Well-intentioned programs can be outgrown by progress in others. That’s a good thing—if we acknowledge shortcomings and move forward.
The creation of prescription drug management programs (PDMPs) was a logical approach to addressing the misuse of controlled substances. But these tools, administered state by state with varying degrees of effectiveness, have not evolved. PDMPs now stifle our nation’s response to the expanding opioid epidemic.
The design of the first several state PDMPs between 1939 and 1988 pre-dated modern technology. The internet was not yet born; health information exchanges (HIEs) did not yet exist. Nearly every state runs a PDMP, but there is little to no evidence that these programs impact patient outcomes with regard to substance use disorder (SUD).
Despite documented increased use of PDMPs, reductions in prescription opioid rates cannot be isolated to their use. A study published by Annals of Internal Medicine, recapped by the American Journal of Managed Care, found “limited to no evidence that they actually work.” Furthermore, there does not appear to be an associated reduction in death rates from opioid overdoses.
Can PDMPs evolve to be useful for patient care? Or should we consider new approaches to incorporate prescribing data—and pharmacists—more broadly into the care team?
There is no doubt the information contained within these programs is valuable. But most PDMPs (and their associated state regulations) are antiquated, were built for a different purpose and demonstrate questionable effects on care. Because PDMPs collect a limited view of the patient’s history and now exist outside of the health data ecosystem, they present challenges, including disruptions to the provider’s workflow, negative effects on patient care and health inequity. This lack of modernization may be hampering our healthcare system’s ability to respond most effectively to the opioid crisis—especially as the crisis evolves, shifting to synthetics and new fentanyl analogs.
Creating silos by design
PDMP information exists separate from a patient’s health history—and these programs were designed that way. That’s because they were built as enforcement and regulatory tools, not as supports for better patient care. Providers can—and in some states are required to—log into the PDMP to look up a patient’s history with controlled substances prior to prescribing an opioid. However, this process is slow and out of workflow. It also provides only one slice of what can be a very complex patient history. And while many states require that PDMP data be integrated into the EHR, even in these states, this data remains difficult to access and out of workflow. In other instances, narrow interpretation of allowable integrations prevents providers from integrating PDMP data into other systems where they coordinate care unless they can do so by adopting select vendors’ proprietary tools.
Beyond the access issues, the patient’s prescription information is often unwieldy, and some providers struggle to make sense of it, especially in a timely manner. Some PDMPs have attempted to deploy algorithms to better present information to providers to improve care. However, these are often not data-driven, a claim backed by evidence from a peer-reviewed study by UCSF researchers. These poorly designed algorithms can, in fact, have a negative effect on patient care, a well-documented negative effect of PDMPs. Examples include an algorithm that inappropriately flagged a patient as a possible drug seeker and resulted in poor patient outcomes.
At best, without intervention, separate PDMP systems will soon become duplicative infrastructure with HIE systems, creating silos of information and creating administrative barriers that distract from patient care. Recognizing this, Bamboo Health, the technology platform for 46 state PDMPs, recently published an opinion piece in HIT Consultant stating that “our country’s healthcare system operates in silos, separating physical care from mental care, even though they are interconnected.” Further, Bamboo Health stated that “while patient privacy is of the utmost importance, it also can hinder care coordination, further separating the healthcare system into silos.”
Did PDMP programs ever “work?”
Because PDMPs were largely designed as enforcement tools in their early days, asking whether these tools work depends on the outcome we’re examining. Do they ultimately result in fewer cases of opioid use disorder and overdose? According to the data: No.
According to the Centers for Disease Control and Prevention (CDC), opioid dispensing per 100 persons increased nationally starting in 2006. It then peaked in 2012 and began to decline from 2012 to 2020, reaching the lowest dispensing rate in 15 years. However, the CDC also reports dramatic discrepancies in opioid dispensing rates across states and counties—irrespective of the specific type of PDMP, quality of that PDMP, or mandate to query a PDMP system. Some counties had rates that were nine times higher than the national average. CDC national data also demonstrates a steady increase in commonly prescribed opioid overdose death rates through 2010 and a subsequent dramatic spike in synthetic opioid death rates around 2015 by 1,040%.
The American Medical Association recently published a report showing “overdose and deaths are spiking even as physicians have greatly increased the use of prescription drug monitoring programs.” The report also noted that while opioid prescriptions decreased 44.4% between 2011-2020, the use of illicit fentanyl, fentanyl analogs, methamphetamine and cocaine increased. Instead of prescription opioids, individuals affected by SUD turned to street drugs, heroin and fentanyl, an arguably worse situation with higher consequences for patient safety.
Due to the historically arduous manual paper process of collecting and reporting information, these tools were designed to provide a narrow slice of a patient’s history to solve the very specific problem of overseeing the use of opioids and other drugs with high likelihood for abuse. Historically, this design met the programs’ original intent. Today, most PDMPs still only collect information on opioids or other addictive medications. Given modern day technology and the move to electronic systems, more robust data can—and should—now move freely between pharmacies and providers in a way that honors patient consent and includes necessary security guardrails to govern access.
