Effects of Implementation and Enforcement Differences in Prescription Drug Monitoring Programs in 3 States: Connecticut, Kentucky, and Wisconsin

Purposeful Shared Decision-Making in Caring for and with Patients with Chronic Pain Receiving Opioid Therapy

CDC guidelines for prescribing opioids for chronic pain recommend that patients and clinicians engage in shared decision-making (SDM), a practice often described as clinicians working with patients to find treatment options that match patient preferences. Some experts have argued otherwise given limited efficacy of opioid use for chronic pain, the potential effects of long-term opioid therapy on patient's decision-making capacity, and the societal consequences of opioid diversion. Chronic pain care involves reaching a shared understanding of how the patient's pain affects living and how to change this situation. The conversation to achieve this shared understanding and to change the problematic situation of the patient is called Purposeful SDM. Purposeful SDM as a method of collaborative care is a useful and usable framework for patient-centered chronic pain care with or without prescription opioids. Chronic pain or long-term opioid therapy do not render patients unable to participate in Purposeful SDM. And yet, some regulatory tools intended to make opioid prescribing safer, when used punitively, may undermine both the trust that sustains the patient-clinician relationship and the possibility of SDM. There is considerable nuance in chronic pain management and opioid prescribing decisions. The Purposeful SDM framework is based on and contributes to a collaborative, non-punitive relationship between patient and clinician to make chronic pain care fit while avoiding unintended harm from unilateral treatment decisions.

How competing needs after incarceration lead to adverse health outcomes among people who use criminalized drugs

In the USA, people with a history of criminalized drug use and drug use disorders reentering the community after incarceration frequently experience adverse health outcomes including overdose, suicide, and infectious disease acquisition. This review presents a conceptual model for understanding risk pathways for these outcomes related to post-release psychosocial needs. We first summarize the literature on post-release needs experienced by people who use criminalized drugs during reentry in multiple domains, including basic needs and those related to relationships as well as medical, mental health, and substance use problems. Drawing from a socioecological model, we demonstrate how vulnerability factors related to criminal legal involvement and criminalized drug use operate at intrapersonal (i.e., individual), interpersonal, institutional, community, and policy levels to negatively affect the ability of people who use drugs to meet each of these types of needs. We present research demonstrating that when people leaving incarceration are met with the overwhelming task of addressing competing demands, they often experience strong negative affect, which can lead to risk-conferring behaviors including criminalized drug use. Competing needs also create environmental conditions that amplify risk. We argue for the importance of interventions that address determinants of post-release health at individual and social-environmental levels to prevent adverse outcomes.

Changes in orthopaedic prescribing patterns of gabapentin associated with state prescribing restrictions: A large database study

Background

Safety concerns have emerged regarding gabapentin, and as a result several states have recently adopted regulations for prescribing gabapentin. As gabapentin has been commonly used off-label for pain management in orthopedics, a retrospective analysis was conducted to investigate trends in orthopedic prescriptions of gabapentin considering novel state regulations.

Methods

The study analyzed gabapentin prescription patterns of orthopedic surgeons from 2013 to 2021 recorded in annual Medicare Part D Public Use Files across the fifty states and Washington DC. Datasets were filtered to only include orthopedic providers. Gabapentin prescriptions were grouped based on state of practice for each surgeon per year for total gabapentin claims, supply in days, and beneficiaries. Twelve states classified gabapentin as a Schedule V drug, seven instituted a Prescription Drug Monitoring Program (PDMP), and 32 had no restrictions. States were grouped by prescription restriction type. Two-tailed t-tests were conducted to compare the annual average percent of change for gabapentin claims, supply, and beneficiaries per state following regulation.

Results

Following regulation, the general trend of gabapentin claims, beneficiaries, and supply was a blunting in the annual rate of change. States with PDMPs for gabapentin had the lowest overall claims, supply, and beneficiaries. States with no regulation eclipsed states with Schedule V classifications for the most beneficiaries and supply in 2019 and claims in 2020. Six of 11 PDMP states had significant reductions across gabapentin claims, beneficiaries, and supply following regulation, compared to three of seven Schedule V states.

Conclusion

The impact that state-based regulations had on gabapentin claims, supply, and beneficiaries was variable, likely due to different requirements in the enactment of their novel PDMP or Schedule V classifications. To optimize the implementation of these regulatory programs, public health authorities may adopt regulatory strategies that resemble those from states that were more effective in regulating gabapentin prescriptions.

Level of evidence

Level III, Therapeutic Study.

