The State of Prescription Opioids

Posted on by BUJPH
opiods

Author: John Lin

It takes six minutes for Dr. Megan Ranney to prescribe painkillers.

It’s six o’clock in the evening, around the time that most workers at The Miriam Hospital in Providence leave for home. Not her or her patient.

Ranney has spent the past two hours rushing from one urgent patient to another. As she strides into this small emergency room, her dark brown frizzy hair flies up behind her.

Her patient is a young woman who serves as a security officer for Miriam. She has been suffering from crippling abdominal pain – again.

Ranney is familiar with her case. But without any test results for her patient, all she can do is prescribe pain relief. She logs onto her computer, signs into the Prescription Drug Monitoring Program (PDMP) database and checks her patient’s medication history.

“I’m prescribing an opioid,” Ranney warns. By taking it, the officer would be running the risk of becoming addicted.

The PDMP shows physicians the other prescriptions that have been issued in the patient’s name. In doing so, they can see whether the patient has already been prescribed a similar medication, or if other drugs would disrupt their medication’s effect.

“[PDMP] helps me to see the patterns of prescription,” Ranney says.

That’s the point, according to Dr. James McDonald, who serves as medical director for the Rhode Island Department of Health. The PDMP primarily targets opioid doctor shopping, in which a patient goes to multiple clinics and pharmacies to obtain several opioid prescriptions.

Tom Coderre, a former senior adviser to Rhode Island Governor Gina Raimondo on substance use, asserted in a town hall hosted by Brown College Democrats that reducing prescriptions is key to getting opioids off the street. “Overprescription by doctors is a big reason for our current opioid crisis,” he said.

Coderre helped pass legislation in Rhode Island that requires healthcare providers to register for Rhode Island’s PDMP when they obtain or renew their controlled substance license. Before the law was passed in May 2014, less than 20 percent of doctors, nurses, dentists, and other medical professionals had registered for the drug database.1 Now, 100% of physicians are registered to access information on their patients’ prescriptions from any pharmacy in the state of Rhode Island.2

For some prescribers, that’s not enough. “It doesn’t include meds from all states,” Ranney says. “So if someone’s not from Rhode Island, Connecticut, Massachusetts, Virginia… I don’t see the prescriptions.”

“We’re trying to get PDMP integrated across state lines,” Rhode Island Department of Health spokesperson Rachael Elmaleh says.

But, authorized PDMP users should already have access to prescription information from 47 states3. Only California, Nebraska, and Missouri are not members of the PMP InterConnect. (PDMP and PMP are different acronyms for similar prescription monitoring programs implemented by each state.) Prescribers should have the ability to request data from other states through PDMP.

The Rhode Island PDMP User Support Manual outlines the steps needed to see prescription information from other states4. The prescriber must manually select each state they request information from through the Interconnect list.

Other than the User Support Manual, physicians haven’t received much guidance on accessing prescriptions from other states. An analysis of the Rhode Island Department of Health website found that PMP Interconnect is only mentioned two times: once in a 2014 press release, and again in a short paragraph tucked into the Board of Medical Licensure and Discipline’s 2016 Annual Report5,6.

More Rhode Island physicians tend to describe the PDMP as difficult to use as compared to similar states, according to Dr. Traci Green, a leading researcher for the Rhode Island Hospital Center of Biomedical Research Excellence on Opioids and Overdose. She conducted a study comparing Rhode Island and Connecticut prescription monitoring programs and found that prescribers in Rhode Island tend to use the PDMP less than those in Connecticut, largely because of the inconvenience of accessing the PDMP7.

Ranney agrees with this assessment. “It has a separate log-in,” she says. “So I have to actually, physically, go check the dataset. It doesn’t appear in my EHR [Electronic Health Records].”

That could be changing soon. The Rhode Island Department of Health has been running a pilot project with Lifespan health system physicians to integrate PDMP data with electronic health records, McDonald says. This would make PDMP more accessible for busy health care workers.

If EHR integration is implemented, Rhode Island would be following in the footsteps of its neighbors. Connecticut began integration in January 2017 with Connecticut Children’s Medical Center8. Massachusetts has allowed hospital systems and clinics to access PMP information from EHRs since 20189. The goal is to encourage prescribers to check the PMP database by making the process more convenient.

“Prescribers are required to check PDMP before prescribing anything,” Elmaleh says. Physicians must check the PDMP when their patients begin opioid therapy and every three months for patients with chronic opioid treatment.