Making PDMP information actionable for patient care
Rather than shut them down, PDMPs could be modernized—assuring improved access by authorized providers—to better leverage centralized, real-time and robust repositories of health information data without building on an infrastructure that was built long ago and for a different purpose. If PDMPs remain a separate silo, patient safety will be compromised, providers will burn out, and patient care will suffer.
Healthcare providers need every efficiency they can get. Pew Charitable Trusts suggested in an issue brief that, “when combined with other datasets, PDMP data may unveil emerging drug trends that can guide harm reduction and prevention efforts.” This is the value that integration with newer health data exchange methods, including the privately run national networks like Carequality and CommonWell, health data utilities and mature HIEs can provide.
As an example, with rich patient information, a mature HIE partner can inform an emergency physician within their workflow that, yes, the person presenting to the emergency department (ED) is in great pain and screaming for an opioid that has been prescribed several times in the past year. However, it would also share that the patient has a confirmed diagnosis of sickle cell disease and requires opioids as part of their treatment plan to manage acute debilitating pain during a crisis. This information is critical for context, yet a PDMP would not provide this context, presenting a barrier to effective treatment.
Likewise, the information contained with an a PDMP, combined with EMS and ED data on overdoses and new SUD diagnoses, can help public health agencies identify emerging regions impacted by new fentanyl analogs, strengthening the public health response.
In more progressive examples, ownership of PDMP operations has already begun migrating to some HIEs with proven results, state support and robust governance. There are currently two HIEs that manage their state PDMPs. The state of Nebraska’s PDMP is managed by its state-designated HIE, CyncHealth, and is a public health model focusing on patient safety. CRISP, the state-designated HIE for Maryland, also operates Maryland’s PDMP at the direction of the state. Both of these HIEs are connected to RxCheck, a fully operational, public-access data sharing system that enables states to securely and efficiently share PDMP data between states or with an HIE and/or EHR system. RxCheck is free to use.
Providers in Nebraska and Maryland, which are mandated to connect to their HIEs, benefit from this arrangement by receiving an in-workflow, comprehensive picture of a patient’s circumstances. The technology infrastructures of both CyncHealth and CRISP have been built to handle sensitive information, protect patient privacy and support care teams with pertinent information for better decision-making—which includes, but is not limited to, prescription opioid information. This allows for a smooth, integrated workflow for the provider that is optimized to provide the best patient care possible.
Expanding beyond controlled substances
Another opportunity to make PDMPs useful to patient care—assuming they are able to be accessed by the provider community effectively—is the expansion of the prescription information collected by these programs. Due to the reduced burden of data collection facilitated by automatic and electronic data capture, all prescription medications dispensed—not just opioids or other addictive drugs—can now be easily captured and integrated into health information systems. This is a huge step forward in improving our nation’s healthcare system, and evidence suggests that monitoring noncontrolled substances is a feature of the most effective PDMPs. Instead of relying on multiple messy data sets or placing the burden on patients to remember complicated drug names and dosages to understand a person’s medication history, a provider could access a streamlined centralized repository of dispensed medication history. This is a game changer: It prevents common and costly medication errors and adverse drug events and gives providers insight into medication adherence. If a patient is not taking their medication, that is a critical window of knowledge into how a provider can more effectively coach that person.
Nebraska is one of two states that require the collection of all dispensed medications into the PDMP. While CyncHealth’s management of the state PDMP and its approach to collecting all medications prescribed is the oldest example of such an arrangement, it’s now not the only one. In the most recent legislative session, the Maryland state legislature passed a requirement that CRISP also collect all medications prescribed. The law went into effect Oct. 1, 2022. The investment in HIEs should be leveraged to provide all prescription information to providers in a comprehensive, real-time manner.
The time is now
Data as important as patient prescription data should not be siloed into proprietary, vendor-limited networks. Rather, it should be easily contextualized alongside the entirety of the patient record so providers can quickly and inexpensively make the best possible care decision for their patients.
Advancing our nationwide healthcare infrastructure requires us to examine what’s working and what’s not. There will assuredly be variations in each state as to how PDMPs evolve to transition into the larger HIE enterprise. Collaborations with state boards of pharmacy, departments of justice, medical associations and other key stakeholders will strengthen the next phase in the country’s fight against the opioid epidemic.
State PDMPs must evolve by streamlining into the country’s modern health data infrastructure to do what is right for patients, physicians, pharmacies, and for the greater good.
Kat McDavitt is the founder and chief strategy officer of Innsena, a health tech consultancy.
Mary Andrawis, PharmD, MPH, is founder and president of Serafina Health Strategy, a consultancy focused on healthcare quality improvement strategy and implementation.