I had always assumed that I would remember my first code. I don’t, but I do remember my first time coding a patient who could have been my peer. He was young and otherwise healthy. His housemates had heard a loud thud but ignored it. Later, they found him lying lifeless on the ground. He was a known heroin user.
In Connecticut, like in many states, prescription medications are the most common drugs of abuse.1 Prescription opioids are known gateways to heroin as patients seek stronger, cheaper, and easier-to-acquire agents. Patients addicted to opioid medication are 40 times more likely to be addicted to heroin.2 More than two-thirds of heroin addicts previously abused prescription opioids.3
One major driver of the opioid epidemic has been the proliferation of prescription pain medicine. The United States consumes nearly all (98 percent) the world’s supply of hydrocodone.4
How did this happen? In 1999, in response to popularized claims that chronic pain was undertreated at epidemic proportions, the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative, requiring a pain-intensity rating at all patient encounters.5 This was disseminated to the rest of the health care system two years later by The Joint Commission, which instituted pain management standards. Pharmaceutical companies seized the opportunity and aggressively campaigned, convincing physicians, patients, and regulators that opioids were safe for chronic non-cancer pain. The misinformation was so explicit that Purdue Pharma, makers of Oxycontin, eventually pled guilty to federal criminal charges.6
From 1991 to 2013, Oxycontin prescriptions skyrocketed from 76 million to nearly 207 million annually. As the prescriptions increased, so did the number of related ED visits, which more than than doubled between 2004 and 2011.7 More recently, the trend has turned lethal. Opioid-related deaths doubled in just one year, killing 5,500 in 2014.8
Well aware of these deadly trends, I initially welcomed the arrival of Connecticut’s prescription drug monitoring program (PDMP), a central database holding statewide accounts of Schedule II-V controlled substances. Signed into law in the summer of 2015, Public Act 15-198 was hailed as legislation that took “necessary and smart steps to stem prescription drug abuse and overdose deaths.”9,10
Unfortunately, the bill creates busywork for doctors, and new evidence suggests that the extra work is not making an impact. The bill mandates that practitioners check each patient’s record in the PDMP. We must check every controlled substance prescription written to last more than three days. For patients who receive prescriptions chronically, providers must recheck the PDMP every 90 days.
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2 Responses to “Prescription Drug Monitoring Programs: Regulatory Burden or an Emergency Physician Function?”
July 28, 2016
Scott WeinerThank you for the insightful article. PDMPs have been proven to be helpful tools (see recent articles by Patrick and Bao in Health Affairs), but they are important to consider in terms of their limitations – they do not detect medication misuse in patients who are diverting meds, for example. However, the best policy is not to treat everyone as “guilty until proven innocent” or even a policy of selective look-ups as clinician gestalt is not great. Simply, consider the PDMP as supplmentary information that should be reviewed prior to any opioid prescription you write. Look it up for EVERY patient for whom you are writing a prescription; don’t allow your biases to assume someone doesn’t have an opioid misuse disorder. You’ll find that if you do it routinely, you’ll be able to obtain the information in <30 seconds. Better yet, technology is making PDMPs integrated into our EMRs, so that the information will eventually be automatically and seamlessly presented. That day isn't here yet, though, but it will come.
August 3, 2016
Rich Greiner, MDRachel, nice article.
I agree, emergency physicians don’t appreciate and don’t need to be told by legislators how to do our job. None of us needs more regulations.
It would be more efficient if the PMP was integrated into the EMR and took only one click to reveal the patient’s controlled substance prescriptions, but requiring that we check a state run website which adds more time, on the order of 2 to 3 minutes, to each patient encounter, is not negligible. Some EMRs can give us a lot of this information, though usually not quickly.
Overall, I appreciate having access to this database, and I use it daily. Anecdotally, I feel like the PMP changes my management in about 1 in 4 cases. It does make me feel like I have a tool to help me not judge the patient. It is somewhat like the pregnancy test: we use it every day, it is quick and cheap, enables us not to judge or always have to believe our patients, and a positive result changes our management.
The well-intentioned three day rule makes it unlikely that I would be compelled to check the database, since I very rarely would prescribe more than three days worth (12-24 tabs) of a controlled substance in the ER. I typically only prescribe 6-12 tabs, to be used when all non-narcotic options have been maximized.
I’m the first one to agree that I don’t like to be told what to do, especially by those who don’t know anything about medicine like the government, but I also feel like the PMP is an excellent tool to help us reduce the risk of prescription (and other) narcotic abuse.
When considering controlled substance abuse potential in the ED, I wouldn’t necessarily consider every patient initially guilty, but a good OB doctor once taught me that every female is pregnant until proven otherwise.