In a JAMA commentary piece last week, Dr Gugelmann and Perrone discuss the role of Prescription Drug Monitoring (access required). They reference appropriately the nature of the problem of Prescription Opioid Abuse in the USA and highlight the White House Office of National Drug Control Policy released in April 2011, and discussed here at the time (Balancing Medical Use… and Reducing Opioid Diversion: Thinking outside the box). The White House Office focused on four issues:
Patient and clinician education
Increased prescription drug trafficking and monitoring
proper medication disposal
Reductions in illegitimate prescription abuse.
So what is my understanding of a prescription monitoring program is a database that collect and distribute data on controlled substance prescribing. Effectively if I am seeing a patient on morphine in clinic, I should as a physician log-in and in real time, find out if in fact I am the only one prescribing these medications. In the US, these are State run and exist to support the legitimate use of controlled substances while limiting drug abuse and diversion (National Alliance for Model State Drug Laws overview of Prescription Drug Monitoring Program).
Do they work? The JAMA commentary points out a paper from Baehren and colleagues in Ohio. Here are some limited numbers:
OARRS data indicated high use of prescription narcotics within the most recent 12 months. The range of prescriptions per patient in a 1-year period was 0 to 128 (mean 18.9 [SD 26.6]). The range of different providers writing prescriptions in a 1-year period was 0 to 40 (mean 5.6 [SD 7.6]). The range of number of pharmacies used to fill controlled substances was 0 to 20 (mean 3.5 [SD 4.4]), and the range of number of different addresses used by patients was 0 to 14 (mean 1.8 [SD 1.9]).
After review of OARRS data, overall (combining across providers) opioid prescribing was altered for 41% (74/179) of patients. In cases of altered management, the majority (61%; n=45) resulted in fewer or no opioid medications prescribed compared with pre-OARRS assessment. Conversely, 39% were prescribed more pain relief than originally planned, after review of the OARRS data.
Sounds great! But given they are state run, there are effectively as many variations to there are states running that have them (44 authorized and 34 operational). Effectively some are apples and some are oranges!
There is a whole discussion of protection of privacy for patients on opioids. Good point. But with good protection of data, that may be something we have need to “sacrifice” to ensure that balance is achieved in this important public health issue!
So a good commentary that should have us looking into this issue in each US state. To those in countries that are only beginning to increase opioid access. PMPs may not necessary from the beginning but with increasing use of mobile technology, may be something that will become much more implementable in the near future of global health and help serve the achievement of balance.
UW Pain and Policy Studies Group.
Baehren DF, Marco CA, Droz DE, Sinha S, Callan EM, Akpunonu P. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010;56(1):19-23.