Utilization of prescription drug monitoring programs for prescribing and dispensing decisions: Results from a multi-site qualitative study

Managing polypharmacy through medication review tools - pros and cons

Inappropriate polypharmacy is a common occurrence in elderly patients, resulting in increased adverse drug reactions, nonadherence, and increased healthcare costs. Medication review and deprescribing are the primary strategies described in the literature for dealing with problematic polypharmacy. To effectively carry out the medication review, various tools have been developed. These tools can support medication review in a variety of ways. Some tools include a list of medications requiring detailed attention, while others guide medical professionals with principles and algorithms for reviewing and prescribing medicines. A third category of tools focuses on tracking and identifying symptoms that may be due to drug-related problems.

Cancer-Chemotherapy-Related Regimen Checks Performed by Pharmacists of General Hospitals Other than Cancer Treatment Collaborative Base Hospitals: A Multicenter, Prospective Survey

Although prescription review is an important role for pharmacists in anticancer drug therapy, there are no guidelines in Japan that specify what pharmacists should check for in chemotherapy regimens. This prospective multicenter survey aimed to investigate the implementation of chemotherapy regimen checks by pharmacists in general hospitals by focusing on 19 recommended confirmation items designed to enhance chemotherapy safety. This study involved 14 hospitals within the National Hospital Organization in different regions of Japan. The top five cancers in Japan (gastric, colorectal, lung, breast, and gynecological) were targeted and specific chemotherapy regimens were analyzed. This study assessed the amount of time required for regimen checks, the number of confirmation items completed, the number and the content of inquiries raised regarding prescriptions, and the pharmacists' opinions using a questionnaire that had a maximum score of 10 points. Pharmacists checked 345 and 375 chemotherapies of patients in the control group (CG) and recommended items group (RIG), respectively. The mean time periods required for completing a chemotherapy regimen check were 4 min and 14 s (SD ±1 min and 50 s) and 6 min and 18 s (SD, ±1 min and 7 s) in the CG and RIG, respectively. The mean of the recommended items for the CG = 12.4 and for the RIG = 18.6. The items that the pharmacists did not confirm included urine protein (sixty-nine cases, 18.4%), allergy history (four cases, 1%), previous history (two cases, 0.5%), and a previous history of hepatitis B virus (sixty-nine cases, 18.4%). The number of inquiries for a doctor's prescription order was higher in the RIG than in the CG (41 vs. 27 cases). This multicenter survey demonstrated the potential effectiveness of implementing 19 recommended confirmation items in the regimen checks by pharmacists in general hospitals other than cancer treatment collaborative base hospitals.

Health-care practitioner use of prescription drug monitoring programs in clinical practice in Australia: A qualitative study

INTRODUCTION

Prescription drug monitoring programs (PDMP) are electronic databases used by prescribers and pharmacists to monitor the use of high-risk prescription medications subject to extramedical use. This study aimed to explore how Australian pharmacists and prescribers are using PDMPs in practice and to gain an understanding of barriers to tool use, as well as practitioner recommendations to increase tool usability and uptake.

METHODS

Semi-structured interviews were conducted with pharmacists and prescribers who use a PDMP (n = 21). The interviews were audio-recorded, transcribed and thematically analysed.

RESULTS

The four themes that emerged were: (i) PDMP notifications combined with practitioner clinical judgement guide PDMP usability; (ii) practitioners use PDMPs to facilitate patient and practitioner communication; (iii) workflow systems integration impacts tool usability; and (iv) optimising PDMP information and data access including practitioner-tool engagement to improve tool uptake and usability.

DISCUSSION AND CONCLUSIONS

Practitioners appreciate the value of PDMP information support for clinical decisions and patient communication. However, they also acknowledge the challenges to tool use and recommend improvements including enhanced workflow, systems integration, optimisation of tool information and national data sharing. Practitioners provide an important perspective on PDMP use in clinical practice. The findings can be drawn on by PDMP administrators to improve tool usefulness. Consequently, this may lead to an increase in practitioner PDMP use and optimise the delivery of quality patient care.

Physician perspective on the implementation of risk mitigation strategies when prescribing opioid medications: a qualitative analysis

OBJECTIVE

To understand the physician perspective on the barriers and facilitators of implementing nine different opioid risk mitigation strategies (RMS) when prescribing opioid medications.

METHODS

We created and dispersed a cross-sectional online survey through the Qualtrics© data collection platform among a nationwide sample of physicians licensed to practice medicine in the United States who have prescribed an opioid medication within the past year. The responses were analyzed using a deductive thematic analysis approach based on the Consolidated Framework for Implementation Research (CFIR) to ensure a holistic approach to identifying the barriers and facilitators for each RMS assessed. In concordance with this method, the themes and codes for the thematic analysis were defined prior to the analysis. The five domains within the CFIR were used as themes and the 39 nested constructs were treated as the codes. Two members of the research team independently coded the transcripts and discussed points of disagreement until consensus was reached. All analyses were conducted in ATLAS.ti© V7.

RESULTS

The completion rate for this survey was 85.1% with 273 participant responses eligible for analysis. Intercoder reliability was calculated to be 82%. Deductive thematic analysis yielded 2,077 descriptions of factors affecting implementation of the nine RMS. The most salient code across all RMS was Knowledge and Beliefs about the Intervention, which refers to individuals' attitudes towards and value placed on the intervention. Patient Needs and Resources, a code referring to the extent to which patient needs are known and prioritized by the organization, also emerged as a salient code. The physicians agreed that the patient perspective on the issue is vital to the uptake of each of the RMS.

