those living in rural areas, individuals suffering from mental illness and those with a history of substance abuse.
In addition to their impact at the ground level on patient care, PDMPs can have far-reaching effects by influencing policy decisions. The National Alliance for Model State Drug Laws (NAMSDL) explains that PDMPs can benefit public health policy because they are fingers on the pulse of substance use and abuse trends at state and local levels. The alternative to data from statewide PDMPs are federal data, which quickly fall out of date. But PDMPs provide relatively current epidemiological information at state and regional levels that can help tailor better healthcare, human services and criminal justice policies.
Pennsylvania: Past, Present and Future
Pennsylvania actually had one of the first PDMPs in the nation, established in 1972, but neither prescribers nor dispensers were permitted to access it. Its utility has also been limited by a lack of IT infrastructure to support data-sharing among systems that new PDMPs need to operate.
In its current form, the legislation leaves certain implementation questions outstanding, including on the best information technology system to support Pennsylvania’s prescription data.
Another question is how PDMP data might be linked to other health IT systems. This is a technical barrier that states everywhere have faced in establishing effective PDMPs: how to establish and coordinate standards and protocols that both PDMPs and health IT can use. PDMPs evolved on their own outside the health IT ecosystem but now need connectivity to health IT to make them more valuable to physicians and pharmacists.
PDMP models are variable across the nation and both Brandeis University and NAMSDL have published their recommendations for PDMP best practices, which include data sharing from state-to-state, linkage to addiction treatment professionals, and confidentiality protections and education for authorized users. Pennsylvania is in a good position to adopt some of these best practices.
In the coming months, we will know if Pennsylvania will join most other states and overhaul our PDMP. Should we opt for the upgrade, in the coming years, we will know much more about its structure, utility, and effects on the health of Pennsylvanians.