But PDMP use is not universally guaranteed, even though it is legally mandatory. To make the PDMP system more direct for prescribers, Rhode Island has introduced a new clinical alert system based on PDMP data. “If a patient has received prescription opioids from five or more pharmacies or providers in the same six-month period,” McDonald says, “We send out alerts to prescribers.”

The goal of the alert program is to reduce opioid doctor shopping. Preliminary PDMP data suggests that this may be working. 11,500 alerts were sent out in the first 10 months of 2019, compared with 15,358 alerts in all of 201810.

Elmaleh attributes much of the PDMP’s success to increased enforcement of PDMP legislation. “The academic detailer goes to the top 200 prescribers in the state and visits them in the office and reminds them to check the PDMP,” she says.

Opioid-related reprimands against Rhode Island physicians have decreased from 8 to 6 between 2017 and 2019.11 Likewise, the number of disciplinary actions relating to PDMP has declined from 3 to 2 between 2017 and 2019. Prescribers are becoming more used to PDMP because the Department of Health regularly communicates with them, Elmaleh adds.

Prescriptions are decreasing, too. PDMP data shows a 20 percent drop in opioid prescriptions in the past three years, from 437,136 in the first three quarters of 2017 to 349,973 in 2019.12 The number of people receiving new opioid prescriptions is down 25 percent. The number of prescriptions for high-dose opioids has fallen 32 percent. Most significantly, prescription opioid overdoses have plummeted from 85 in 2009 to 35 in 2018, or 59 percent.

“The PDMP is a great program,” Ranney says. Hopefully, it will be enough to address Rhode Island’s opioid epidemic.

REFERENCES:

  1. Arditi, L. (2014, May 29). New law: Health-care providers must register in prescription database. Providence Journal. Retrieved February 10, 2021, from https://www.providencejournal.com/article/20140529/news/305299995
  2. R.I. Gen. Laws § 21- 28-3.18(n). (2014)
  3.  National Association of Boards of Pharmacy. (2016, May 18). Over forty states are now members of pmp interconnect. Retrieved February 10, 2021, from https://nabp.pharmacy/news/news-releases/over-forty-states-are-now-members-of-pmp-interconnect/
  4. Rhode Island Department of Health, Board of Pharmacy. (n.d.). Prescription Drug Monitoring Program User Support Manual. Retrieved February 10, 2021, from https://health.ri.gov/publications/guides/HowToUseThePDMP.pdf
  5. Rhode Island Department of Health. (2014, November 6). HEALTH Announces Prescription Monitoring Data Link with Connecticut. Retrieved February 10, 2021, from https://www.ri.gov/press/view/23308
  6. Rhode Island Department of Health, Board of Medical Licensure and Discipline. (2016). 2016 Annual Report. Retrieved February 10, 2021, from https://health.ri.gov/publications/annualreports/2016BoardOfMedicalLicensureAndDiscipline.pdf
  7. Green, T. C., Mann, M. R., Bowman, S. E., Zaller, N., Soto, X., Gadea, J., Cordy, C., Kelly, P., & Friedmann, P. D. (2012). How does use of a prescription monitoring program change medical practice?. Pain medicine (Malden, Mass.), 13(10), 1314–1323. https://doi.org/10.1111/j.1526-4637.2012.01452.x
  8. Buchanan, M. (2017, March 18). Connecticut Children’s Medical Center first in state to connect electronically to Prescription Monitoring Program. Retrieved February 10, 2021, from https://www.connecticutchildrens.org/news/connecticut-childrens-medical-center-first-in-state-to-connect-electronically-to-prescription-monitoring-program/
  9. Massachusetts Department of Health. (2018, March 26). MASSPAT Electronic Health Record (EHR) Integration Guide. Retrieved February 10, 2021, from https://www.mass.gov/doc/masspat-ehr-integration-welcome-packet/download
  10. Rhode Island Governor’s Office, Overdose Prevention and Intervention Task Force. (2020). Opioid Prescribing Data. Providence, RI.
  11. Rhode Island Department of Health, Center for Professional Boards and Licensing. (n.d.). Find Disciplinary Actions and Orders. Retrieved February 10, 2021, from https://health.ri.gov/lists/disciplinaryactions/
  12. Rhode Island Governor’s Office, Overdose Prevention and Intervention Task Force. (2020). Overdose Death Data. Providence, RI.