CONCLUSIONS

This deductive thematic analysis identified key points for actionable intervention across the nine RMS assessed and established the importance of patient concordance with physicians when deciding on a course of treatment.

Evaluation of Interprofessional Quality Improvement Interventions Led by an Ambulatory Care Pharmacist on Adherence to a Controlled Substance Agreement Policy

Background: A controlled substance agreement (CSA) is a risk mitigation strategy for patients managed on controlled substance medications such as opioids and benzodiazepines. Limited literature exists to describe the role of the clinic pharmacy team to promote adherence to CSA monitoring parameters. Objective: The objective of this study is to evaluate the impact of interprofessional educational and clinical interventions led by an ambulatory care pharmacist on adherence to monitoring parameters within a CSA policy. Methods: This retrospective observational study included patients on long-term controlled substances who had a clinic visit every 3 months during the study period. The primary outcomes were the proportion of patients with a signed CSA in the electronic medical record (EMR), urine drug screen (UDS) completion, and documentation of review of the statewide prescription drug monitoring program (PDMP) in the EMR 8 months prior to as compared to 8 months after implementation of pharmacist interventions. Results: Among 79 patients (mean age 55.7 years, 65.8% female, 54.4% African American), 8.9% pre- vs 88.6% post-interventions had a signed CSA (p<0.001), 35.4% pre- vs 65.8% post-interventions had a UDS completed (p<0.001), and 32.9% pre- vs 57% post-interventions had documentation of PDMP review (p=0.002). Conclusion: Adherence to monitoring parameters within a CSA policy significantly improved after educational and clinical interventions led by an ambulatory care pharmacist.

A Review of Federal and Statewide Guidelines and Their Effects on Orthopedics

In the past three decades, the use of opioids has risen tremendously. Pain was named the "fifth patient vital sign" in the 1990s, and from that point, opioid usage has continued to grow throughout the 2010s leading to its recognition as a crisis. The United States is responsible for 80% of the global opioid usage while only accounting for less than 5% of the global population. Previously opioids were mostly used to treat acute pain, however, opioids have been most recently used to manage chronic pain as well. The opioid crisis has presented new challenges in treating pain while preventing the abuse of these medications in a system that lacks standardization of treatment guidelines across the United States. Therefore, the authors of this review examine the current national recommendations to help manage the ongoing opioid crisis and explore how they may impact orthopedic patient care.

Mapping prescription drug monitoring program data to self-report measures of non-medical prescription opioid use in community pharmacy settings

BACKGROUND

Community pharmacists are well-positioned to identify patients engaged in non-medical prescription opioid use (NMPOU) through Prescription Drug Monitoring Program (PDMP) databases. Integrating patient-reported outcomes with PDMP data may improve the interpretability of PDMP information to support clinical decision-making.

OBJECTIVE

This study linked patient-reported clinical measures of substance use with PDMP data to examine relationships between average daily opioid dose in morphine milligram equivalents (MME) and visits to multiple pharmacies/prescribers with self-reported NMPOU.

METHODS

Data from a cross-sectional health assessment given to patients aged ≥18 years filling opioid prescriptions were linked to PDMP records. NMPOU in the past three months was assessed on a continuous scale (range 0-39) using an adapted version of the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). PDMP measures included average daily MME and number of distinct pharmacies/prescribers visited in the past 180 days. Univariable and multivariable zero-inflated negative binomial models estimated associations between PDMP measures and any NMPOU and severity of use.

RESULTS

The sample included 1421 participants. In multivariable models adjusted for sociodemographic, mental health, and physical health characteristics, any NMPOU was associated with higher average daily MME (adjusted OR = 1.22, 95% CI = 1.05-1.39) and number of distinct prescribers visited (adjusted OR = 1.15, 95% CI = 1.01-1.30). Higher average daily MME (adjusted mean ratio (MR) = 1.12, 95% CI = 1.08-1.15), number of distinct pharmacies visited (adjusted MR = 1.11, 95% CI = 1.04-1.18), and number of distinct prescribers visited (adjusted MR = 1.07, 95% CI = 1.02-1.11) were associated with increased NMPOU severity.

CONCLUSIONS

We observed significant, positive associations between average daily MME and visits to multiple pharmacies/prescribers with any NMPOU and severity of use. This study demonstrates self-report clinical measures of substance use can be cross-walked to PDMP data and translated into clinically interpretable information.

Evaluating State-Level Prescription Drug Monitoring Program (PDMP) and Pill Mill Effects on Opioid Consumption in Pharmaceutical Supply Chain

The opioid crisis in the United States has had devastating effects on communities across the country, leading many states to pass legislation that limits the prescription of opioid medications in an effort to reduce the number of overdose deaths. This study evaluates the impact of two categories of PDMP and Pill Mill regulations on the supply of opioid prescriptions at the level of dispensers and distributors (excluding manufacturers) using ARCOS data. The study uses a difference-in-difference method with a two-way fixed design to analyze the data. The study finds that both of the regulations are associated with reductions in the volume of opioid distribution. However, the study reveals that these regulations may have unintended consequences, such as shifting the distribution of controlled substances to neighboring states. For example, in Tennessee, the implementation of Operational PDMP regulations reduces the in-state distribution of opioid drugs by 3.36% (95% CI, 2.37 to 4.3), while the out-of-state distribution to Georgia, which did not have effective PDMP regulations in place, increases by 16.93% (95% CI, 16.42 to 17.44). Our studies emphasize that policymakers should consider the potential for unintended distribution shifts of opioid drugs to neighboring states with laxer regulations as well as varying impacts on different dispenser types.

