Prescription Monitoring Programs: Do They Work?

Aaron Gilson, MS, MSSW, PhD

Disclosures

July 07, 2010

Question

How can I tell if a patient is doctor shopping for prescription drugs? Do prescription monitoring programs work?

Response from Aaron Gilson, MS, MSSW, PhD
Senior Scientist, Paul P. Carbone Comprehensive Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

National, state, and local media coverage reinforces the public health imperative to effectively mitigate morbidity and mortality resulting from the nonmedical use of prescription opioid analgesics. Although disparate diversion sources exist for prescription medications,[1,2] "doctor shopping" (eg, obtaining the same or similar drugs from more than 1 practitioner) has long been recognized as an important method by which drugs enter the illicit market.[3] To address this diversion source, 34 states have an operational prescription monitoring program (PMP) in which information about dispensed medications is entered into an electronic database. Practitioners can then access this information for their patients to determine whether additional medications are being acquired from other clinicians.

PMPs have proliferated in the last 2 decades, but only about 10 research articles have been published, and most of these have focused on the effect of state-mandated use of government-issued serialized prescription forms for Schedule II medications on practitioner prescribing.[4,5,6,7,8,9,10,11,12,13,14] Results demonstrated that many practitioners avoided prescribing Schedule II medications and instead used medications that the program did not cover (termed the "substitution effect").[15] Such findings have limited relevance today because few programs continue to require a serialized form, but they substantiate the contention that drug control programs focusing on a single medication class can contribute to a pronounced substitution effect.[16]

Therefore, little is known about the success of PMPs in identifying and reducing doctor shopping. Only 1 recent study has attempted to describe the distribution of individuals receiving prescriptions for Schedule II opioids from number of prescribers and pharmacies, finding that more than 90% of individuals used either 1 or 2 prescribers and a single pharmacy.[5] This study also highlights the importance of using PMPs as a clinical tool to guide treatment decision making and patient care choices. The following conditions should facilitate this:

  • The PMP should collect information about medications of multiple schedules;

  • Practitioners should have electronic access to accurate prescribing information soon after it is entered;

  • Educational programs should be provided to database users about data access and utilization; and

  • Practitioners should not be obligated to check the database before prescribing a medication.

A critical consideration with respect to the effect of PMPs on patient care is how prescribers use the accessed data. For example, what should a physician do if he or she determines that a patient has obtained opioid prescriptions from 2 other practitioners and had them filled at separate pharmacies? Absent a valid method to operationalize the concept of doctor shopping, as well as considering the possibility that the patient information is incorrect, false positives can occur, and patients could be erroneously labeled as abusers or drug seekers.[5] Also, doctor shopping is not motivated solely by illicit intent. A patient who is inadequately treated by a practitioner may seek additional analgesia, a phenomenon known as "pseudoaddiction."[17] Successfully translating PMP data into practice often requires clinicians to navigate through this complex and ill-defined landscape.

In conclusion, the PMP is but one mechanism to address a single source of nonmedically used prescription opioids, and further resources must be directed toward evaluating program effects. Consequently, a broader approach is warranted to effectively reduce the public health problem of medication abuse and diversion. Given this context, PMPs still can serve a crucial function by making prescription data readily available for clinical use, but it is up to practitioners to use the information to benefit their patients' treatment needs. Efforts are underway within various states to enhance the clinical utility of PMPs, including educational programs for database users, but more can and must be done to make this objective a reality for prescribing practitioners.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....