Part IV: PDMPs
BY JIM HUIZENGA, M.D. AND CHIEF CLINICAL OFFICER OF APPRISS HEALTH
Series Introduction – Appriss Health has long held that chronic pain and addiction (substance use disorder) are separate medical conditions and that each deserve a unique clinical approach. We have spent years developing clinical decision support tools and in doing so have obtained the feedback from countless medical professionals, including many pain providers. Through those providers we have also heard (directly and indirectly) from many chronic pain patients as well.
To continue this conversation, over a long series of blog posts, we will explore our approach to benefit/risk assessment, data presentation, and clinical support…and how they relate to our goal of creating a usable and balanced, clinical viewpoint that protects access to care while highlighting areas of risk that clinicians and patients should be aware of.
What is a PDMP?
The initial posts of our blog series “A Balanced Approach to Opioids and Chronic Pain” examined the details around the risks and benefits of using opioids for chronic pain. The goal of that effort was to level set what opioids are out there, their uses and what risks they can pose to patients. This helped us to begin to examine how complex it is for providers and patients alike to assess when opioids are appropriate, when they’re being used properly, and when they’re not.
One of the many tools available to aid such an assessment is a prescription drug monitoring program, also known as a PDMP. Many people believe PDMPs are relatively new to the medical community but the first PDMP rolled out in 1917 in New York and was designed to track morphine, cocaine, and heroin. The oldest, continuously running PDMPs have been around since the 1930s.
There are 53 operating PDMPs now in the U.S. (including Puerto Rico, Guam and the District of Columbia), and when a PDMP program goes into effect, all dispensaries (usually pharmacies) are required by law to report controlled substance dispensations to the state managed database. This reported dispensation information is then carefully made available to providers and pharmacists under specific use restrictions. Typically, only a provider or pharmacist actively caring for a patient is able to access the prescription data. The belief is that with better knowledge of a patient’s use of controlled substances, better prescribing decisions will be made. In many states, providers and pharmacists are required by law to check the PDMP under certain clinical situations.
What type of data is contained in a PDMP?
Basically, the answer to that question is just about every detail of any controlled substance prescription filled in the state, including the date the prescription was written, the date it was filled, the prescriber’s identification, the medication name and strength, quantity, etc.
Here’s what a typical line of PDMP data looks like:
And a PDMP report is made up of many lines of prescription data, depending on the patient.
If these images look complicated, it’s because, well… They are! A Massachusetts study found that it took providers more than 4 minutes and 51 clicks to access and review a report like this.
What information are providers expected to glean from a PDMP report?
Basically, providers are looking for the presence of elements of risk that scientific literature has shown can possibly lead to negative (bad) outcomes for the patient such as addiction, overdose, death, etc. These elements of risk basically break down to the following categories:
- The number of providers the patient has seen.
- The number of pharmacies where the patient has filled prescriptions.
- The amount of medication used.
- The presence and/or amount of potentiating medications used (like narcotics, sedatives, and stimulants).
- Overlapping of medications.
All of the above elements have been shown to be associated with risk, for example a Pain Medicine study, found that risk of overdose death went up with the number of prescriptions filled, prescribers seen, as well with increasing dose of medication. The following graph was included in the study showing the relationship between risk and number of providers:
What the above graph illustrates is that if we consider the risk of overdose of seeing one provider to be equal to “1” (baseline risk) then patients who saw between 6 and 9 providers had 4 times greater risk.
There are hundreds (or thousands) of these types of graphs and statistics that have been generated related to the study of opioid misuse, abuse, overdose, and death, as well as other potential negative patient outcomes. Buried in the details of all of these studies are many decisions about how to count, who to exclude, what time frame to use, etc. These details can be important.
Next up in the blog series, we will dissect one of the published risk variables (the number of providers seen) and begin to show how we at Appriss Health have worked to provide a balanced viewpoint to providers who are choosing (or required) to review PDMP data while they care for a patient.
To read more on this series:
- Part I – Benefit and Risk
- Part II – Risk Defined
- Part III – Dependence and Addiction
- Part IV – PDMPs
- Part V – Multiple Provider Episodes
- Part VI – PDMP Visualization
- Part VII – Interpreting PDMP Visualizations
- Part VIII – Scoring PDMP Data
- Part IX – Understanding How PDMP Data is Scored
- Part X – Machine Learning
- Part XI – Epilogue
Thanks, again, for following along.