Narcotics information management system in South Korea: system development and innovation

BACKGROUND

As the misuse and abuse of medical narcotics are increasing in South Korea, an information system for the integrated information management of medical narcotic drugs across the nation is needed. This paper presents the development process of the Narcotics Information Management System (NIMS) for the monitoring of medical narcotics usage and the results of its implementation.

METHODS

As the NIMS enforces that all narcotics handlers digitally report all information on handling medical narcotic drugs, the functional requirements of the NIMS have been identified in accordance with the Narcotics Control Act. In addition to the functional requirements, the non-functional requirements of the NIMS have been elicited by major narcotics handlers and their associations. The non-functional requirements include privacy, availability, connectivity, interoperability, and data integrity. The system design with entity-relationship diagrams and its implementation processes have been presented.

RESULTS

The NIMS encompasses all narcotic handlers, which comprise exporting, importing, and pharmaceutical companies; wholesalers; hospitals and clinics; and pharmacies, collecting over 120 million cases annually. It enables transparent monitoring throughout the life cycle, from manufacturing, sales, purchase, and disposal of narcotics. As a result, the number of prescriptions for medical narcotics has been reduced by 9.2%.

CONCLUSIONS

To the best of our knowledge, the NIMS is the world's first system to manage all information on the total life cycle of medical narcotics, including imports, production, distribution, use, and disposal of drugs. This system has enabled the safety management and monitoring of medical narcotic drugs. Additionally, it provides consistent and transparent information to physicians and patients, leading to the autonomous safety management of narcotics. The successful development of the NIMS can provide guidelines for implementing a narcotics management system in other countries.

Barriers to Increasing Prescription Drug Monitoring Program Use: A Multidisciplinary Perspective

Prescription drug monitoring programs are implemented through individual state policies and are one solution to curb the opioid crisis. The objectives of this study are to: (1) describe the multidisciplinary experiences using this program in practice; (2) identify limitations of the program and the desired features for improvement; and (3) characterize expectations for improved access when prescription drug monitoring programs are embedded in the electronic health record. A qualitative descriptive study design used semistructured interviews of 15 multidisciplinary healthcare providers. Textual data were analyzed using content analysis. Results showed the prescription drug monitoring program was helpful to decision-making processes related to opioid prescribing and referral to treatment; there were barriers limiting healthcare providers' use of the prescription drug monitoring program; preferences were delineated for integrating prescription drug monitoring program into electronic health record; and recommendations were provided to improve the program and increase use. In conclusion, the prescription drug monitoring program was viewed as useful in making strides to reduce the impact of inappropriate opioid prescribing in our country. By engaging a multidisciplinary group of healthcare providers, solutions were offered to improve the interface and function of the prescription drug monitoring program to assist in increasing use.

"1,000 conversations I'd rather have than that one:" A qualitative study of prescriber experiences with opioids and the impact of a prescription drug monitoring program

BACKGROUND

Prescription Drug Monitoring Programs (PDMPs) have shown impacts on a number of opioid-related outcomes but their role in clinician emotional experience of opioid prescribing has not been studied.

OBJECTIVES

This study explores the impact of PDMPs on clinician attitudes toward and comfort with opioid prescribing, their satisfaction with patient interactions involving discussion of opioid prescriptions, and their recognition of opioid use disorder (OUD) and ability to refer patients to treatment.

METHODS

Researchers conducted semi-structured interviews with five physicians and two nurse practitioners from a variety of specialties and practice environments.

RESULTS

Many participants reported negative emotions surrounding opioid-related patient encounters, with decreased anxiety related to PDMP availability. These effects were less pronounced with clinicians who had greater opioid prescribing experience (either longer careers or higher-volume pain practices). Many participants felt uncomfortable around opioid prescribing. Data from the PDMP often changed prescribing practices, sometimes leading to greater comfort writing a prescription that might have felt riskier without PDMP data. Clinicians easily recognized patient behaviors, symptoms, and prescription requests suggesting that opioid-related adverse events were accumulating, but did not usually apply a label of OUD to these situations. PDMP findings occasionally contributed to a diagnosis and treatment referral for OUD.

CONCLUSIONS

PDMP data is part of a nuanced approach to prescribing opioids. The objectivity of the data may be helpful in mitigating clinician negative emotions that are common around opioid therapy.

How do patient, pharmacist and medication characteristics and prescription drug monitoring program alerts influence pharmacists' decisions to dispense opioids? A randomised controlled factorial experiment

BACKGROUND

Prescription drug monitoring programs (PDMP) are electronic databases that track the prescribing and dispensing of high-risk medicines such as opioids. They have the ability to provide clinicians with alerts, which identify medication-related risks, and are used to help inform decisions to supply. This study aimed to determine to what extent patient, pharmacist, and medication related characteristics and PDMP alerts influence decisions to dispense opioids and take other action, using a randomised controlled factorial design.

