Health Policy$ense

Pennsylvania Launches its Prescription Drug Monitoring Program

New tool to address opioid crisis

Prescribers are drawing a lot of attention as a key target of initiatives to combat the opioid crisis. This week, the US Surgeon General, Vivek Murthy, took the unprecedented step of sending 2.3 million clinicians a letter calling for a national movement to turn the tide on the opioid crisis. More locally, Pennsylvania Governor Tom Wolf announced the launch of the PA Prescription Drug Monitoring Program (PDMP), PMP AWARxE.  With one of the highest overdose rates in the country (3,500 drug overdose deaths in the state in 2015), Pennsylvania’s PDMP is a timely and critical tool to save lives and address this crisis. 

How did we get here?

The underlying cause of the rapid risk of opioids is not clear, and is likely multifactorial. Not that long ago, well-meaning people strongly advocated that pain assessment and treatment be integrated into the care we provide to patients in a wide variety of settings. The idea was simple and noble - such a policy would lead to improved treatment of people experiencing pain, and as a result decrease suffering and improve patient outcomes.

Unfortunately, all too often providers did not understand just how complex the pain experience is, and that not all pain can be effectively treated with opioids. Opioid use dramatically expanded, and opioids were often used when other pain treatments would have likely been both safer and more effective.  The increase in opioid use was likely accelerated by aggressive marketing by pharmaceutical firms, which benefited by soaring profits as the use of branded opioid products increased.

Over the years we have learned a great deal regarding the risks and limited benefits of using opioids to treat chronic noncancer pain. We discovered that opioids for noncancer pain have limited impact on pain control, and even more limited impact on physical or mental functioning. In addition, chronic opioids, especially when taken with other centrally-acting sedatives, such as benzodiazepines, or in high doses, have several potentially serious adverse effects, including sleep-disordered breathing, misuse, and abuse, all leading to an increased risk of death. 

The CDC recently reported that 47,055 people died from drug overdose in the United States in 2014. To put that in perspective, there were 47,424 United States combat deaths during the Vietnam War, which lasted from 1955 to 1975.  And it is very possible that we are underestimating the death rate associated with acute and chronic opioid therapy.

What is Pennsylvania doing?

Several Pennsylvania policymakers have been working hard to develop and implement strategies to address the overuse of opioids. This included the creation of an interdisciplinary task force chaired by the Secretary of Drug and Alcohol Programs and the Pennsylvania Physician General.  This task force advocated for the creation of a prescription drug monitoring program, (PDMP), as well as the creation of several state-based guidelines related to the use of opioids and other controlled substances in medical practice. This unique partnership, under the leadership of Secretary Gary Tennis and Dr. Rachel Levine, included several thought leaders, numerous representatives of interested organizations, and representatives of the community, and led to real action that will make a difference.

Until recently, Pennsylvania was one of a handful of states that did not have a functioning prescription drug monitoring program. This legislation was passed by the Pennsylvania legislature and signed into law in the fall of 2014. The PDMP went live on August 25, 2016.

What are prescription drug monitoring programs?

PDMPs collect information regarding controlled substance prescriptions that have been dispensed from pharmacies and store this information in a database that can be accessed by prescribers, state policymakers, and law enforcement. The goal of a PDMP is to help prescribers avoid improper prescribing, while allowing for proper prescribing to patients with a legitimate medical need for controlled substances.  Data from PDMPs can be used by state agencies to identify both patients and providers who engage in risky or illegal behavior. From a physician’s perspective, a PDMP can provide important information that simply cannot be obtained in any other manner. This information can be used to guide clinical decision-making, thus improving patient outcomes. A recent study found that states implementing a PDMP reduced their rate of prescribing Schedule II opioids by 30%.

For information from a PDMP to be useful, it has to be accurate, timely, and easily available. The database also needs to be secure, as it contains information that must be kept private. Of course, available data will be of no value if it is not actually looked at by the health care provider.  Most providers wish they had more time to take care of patients, and do not want additional mandates for them to do yet another time consuming task during the course of patient care. Therefore, it will be important for physicians to understand the PDMP’s value in guiding clinical decision-making, as well as their obligations under this new state law. 

State government and health care systems must work together to develop and implement the technology to allow for seamless transfer of the PDMP data to the electronic health record, thus truly integrating this information into the process of patient care.  Such integration will also allow health care systems to better document the dose of controlled substances that is actually taken by the patient, again improving our ability to monitor and lower the risk of harm.  This integration is possible but is not an easy task, and likely will require the state to allocate additional resources to the PDMP.

I am hopeful that physicians and other health care providers will rapidly discover that the PDMP data are very valuable and worth the effort to obtain and review.  I have had an opportunity to use the Pennsylvania PDMP, and the information I obtained from the PDMP did indeed guide my decision-making for several patients. At the Penn Pain Medicine Center, we plan to access the PDMP to guide patient care during every visit for patients receiving controlled substances prescriptions.

While the launch of the Pennsylvania PDMP is a major step forward, a PDMP will most certainly not solve the prescription drug crises we are experiencing in Pennsylvania. Indeed, concern has been raised that Pennsylvania might experience a growth in IV heroin use as prescription drugs become less available for nonmedical use. There are several other initiatives underway, including the creation and implementation of new core competencies that will be used in medical school education, several provider education initiatives based on the state clinical practice guidelines, innovative changes to the process of pain care to lower our inappropriate use of opioids, and improvements in the process of screening, referral and treatment for addiction.  Ultimately, the appropriate use of the PDMP will help prevent nonmedical use of controlled substances. However, we now have a generation of individuals who now have an addiction disorder, and these individuals deserve compassionate, appropriate care for this life-threatening disorder.

 

Michael Ashburn, MD is a Professor in the Department of Anesthesiology and Critical Care at the University of Pennsylvania, Director of the Penn Pain Medicine Center, and a Senior Fellow of the Leonard Davis Institute of Health Economics.  Dr. Ashburn has been active in supporting the development of the PDMP, and is on the Pennsylvania PDMP Advisory Committee.