Prescription drug monitoring program in Australia: a qualitative study of stakeholders' experiences and perceptions of a state-wide implementation

BACKGROUND

Prescription Drug Monitoring Programs (PDMPs) are increasingly implemented across the globe with aims of managing and mitigating risks relating to high-risk prescription medicines. There is limited research focused on identifying strategies or processes for large-scale PDMP implementation. This study aimed to identify strategies perceived as necessary for successful state-wide implementation of a PDMP by exploring the experiences and perceptions of stakeholders responsible for the implementation in New South Wales (NSW), Australia: to identify (1) the drivers of implementation; (2) perceived strategies that worked well; (3) barriers to implementation; and (4) the elements needed for long-term success of SafeScript NSW.

METHODS

This study used a qualitative descriptive design. Theoretical frameworks used to design interview questions and guide thematic analysis were the non-adoption, abandonment, scale-up, spread, and sustainability (NASSS) framework and Quadruple Aim framework. Participants were stakeholders responsible for PDMP implementation in NSW. Recruitment and data collection were completed between March and April 2022. Semi-structured interviews were audio-recorded and transcribed. Two researchers independently reviewed transcripts, generated codes from the data, and mapped these to each NASSS domain. They came together multiple times during data analysis to review the codes and grouped them into higher level themes via a discussion and consensus process. Themes were then organised according to the four objectives of the study.

RESULTS

Eight interviews were conducted and analysed after which thematic saturation was reached. All participants had a common understanding of the perceived benefits and drivers for PDMP implementation. Participants outlined ten key ingredients for perceived successful state-wide implementation. Strong and iterative engagement with a large number of stakeholder groups was viewed as critical, as was targeting user experience, ongoing monitoring and evaluation. These were facilitated by a phased roll-out strategy. Participants identified some barriers to implementation, particularly around poor usability and user experience of the tool.

CONCLUSIONS

This is one of the first studies focused on strategies for what was perceived to be successful state-wide implementation of PDMP. Successful implementation requires significant time and resourcing, with the design and configuration of the technology being only one component of a multi-strategy process. Knowledge and insights gained from this study may be useful for other implementations of similar digital health tools in large-scale jurisdictions.

Association Between Prescription Drug Monitoring Program Use Mandate and Opioid Prescribing and Patient-Reported Outcomes After Surgery

OBJECTIVE

To evaluate changes in opioid prescribing and patient-reported outcomes after surgery following implementation of Michigan's prescription drug monitoring program (PDMP) use mandate in June 2018.

BACKGROUND

Most states mandate clinicians to query prescription drug monitoring program (PDMP) databases before prescribing controlled substances. Whether these PDMP use mandates affect opioid prescribing and patient-reported outcomes after surgery is unclear, especially among patients with elevated "Narx" scores, a risk score for overdose death used in most PDMPs.

METHODS

We conducted an interrupted time series analysis of a statewide surgical registry linked to Michigan's PDMP database. Analyses included adults undergoing general surgical procedures during January 2017-October 2019. Outcomes included monthly mean days supplied in dispensed opioid prescriptions (those filled within 3 days of discharge) and monthly mean scores for 3 patient-reported outcomes (pain in the week after surgery, care satisfaction, regret undergoing surgery). Segmented regression models were used to assess for level and slope changes in outcomes in June 2018. Analyses were repeated among patients with Narx scores ≥200, a threshold that defines the top quartile.

RESULTS

Analyses included 21,897 patients. The mandate was associated with a -0.5 (95% CI: -0.8, -0.2) level decrease in mean days supplied in dispensed opioid prescriptions, but not with worsened patient-reported outcomes. Findings were similar among patients with Narx scores ≥200.

CONCLUSIONS

Following implementation of Michigan's PDMP use mandate, the duration of opioid prescriptions decreased, but patient-reported outcomes did not worsen. Findings suggest PDMP use mandates may not be associated with worsened experience among general surgical patients.

Health disparities in ethnic and racial minority populations with pain and opioid use disorder

Healthcare providers are not prepared to address health disparities among ethnic and racial minority populations with either persistent and chronic pain or substance use disorder (SUD). Recognizing biases from policies to provide pain management and treatment for SUD in our healthcare systems, from our individual state laws and federal guidelines, is necessary. Biases are embedded in the screening and treatment of patients with chronic pain through the use of screening tools, opioid treatment agreements, and prescription drug monitoring programs. Additionally, the punitive treatment of people of ethnic and racial minority populations who experience persistent and chronic pain, opioid use disorders, or other SUDs needs to be redirected to facilitate solutions rooted in equity.

Cycles of Chronic Opioid Therapy Following Mandatory Prescription Drug Monitoring Program Legislation: A Retrospective Cohort Study

BACKGROUND

Mandates for prescriber use of prescription drug monitoring programs (PDMPs), databases tracking controlled substance prescriptions, are associated with reduced opioid analgesic (OA) prescribing but may contribute to care discontinuity and chronic opioid therapy (COT) cycling, or multiple initiations and terminations.

OBJECTIVE

To estimate risks of COT cycling in New York City (NYC) due to the New York State (NYS) PDMP mandate, compared to risks in neighboring New Jersey (NJ) counties.