METHODS

Pharmacists completed an online factorial experiment, comprising six randomly generated vignettes, describing a hypothetical pharmacy patient. Pharmacists ranked the likelihood of dispensing an opioid prescription and indicated other actions, if any, they would make. Mixed-effects linear and logistical models were used to examine the association between the vignette (patient, medication and alerts), and pharmacist characteristics and the likelihood to dispense and take other actions.

RESULTS

241 pharmacists were included in the analysis (n = 1353 vignettes). The PDMP alert for high dose and multiple prescriber episodes were significant predicators of reduced likelihood to dispense, with a respective 2.73- and 4.1-unit decrease in likelihood to dispense (p < 0.001). Alerts had the strongest association with other actions such as contacting the prescriber, talking to the patient and recommending naloxone, though patient and medication characteristics including age, opioid dose, benzodiazepine use and co-morbidity were also associated with increased odds of engaging in some actions.

CONCLUSION

PDMP alerts were the most significant predictor of reduced likelihood to dispense and were associated with the greatest odds of taking other actions. Well-established risk factors such as high dose and high-risk drug combinations, in the absence of PDMP alerts, were associated with some actions, though to a lesser degree than PDMP alerts. These findings have significant policy implications and suggest PDMP alerts are a greater driver of decisions to dispense opioids and take other actions, compared with other known clinical risk factors.

Provider perspectives and experiences following the integration of the prescription drug monitoring program into the electronic health record

Prescription drug monitoring programs (PDMPs) are a public health tool for prescribers and pharmacists to monitor controlled substance use at the patient level. The objectives of this study were to (1) assess attitudes about the PDMP and perceived changes in experience and decision-making following integration into the electronic health record (EHR), and (2) identify barriers to optimal PDMP use and user recommendations for improvement. This descriptive study used an electronic survey to obtain feedback from prescribers and pharmacists at a single academic medical center. Descriptive statistics were calculated, and textual data were analyzed. Of 1480 PDMP users 208 responded (14.1%). Responses demonstrated the integration of the PDMP into the EHR simplified log-in and access to PDMP information resulting in more frequent access and perceived improvement of care quality. Barriers included technical issues accessing the PDMP within the EHR and the lack of integration of other state PDMPs. Overall, the benefit of integrating the PDMP into the EHR was positive but largely limited to streamlining log-in and patient selection. Recommendations for improvement include addressing technological issues and education on PDMP interpretation and integrating new features that may modify prescribing, referral, and co-prescribing behaviors.

Mapping the research addressing prescription drug monitoring programs: A scoping review

ISSUES

Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice.

APPROACH

A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021.

KEY FINDINGS

A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use.

IMPLICATIONS

Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement.

CONCLUSION

Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.

"Nobody Knows How You're Supposed to Interpret it:" End-user Perspectives on Prescription Drug Monitoring Program in Massachusetts

OBJECTIVES

America's overdose crisis spurred rapid expansion in the number and scope of prescription drug monitoring programs (PDMPs). As their public health impact remains contested, little is known about PDMP user experiences and perspectives. We explore perspectives of PDMP end-users in Massachusetts.

METHODS

Between 2016 and 2017, we conducted semi-structured qualitative interviews on overdose crisis dynamics and PDMP experiences with a purposive sample of 18 stakeholders (prescribers, pharmacists, law enforcement, and public health regulators). Recordings were transcribed and double-coded using a grounded hermeneutic approach.

RESULTS

Perspectives on prescription monitoring as an element of overdose crisis response differed across sectors, but narratives often critiqued PDMPs as poorly conceived to serve end-user needs. Respondents indicated that PDMP: (1) lacked clear orientation towards health promotion; (2) was not optimally configured or designed as a decision support tool, resulting in confusion over interpreting data to guide health care or law enforcement actions; and, (3) problematized communication and relationships between prescribers, pharmacists, and patients.

CONCLUSIONS

User insights must inform design, programmatic, and policy reform to maximize PDMP benefits while minimizing harm.

Association of prescription drug monitoring program laws with bedridden and missed work days

OBJECTIVE

To examine the relationship between optional and must-use prescription drug monitoring programs (PDMPs) and markers of disability.

DATA SOURCES

Nationwide data from the National Health Interview Survey for 2006-2015.

STUDY DESIGN

Generalized difference-in-difference models with state-specific time trends were used to assess the relationship between PDMPs and two outcomes: missed days of work and bedridden days.

DATA COLLECTION/EXTRACTION METHODS

All respondents above the age of 18 years with complete data on key measures were included. A subpopulation of respondents who had a recent surgery or injury was identified.

PRINCIPAL FINDINGS

We found an increase of 3.3 and 5.9 bedridden days associated with optional and must-use PDMPs, respectively, for respondents reporting a recent injury or surgery (p-values <0.05; unadjusted population average 12.2 bedridden days). Increases in days of missed work were not statistically significant.

CONCLUSIONS

Implementation of PDMPs was associated with negative unintended consequences in the injury/surgery subpopulation. The association between bedridden days and PDMPs suggests a gap between clinical trials showing equivalence of opioids and nonopioids for pain treatment and real-world results. As increasingly tighter opioid restrictions proliferate, evidence-based strategies to address pain without opioids in the acute pain population likely need to be more widely disseminated.

