When to Consult Prescription Monitoring Programs

An AAAP Poster Brief

Bret S. Stetka, MD; Jonathan C. Fellers, MD


December 27, 2013

Editor's Note:
While browsing a poster session at the 2013 Annual Meeting of the American Psychiatric Association in Scottsdale, Arizona, Medscape spoke with Jonathan C. Fellers, MD, Instructor in the Department of Psychiatry at Oregon Health and Science University and Staff Psychiatrist at the Portland VA Medical Center in Portland, Oregon, about whether or not prescription monitoring programs (PMPs) should be consulted on all new psychiatric patients.

Medscape: Dr. Fellers, Tell us a bit about your study.

Dr. Fellers: This study was completed while I was a resident at the University of Virginia in Charlottesville. This was at an outpatient psychiatric clinic. Charlottesville is not a huge metropolis, but we saw a wide variety of patients all the way from indigent to self-pay. The PMPs are a relatively new phenomenon, and there isn't a great deal of guidance on how to use them. So the point of our study was to look at the epidemiology of what you would see and determine whether or not we have to check with the PMP for every patient that comes through the door or whether they can be used with a more tailored approach.

Medscape: What exactly is a PMP?

Dr. Fellers: A PMP is a state database that gathers pharmacy information on all the controlled substance prescriptions for people in that state. It's essentially a central warehouse on controlled substance prescriptions. You can keep track of these substances that people may be getting from multiple providers. Often providers don't communicate with each and may not know that others are providing prescriptions for the same patients, so PMPs help solve the problem of "doctor shopping." This is a huge concern, especially in psychiatric patients in whom there is a higher risk for substance use disorders.

So we made a clinic policy to pull a PMP report on all new intakes to the clinic over a 9-month period. The residents would meet with the patients and complete evaluations including medical, psychiatric, and substance abuse history. They would then present the patients to their attending while the clinic nurse would pull the prescription marker and put it in their file. Prior to looking at the report, the residents would make a prediction as to whether they thought the report showed misuse or not. They would then look at it and confirm misuse or not and determine whether that report would subsequently alter their management decisions.

The results that we found are that for most patients, you didn't really need to check the PMP because it didn't alter management. Discrepancies [in management] were only found in 2.2% of patients, so the residents' own ability to fish out what's there was very adequate.

Conditions associated with prescription misuse were anxiety disorders, personality disorders, and chronic pain, which have been pretty well established in the literature as predictors of misuse. Other things that were important were prior use of any benzodiazepine or opiate. About 30% of psychiatric outpatients had some criteria of misuse of prescriptions just based on the report, which is relatively high.

Medscape: I assume some of the screening success is due to the fact that, being part of this study, residents were especially thorough in taking their histories. What do you think the results would show in the community?

Dr. Fellers: In the community you probably wouldn't be checking the PMP because it takes a lot of time to do that! But I think what this study suggests is that in a general psychiatric practice, it doesn't make sense to check the PMP on every patient. But if you have the risk factors we discussed (eg, anxiety, personality disorders, chronic pain, or benzodiazepine or opioid use), it makes sense to check it. These are the red flags.


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