The earliest version of a prescription drug monitoring program (PDMP) started in California with triplicate prescription blanks. In 1940, a prescription for a Schedule II controlled substance had to be written on a state-issued prescription form. The prescriber retained the third copy, the pharmacy received the original and first copy. The original was the pharmacy record, and the first copy was mailed to the state department of justice. The goal was to monitor the dispensing of these highly addictive drugs for doctor shopping by patients and pill mills operated by prescribers.
Several states followed suit, although some used duplicate prescription blanks instead: Hawaii (1943), Illinois (1961), Idaho (1967), New York (1977), Rhode Island (1979), Texas (1982), Washington, (1987), and Michigan (1989).
When Oklahoma was considering triplicate prescription legislation for Schedule II drugs, Bryan Potter, then executive director of the Oklahoma State Board of Pharmacy, noted that prescription data was routinely being transmitted electronically to third-party payers. He suggested that prescription information could also be transmitted to the state to populate an electronic database in lieu of all the challenges associated with paper. The parties agreed, and in 1991 the modern, electronic PDMP was born. The first version was real time, and the state paid its vendor $0.50 per prescription to upload and maintain the database. (The pharmacies were not paid to transmit the data.)
The expense and challenges of the real-time system were not scalable. As other states began to look at the advantages of an electronic PDMP, they modified the Oklahoma approach to require data to be electronically transmitted but submitted monthly in batch files. Since no file format existed that met the need, the American Society for
Automation in Pharmacy (ASAP) created one in 1995 for Massachusetts and has continuously evolved the standard over the years with input from PDMP administrators and other stakeholders. The beauty of the ASAP format was its simplicity and scalability to implement in additional states.
As an aside, Oklahoma abandoned the real-time approach after a few years and switched to batch reporting until it was able to develop its current near-real-time system that is used today.
With electronic data files, the next group of states, including Indiana (1995), Kentucky (1999), Nevada (1997), and Utah (1997), also noted that the cost of receiving and electronic file is the same, regardless of the number of records contained.
By the early 2000s, the use of opioids to treat chronic pain was on the rise. More states saw the value of a PDMP to monitor doctor shopping and inappropriate prescribing. In 2003, the Harold Rogers PDMP grant program began to offer federal grants to states to implement new PDMPs or enhance older ones. At the same time, physicians and pharmacists began to value information about their patients’ prescription history with controlled substance prescriptions. PDMPs began the transformation to a primarily public health service, as well as a tool for law enforcement purposes.
Today, 49 states have a state-run PDMP, and Missouri has a collaboration of cities and counties that operate a PDMP; the District of Columbia and Puerto Rico also operate programs. All PDMPs collect the same core data for prescriptions dispensed, but added optional data elements in the ASAP standard for a better picture and have expanded prescriptions reported from just Schedule IIs to include Schedules III–IV. Most states now collect Schedules II–V. Almost all PDMPs operate with near-real-time data by requiring pharmacies to report within 24 hours of dispensing.
While we can debate the cause, there’s no doubt that increasing consumption of opioids, both legal and illegal, has created huge challenges for our country. Federal, state, and local governments are faced with expensive public health challenges and are seeking various solutions to this complex, multifaceted problem.
When public officials search for avenues to address the opioid challenge, the value that PDMPs have brought to healthcare comes to mind. It seems natural to expand an already operational program by adding new data. So while the PDMPs originally gathered data only from pharmacies and dispensing practitioners, now they are being asked to collect, and sometimes disseminate, a great deal of new data from new entities with sometimes nonexistent reporting tools or less-than-complete coverage networks. Then the state agencies that operate the PDMPs must bear the expense of developing the mechanisms to receive, store, and utilize the data.
Over the last couple of years, new data has been added or proposed for addition to PDMP databases (see box below).
PDMPs are being asked to collect and disseminate more information. Here’s what’s been added or proposed.
■ Naloxone administration by first responders. (What if it turns out the patient is in a diabetic coma? There’s a risk that the patient is “branded” as a drug abuser if the PDMP report is not carefully scrutinized.)
■ Naloxone dispensing/sales at pharmacies. (Friends and family members are encouraged to purchase naloxone to be administered to someone else.)
■ Noncontrolled substances such as gabapentin or pseudoephedrine (Rx only).
■ All prescription drugs. (Often valuable for assessing the patient’s condition, but the volume of data can be a challenge.)
■ Diagnosis codes on some prescriptions. (Diagnosis code is now a reportable data element in the ASAP Version 4.2A standard to help explain when a quantity dispensed exceeds a state’s limit. However, the ICD-10 code can only be reported when provided with the prescription.)
■ Medical marijuana cards and/or dispensing.
■ Controlled substances overdose events.
■ Records of prescribing consultation between nurse practitioners and physicians.
■ Patient opioid treatment agreements between patients and their prescriber.
While each of these pieces of data can be beneficial, there will be unintended costs to the PDMP and likely some unintended consequences, at least for some patients.
The good news on the PDMP front is the rapid expansion of patient reports within the workflow of healthcare practitioners within the last two years. Most states allow or encourage “one-click access” from the home state PDMP by prescribers and pharmacists. A data field or an icon on the electronic patient record positions the data readily available while treating a patient. Current data that is usable at the time of prescribing or dispensing is infinitely more valuable to appropriate decision-making. Patients can be counseled with current PDMP data and referred to additional treatment resources such as substance abuse counseling, detox programs, or residential drug treatment, if appropriate. More than 40 states have approved these integrations into healthcare workflow.
Another development that promotes the use of PDMP data in healthcare is mandatory registration and mandatory queries by prescribers and pharmacists. More than half the states require prescribers and dispensers to check the PDMP data before prescribing or dispensing an opioid. This forces the use of the PDMP data, and either surprises or reassures the practitioners.
Several states that mandate use and also allow integrated PDMP data are now reporting significant decreases in opioid prescribing. So while PDMPs are being challenged on the data end, healthcare practitioners are increasingly using the data available during the medical/pharmacy visit. PDMPs struggled for many years to expand the use of their data by prescribers and pharmacists. Mandatory queries and one-click access have caused the use of PDMP data to soar.
PDMPs and the agencies that operate them will continue to evolve to meet public health needs. If and when the opioid crisis is abated, there will continue to be value in monitoring the use of these necessary, albeit addictive, drugs when they are needed to treat legitimate medical conditions in patients who use them appropriately. CT
Danna E. Droz, J.D., R.Ph., is the prescription monitoring program liaison for the National Association of Boards of Pharmacy in Mount Prospect, Ill. She can be reached at firstname.lastname@example.org.