Improving Opioid Stewardship in Pediatric Emergency Medicine

OBJECTIVES

Poor opioid stewardship contributes to opioid misuse and adverse health outcomes. We sought to decrease opioid prescriptions in children 0 to 18 years treated for pain after fractures and cutaneous abscess drainage from 13.5% to 8%. Our secondary aims were to reduce opioid prescriptions written for >3 days from 41% to 10%, eliminate codeine prescriptions, increase safe opioid storage and disposal discharge instructions from 0% to 70%, and enroll all emergency department (ED) physicians in the state prescription drug monitoring program.

METHODS

We implemented an intervention bundle on the basis of 4 key drivers at a pediatric ED: ED-wide education, changes in the electronic medical record, discharge resources, and process standardization. Two plan-do-study-act cycles were performed. Interventions included provider feedback on prescribing, safe opioid storage and disposal instructions, and streamlined electronic medical record functions. Run charts were used to analyze the effect of interventions on outcomes. Our balance measure was return ED or clinic visits for inadequate analgesia within 3 days.

RESULTS

During the intervention period, 249 of 3402 (7.3%) patients with fractures and cutaneous abscesses were prescribed opioids. The percentage of opioid prescriptions >3 days decreased from 41% to 13.2% (P < .0001), codeine prescription dropped from 1.1% to 0% (P = .09), opioid discharge instructions increased 0% to 100% (P < .0001), and all physicians enrolled in the prescription drug monitoring program. There was no change in return visits for uncontrolled analgesia compared with the baseline (P = .79).

CONCLUSIONS

A comprehensive opioid stewardship program can improve opioid prescribing practices of ED physicians and deliver information on safe storage and disposal of prescription opioids with a negligible effect on return visits for uncontrolled pain.

The use of an integrated opioid and medical marijuana prescription drug monitoring program

OBJECTIVES

To (1) identify the reasons for which pharmacists in Connecticut use the CPMRS when dispensing opioid medications and medical marijuana products, (2) determine pharmacists' perceived value of the CPMRS when dispensing opioids or medical marijuana, and (3) compare practices and the perceived value of the CPMRS among community-based pharmacists (CBPs) and medical marijuana dispensary pharmacists (MMDPs).

METHODS

An online survey was administered from May 2019 to June 2019 to CBPs (n = 178) and MMDPs (n = 12). The survey included items about background, use, and attitudes about current and future use of the CPMRS.

RESULTS

Both pharmacist groups indicated that opioid use information was the most useful aspect of the CPMRS. Ninety percent of both groups checked patients' use of opioids using the CPMRS, and 81.2% of the MMDPs compared with 38.4% of the CBPs indicated that they checked for patients' use of medical marijuana. A greater percentage of MMDPs than CBPs felt that access to the marijuana use information was useful and needed for counseling. Several pharmacists recommended improvements in marijuana use information in the CPMRS and greater efficiencies for users of the system.

CONCLUSION

Access to both marijuana and opioid use information can allow pharmacists to make specific recommendations on the basis of potential drug interactions and dose adjustments. The results from the present study highlight how integrated systems of opioid and marijuana dispensing information can be further enhanced by resolving existing pharmacy barriers involving technology, workflow, and need for systems with more detailed marijuana product information.

Attending and Resident Surgeon Perspectives and Prescribing Practices of Pain Medication During the Opioid Epidemic

OBJECTIVE

Over 67,000 individuals died in the United States due to drug overdose in 2018; the majority of these deaths were secondary to opioid ingestion. Our aim was to determine surgeon perceptions on opioid abuse, the adequacy of perioperative and graduate medical education, and the role surgeons may play. We also aimed to investigate any differences in attending and resident surgeon attitudes.

DESIGN

Anonymous online survey assessing surgeons' opioid counseling practices, prescribing patterns, and perceptions on opioid abuse, adequacy of education about opioid abuse, and the role physicians play.

SETTING

Two Accreditation Council for Graduate Medical Education accredited general surgery programs at a university-based tertiary hospital and a community hospital in the Midwest.

PARTICIPANTS

Attending and resident physicians within the Departments of Surgery participated anonymously.

RESULTS

Attending surgeons were more likely than residents to discuss posoperative opioids with patients (62% vs. 33%; p < 0.05), discuss the potential of opioid abuse (31% vs. 6%; p < 0.05), and check state-specific prescription monitoring programs (15% vs. 0%; p < 0.05). Surgeons and trainees feel that surgeons have contributed to the opioid epidemic (76% attending vs. 88% resident). Overall, attending and resident surgeons disagree that there is adequate formal education (66% vs. 66%) but adequate informal education (48% vs. 61%) on opioid prescribing. However, when attending physicians were broken down into those who have practiced ≤5 years vs. those with >5 years experience, those with ≤5 years experience were more confident in recognizing opioid abuse (61% vs. 34%) and fewer young faculty disagreed that there is adequate formalized education on opioid prescribing (45% vs. 84%).

CONCLUSION AND RELEVANCE

Patient education should be improved upon in the preoperative setting and should be treated as an important component of preoperative discussions. Formalized opioid education should also be undertaken in graduate surgical education to help guide appropriate opioid use by resident and attending physicians.