DESIGN

We estimated cycling risk using Prentice, Williams, and Peterson gap-time models adjusted for age, sex, OA dose, payment type, and county population density, using a life-table difference-in-differences design. Failure time was duration between cycles. In a subgroup analysis, we estimated risk among patients receiving high-dose prescriptions. Sensitivity analyses tested robustness to cycle volume considering only first cycles using Cox proportional hazard models.

PARTICIPANTS

The cohort included 7604 patients dispensed 12,695 prescriptions.

INTERVENTIONS

The exposure was the August 2013 enactment of the NYS PDMP prescriber use mandate.

MAIN MEASURES

We used monthly, patient-level data on OA prescriptions dispensed in NYC and NJ between August 2011 and July 2015. We defined COT as three sequential months of prescriptions, permitting 1-month gaps. We defined recurrence as re-initiation of COT after at least 2 months without prescriptions. The exposure was enactment of the PDMP mandate in NYC; NJ was unexposed.

KEY RESULTS

Enactment of the NYS PDMP mandate was associated with an adjusted hazard ratio (HR) for cycling of 1.01 (95% CI, 0.94-1.08) in NYC. For high-dose prescriptions, the risk was 1.16 (95% CI, 1.01-1.34). Sensitivity analyses estimated an overall risk of 1.01 (95% CI, 0.94-1.11) and high-dose risk of 1.09 (95% CI, 0.91-1.31).

CONCLUSIONS

The PDMP mandate had no overall effect on COT cycling in NYC but increased cycling risk among patients receiving high-dose opioid prescriptions by 16%, highlighting care discontinuity.

A qualitative examination of naloxone access in three states: Connecticut, Kentucky, and Wisconsin

BACKGROUND

Prevention of opioid-involved overdose deaths remains a public health priority in the United States. While expanding access to naloxone is a national public health strategy, it is largely implemented at the state and local level, where significant variability in policies, resources, and norms exist. The aims of the current study were to examine the social context of naloxone access in three different states (Connecticut, Kentucky, Wisconsin) from the perspectives of key informants (first responders, harm reduction personnel, and pharmacists), who play some role in dispensing or administering naloxone within their communities.

METHODS

Interviews were conducted with key informants who were in different local areas (urban, suburban, rural) across Connecticut, Kentucky, and Wisconsin. Interview guides explored the key informants' experiences with administering or dispensing naloxone, and their perspectives on opioid overdose prevention efforts in their areas. Data analysis was conducted using multistage inductive coding and comparative methods to identify dominant themes within the data.

RESULTS

Key informants in each of the three states noted progress toward expanding naloxone access, especially among people who use opioids, but also described inequities. The key role of harm reduction programs in distributing naloxone within their communities was also highlighted by participants, as well as barriers to increasing naloxone access through pharmacies. Although there was general consensus regarding the effectiveness of expanding naloxone access to prevent overdose deaths, the results indicate that communities are still grappling with stigma associated with drug use and a harm reduction approach.

CONCLUSION

Findings suggest that public health interventions that target naloxone distribution through harm reduction programs can enhance access within local communities. Strategies that address stigmatizing attitudes toward people who use drugs and harm reduction may also facilitate naloxone expansion efforts, overall, as well as policies that improve the affordability and awareness of naloxone through the pharmacy.

"The DEA would come in and destroy you": a qualitative study of fear and unintended consequences among opioid prescribers in WV

Background

West Virginia has one of the highest rates of opioid overdose related deaths and is known as the epicenter of the opioid crisis in the United States. In an effort to reduce opioid-related harms, SB 273 was signed in 2018, and aimed to restrict opioid prescribing in West Virginia. SB 273 was enacted during a time when physician arrests and convictions had been increasing for years and were becoming more prevalent and more publicized. This study aims to better understand the impact of the legislation on patients and providers.

Methods

Twenty semi-structured interviews were conducted with opioid-prescribing primary care physicians and specialists practicing throughout West Virginia.

Results

Four themes emerged, 1. Fear of disciplinary action, 2. Exacerbation of opioid prescribing fear due to restrictive legislation, 3. Care shifts and treatment gaps, and 4. Conversion to illicit substances. The clinicians recognized the harms of inappropriate prescribing and how this could affect their patients. Decreases in opioid prescribing were already occurring prior to the law implementation. Disciplinary actions against opioid prescribers resulted in prescriber fear, which was then exacerbated by SB 273 and contributed to shifts in care that led to forced tapering and opioid under-prescribing. Providers felt that taking on patients who legitimately required opioids could jeopardize their career.

Conclusion

A holistic and patient-centered approach should be taken by legislative and disciplinary bodies to ensure patients are not abandoned when disciplinary actions are taken against prescribers or new legislation is passed.