Clinical decision making involving prescription drug monitoring programs: A factorial, vignette-based study among student pharmacists

OBJECTIVES

Prescription drug monitoring programs (PDMPs) are state-maintained databases that providers may reference when deciding to prescribe or dispense controlled substances. As more states begin to mandate PDMP use at the point of care, it is imperative to assess how pharmacists use PDMP information when determining whether to fill a controlled substance prescription (CSP). The objective of this study was to evaluate which factors affected fourth-year student pharmacists' decision to fill an opioid prescription, their level of confidence in their decision making, and familiarity with the PDMP.

METHODS

We used a 2⁴ factorial design to present a series of text-based vignettes to fourth-year student pharmacists. Each participant received 8 vignettes (5 randomly selected, 3 fixed), representing a hypothetical hydrocodone-acetaminophen combination prescription with varying levels of the following dichotomous factors: doctor shopping, dosage, pharmacy shopping, and concurrent benzodiazepine prescription. Participants were asked to decide whether or not they would fill each of the hypothetical prescriptions they received. A multilevel model was used to measure the association between each of the vignette factors, age, race, sex, experience with PDMP, and the decision to refuse to fill a prescription. Each vignette response served as an independent observation.

RESULTS

A total of 87 participants yielded 696 vignette responses. Participants were significantly more likely to refuse to fill prescriptions with doctor shopping (adjusted odds ratio [aOR] 19.86 [95% CI 10.78-36.58]), pharmacy shopping (6.78 [4.13-11.12]), dosage (1.83 [1.16-2.90]), or if the student pharmacist was of female sex (1.73 [1.02-2.93]). Concomitant benzodiazepine use was not associated with a no-fill decision (1.45 [0.92-2.27]).

CONCLUSION

This study reveals that student pharmacists' decision to fill a prescription is dependent on both prescription characteristics and a patient's CSP history. The importance of PDMP history cannot be downplayed and suggests that PDMP use may be effective in informing patient care decisions. Still, the variability in filling decision highlights the need to teach a formulaic approach to CSP dispensing in colleges of pharmacy.

Factors Related to Prescription Drug Monitoring Program Queries for Veterans Receiving Long-Term Opioid Therapy

Objective

State prescription drug monitoring programs (PDMPs) identify controlled medications dispensed across providers and systems. Department of Veterans Affairs (VA) policy requires electronic health record documentation of PDMP queries at least annually for VA patients receiving controlled medications; however, queries are not uniformly conducted. We examined factors associated with PDMP queries for veterans receiving long-term opioid therapy.

Methods

Veterans with a VA provider who received long-term opioid therapy between August 2015 and August 2016 within a four-state region were identified; 9,879 were due for a PDMP query between August 2016 and February 2017. Likelihood of veterans’ PDMP queries during this follow-up period was modeled as a function of patient, provider, and facility characteristics of interest in mixed-effects modified Poisson models estimating relative risk and 95% confidence intervals. Multivariable models controlled for potential confounders identified through the use of directed acyclic graphs.

Results

PDMP queries were documented for 62.1% of veterans that were due for a PDMP query. Veterans were more likely to be queried if they were Hispanic or if they received methadone, had average daily milligram morphine equivalents &gt;20, or received urine drug screening during the studied period. Veterans were less likely to be queried if they had a rural address, mail order medication, or cancer diagnosis. Likelihood of PDMP queries was also lower for veterans whose opioid-prescribing provider was an oncologist or working in a low-complexity facility.

Conclusions

Adherence to PDMP query policy within the VA varied by patient, clinician, and facility factors. Mechanisms to standardize the conduct of PDMP queries may be needed.

Health Information Technology and Doctor Shopping: A Systematic Review

Doctor shopping is the practice of visiting multiple physicians to obtain multiple prescriptions. Health information technology (HIT) allows healthcare providers and patients to leverage records or shared information to improve effective care. Our research objective was to determine how HIT is being leveraged to control for doctor shopping. We analyzed articles that covered a 10-year time period from four databases and reported using preferred reporting items for systematic reviews and meta-analysis (PRISMA). We compared intervention, study design, and bias, in addition to showing intervention interactions with facilitators, barriers, and medical outcomes. From 42 articles published from six countries, we identified seven interventions, five facilitator themes with two individual observations, three barrier themes with six individual observations, and two medical outcome themes with four individual observations. Multiple HIT mechanisms exist to control for doctor shopping. Some are associated with a decrease in overdose mortality, but access is not universal or compulsory, and data sharing is sporadic. Because shoppers travel hundreds of miles in pursuit of prescription drugs, data sharing should be an imperative. Research supports leveraging HIT to control doctor shopping, yet without robust data sharing agreements, the efforts of the system are limited to the efforts of the entity with the least number of barriers to their goal. Shoppers will seek out and exploit that organization that does not require participation or checking of prescription drug monitoring programs (PDMP), and the research shows that they will drive great distances to exploit this weakest link.

Advances in prescription drug monitoring program research: a literature synthesis (June 2018 to December 2019)

PURPOSE OF REVIEW

Nearly every U.S. state operates a prescription drug monitoring program (PDMP) to monitor dispensing of controlled substances. These programs are often considered key policy levers in the ongoing polydrug epidemic. Recent years have seen rapid growth of peer-reviewed literature examining PDMP consultation and the impacts of these programs on diverse patient populations and health outcomes. This literature synthesis presents a review of studies published from June 2018 to December 2019 and provides relevant updates from the perspective of three researchers in this field.

RECENT FINDINGS

The analyzed studies were primarily distributed across three overarching research focus areas: outcome evaluations (n = 29 studies), user surveys (n = 23), and surveillance (n = 22). Identified themes included growing awareness of the unintended consequences of PDMPs on access to opioids, effects on benzodiazepines and stimulant prescribing, challenges with workflow integration across multiple specialties, and new opportunities for applied data science.

SUMMARY

There is a critical gap in existing PDMP literature assessing how these programs have impacted psychiatrists, their prescribing behaviors, and their patients. Although PDMPs have improved population-level monitoring of controlled substances from medical sources, their role in responding to a drug epidemic shifting to illicitly manufactured drugs is under scrutiny.

Prescriber and pharmacist understanding of revised Rhode Island pain management regulations

INTRODUCTION

Federal agencies and national associations have implemented action plans in response to the opioid crisis. Furthermore, over 30 states have enacted legislation with opioid-related restrictions, guidance, or requirements. Following recommendations from the governor-appointed Overdose Prevention and Intervention Task Force, the Rhode Island Department of Health developed an original and updated version of Pain Management Regulations in March 2017 and July 2018, respectively. Our study aimed to identify disparities in interpretation and misconceptions of the updated Rhode Island Department of Health new Pain Management Regulations.

METHODS

Our 29-question survey evaluated pharmacist and prescriber knowledge of regulations, with special attention given to pain management in patients with cancer.

RESULTS

Thirty-two prescribers and 33 pharmacists completed the survey. The survey identified significant variance in regulation knowledge. Pharmacists correctly identified diagnosis exclusions 13-84% of the time, with a much greater understanding when diagnosis language was used instead of ICD-10 codes. Prescribers correctly identified exclusions 24-46% of the time, with little difference noted when using diagnosis language versus ICD-10 codes. The majority (59.3%) of pharmacists misclassified patients with no prescription dispensed in 30 days as patients who would be considered opioid-naïve. Both prescribers and pharmacists commonly misidentified the frequency with which the prescription drug monitoring program needs to be checked, although in both scenarios were stricter than the regulations themselves. In addition, there were significant differences in interpretation regarding naloxone co-prescribing requirements and patient awareness of naloxone co-prescribing between prescribers and pharmacists.

CONCLUSION

Our findings outline several misinterpretations that affect access to chronic and cancer-related pain opioid prescriptions, despite several Rhode Island Department of Health-initiated interventions. When adopting regulations, states should proactively develop educational initiatives to avoid access challenges for patients with diagnoses of exclusion.

Provider beliefs on the Barriers and Facilitators to Prescription Monitoring Programs and Mandated Use

Background: Underutilization of Prescription monitoring programs (PMP), especially in states where participation is voluntary could limit their impact against opioid epidemic. Objectives: To (1) examine PMP use among Iowa healthcare providers (HCPs); (2) identify factors prompting and impeding PMP use, and (3) assess beliefs toward mandating PMP use. Methods: A cross-sectional survey of Iowa HCPs was conducted using a 12-item questionnaire. Survey domains include demographics, current PMP utilization, conditions and barriers associated with PMP use, and perspectives on use mandates. Analyses were based on descriptive statistics, proportional odds and poisson regression models. Results: There were 704 usable responses. Almost all respondents were registered with the PMP with dentists having the lowest rate (p < .001). Nurse practitioners consulted the PMP for the largest proportion of prescriptions, while pharmacists and dentists used significantly less (p < .001). Lack of time was the most common reported barrier impeding PMP use. Red flag behaviors and unfamiliarity with patient were the most common conditions prompting PMP review. HCPs estimated their use of the PMP would significantly increase if integrated into their electronic health records (p < .001). Almost half of HCPs held the opinion that PMP use should never be mandated, although inter-provider variation was present with nurse practitioners most amenable to mandates. Discussion: HCPs displayed variation in PMP use. EMR integration appears to be a strategy for increasing PMP use. There was resistance to mandating PMP use for all controlled substances prescribed and dispensed, with some interest in mandates for new patients only or new controlled substance prescriptions only.

Barriers to Utilization of Prescription Drug Monitoring Programs Among Prescribing Physicians and Advanced Practice Registered Nurses at Veterans Health Administration Facilities in Oregon

Objective

To identify barriers to using state prescription drug monitoring programs (PDMPs) among prescribing physicians and advanced practice registered nurses across a variety of Veterans Health Administration (VA) settings in Oregon.

Design

In-person and telephone-based qualitative interviews and user experience assessments conducted with 25 VA prescribers in 2018 probed barriers to use of state PDMPs.

Setting

VA health care facilities in Oregon.

Subjects

Physicians (N = 11) and advanced practice registered nurses (N = 14) who prescribed scheduled medications, provided care to patients receiving opioids, and used PDMPs in their clinical practice. Prescribers were stationed at VA medical centers (N = 10) and community-based outpatient clinics (N = 15); medical specialties included primary care (N = 10), mental health (N = 9), and emergency medicine (N = 6).

Methods

User experience was analyzed using descriptive statistics. Qualitative interviews were analyzed using conventional content analysis methodology.

Results

The majority of physicians (64%) and advanced practice registered nurses (79%) rated PDMPs as “useful.” However, participants identified both organizational and software design issues as barriers to their efficient use of PDMPs. Organizational barriers included time constraints, clinical team members without access, and lack of clarity regarding the priority of querying PDMPs relative to other pressing clinical tasks. Design barriers included difficulties entering or remembering passwords, unreadable data formats, time-consuming program navigation, and inability to access patient information across state lines.

Conclusions

Physicians and advanced practice registered nurses across diverse VA settings reported that PDMPs are an important tool and contribute to patient safety. However, issues regarding organizational processes and software design impede optimal use of these resources.

Leveraging the role of community pharmacists in the prevention, surveillance, and treatment of opioid use disorders

The global rise in opioid-related harms has impacted the United States severely. Current efforts to manage the opioid crisis have prompted a re-evaluation of many of the existing roles in the healthcare system, in order to maximize their individual effects on reducing opioid-associated morbidity and preventing overdose deaths. As one of the most accessible healthcare professionals in the US, pharmacists are well-positioned to participate in such activities. Historically, US pharmacists have had a limited role in the surveillance and treatment of substance use disorders. This narrative review explores the literature describing novel programs designed to capitalize on the role of the community pharmacist in helping to reduce opioid-related harms, as well as evaluations of existing practices already in place in the US and elsewhere around the world. Specific approaches examined include strategies to facilitate pharmacist monitoring for problematic opioid use, to increase pharmacy-based harm reduction efforts (including naloxone distribution and needle exchange programs), and to involve community pharmacists in the dispensation of opioid agonist therapy (OAT). Each of these activities present a potential means to further engage pharmacists in the identification and treatment of opioid use disorders (OUDs). Through a careful examination of these approaches, we hope that new strategies can be adopted to leverage the unique role of the community pharmacist to help reduce opioid-related harms in the US.

Advanced visualizations to interpret prescription drug monitoring program information

OBJECTIVES

Prescription drug monitoring programs (PDMPs) are state-based databases that contain information about controlled substance prescriptions dispensed by pharmacies. Many states now mandate PDMP use by prescribers, despite unclear effectiveness. We hypothesize that it is possible to improve the interpretability, and hence effectiveness, of PDMPs by enhancing them.

METHODS

This was a real-time simulation of an enhanced PDMP. Fifty practicing physicians (25 primary care, 25 emergency medicine) were randomized to see three cases with a standard profile or an enhanced profile that included graphical representation of prescriptions and identified risky prescribing patterns. After a two-month washout period, participants were placed in the opposite group.

RESULTS

Physicians presented with the enhanced profile were more likely to correctly identify patients with multiple providers (97.0% vs. 85.8%, p = 0.002), overlapping opioid and benzodiazepine prescriptions (94.7% vs. 87.5%, p = 0.03), overlapping opioid prescriptions (89.5% vs. 70.8%, p < 0.01), high daily dosages of opioids (99.2% vs. 25.0%, p = 0.02), and traveling to distant pharmacies (79.7% vs. 2.5%, p < 0.01). There was no difference in interpretation time for the three cases (standard profile 657.3 s vs. enhanced profile 686.3 s, p = 0.31).

CONCLUSIONS

A simulated PDMP with graphical displays and interpretation of findings was, for this cohort of emergency physicians and primary care physicians, associated with an increased ability to determine high-risk features on PDMP profiles.

Pharmacist Services in the Opioid Crisis: Current Practices and Scope in the United States

Introduction: Pharmacist roles promoting safe opioid use are recognized in literature and practice. Pharmacists can offer services such as counseling on opioid risks, naloxone dispensing, education on opioid storage and disposal, prescription drug monitoring program (PDMP) utilization, opioid deprescribing, and providing resources for addiction treatment to help mitigate the opioid crisis. Objective: This commentary seeks to describe current and potential roles for pharmacists to combat the United States opioid crisis and identify key factors affecting service provision. Methods: The paper summarizes evidence-based studies describing current pharmacist roles and services, factors affecting service implementation, and strategies to further improve pharmacist roles and services related to promoting safe opioid use for patients. Results: Pharmacists recognize their roles and responsibilities to counsel patients on opioid risks, dispense naloxone, educate on opioid storage and disposal, utilize prescription drug monitoring programs (PDMPs), offer opioid deprescribing, and provide resources for addiction treatment. However, pharmacists express low confidence, time, and training as barriers to service provision. This suggests a need for structured training, resources, and organizational support for pharmacists to improve confidence and participation in such services. Conclusions: Although pharmacists are aware of roles and responsibilities to help reduce the opioid crisis, more training, education, organizational support and resources are needed to increase their ability to embody these roles.

Provider perceptions of system-level opioid prescribing and addiction treatment policies

Stakeholders have implemented a multitude of system-level policies to address the U.S. opioid overdose epidemic. Because opioid prescribing partly fueled the crisis and because prescribing of medications for opioid addiction treatment is a key prevention strategy, it is critical to understand prescriber perceptions of policies in these domains. This article reviews prescriber awareness and opinions of the following system-level policies: opioid prescribing guidelines, prescription drug monitoring programs (PDMPs), medications for addiction treatment, and naloxone distribution programs. Most providers are aware of these policies, especially PDMPs, albeit a smaller proportion actively participate in their implementation. Low engagement in certain system-level policies is concerning and deserves attention, given that prescribers play an integral role in achieving optimal impact and mitigating the crisis.