A History of Prescription Drug Monitoring Programs in the United States: Political Appeal and Public Health Efficacy

The Combined Relationship of Prescription Drug Monitoring Program Enactment and Medical Cannabis Laws with Chronic Pain-Related Healthcare Visits

BACKGROUND

U.S. state electronic prescription drug monitoring programs (PDMPs) are associated with reduced opioid dispensing among people with chronic pain and may impact use of other chronic pain treatments. In states with medical cannabis laws (MCLs), patients can use cannabis for chronic pain management, reducing their need for chronic-pain related treatment visits and moderating effects of PDMP laws.

OBJECTIVE

Given high rates of chronic pain among Medicaid enrollees, we examined associations between PDMP enactment in the presence or absence of MCL on chronic pain-related outpatient and emergency department (ED) visits.

DESIGN

We created annual cohorts of Medicaid enrollees with chronic pain diagnoses using national Medicaid claims data from 2002-2013 and 2016. Negative binomial hurdle models produced adjusted odds ratios (aOR) for the likelihood of any chronic pain-related outpatient or ED visit and incident rate ratios (IRR) for the rate of visits among patients with ≥ 1 visit.

PARTICIPANTS

Medicaid enrollees aged 18-64 years with chronic pain (N = 4,878,462).

MAIN MEASURES

A 3-level state-year variable with the following categories: 1) no PDMP, 2) PDMP enactment in the absence of MCL, or 3) PDMP enactment in the presence of MCL. Healthcare codes for chronic pain-related outpatient and ED visits each year.

KEY RESULTS

The sample was primarily female (67.2%), non-Hispanic White (51.2%), and ages 40-55 years (37.2%). Compared to no-PDMP states, PDMP enactment in the absence of MCL was not associated with chronic pain-related outpatient visits but PDMP enactment in the presence of MCL was associated with lower odds of chronic pain-related outpatient visits (aOR = 0.81, 95% CI:0.71-0.92). PDMP enactment was not associated with ED visits, irrespective of MCL.

CONCLUSIONS

During a period of PDMP and MCL expansion, our findings suggest treatment shifts for persons with chronic pain away from outpatient settings, potentially related to increased use of cannabis for chronic pain management.

Microbetting, Fantasy Sports and Risk of Gambling Disorder: A Scoping Review

The rapid growth of fantasy sports might facilitate constant play and harm. Micro-betting allows constant and impulsive betting, possibly augmenting the risk for gambling disorder. This work provides a rapid scoping review of recent publications regarding micro-betting and fantasy sports betting, including characteristics, prevalence, and causes across different age groups. A search in the PubMed database was set for November 2014-November 2019, with inclusion criteria of human studies and written in English. The search terms included: "Sports betting AND children", "Sports betting AND young adult", "Sports betting AND adult". One hundred and thirty-one references were found and 13 complementary reference was added to the discussion and methods sections. Following elimination of 49 duplicate references and 73 other references deemed not of relevance to the study's objectives, a total of 22 references was selected for inclusion. Current evidence suggests a number of public health problems linked to fantasy sports and micro-betting, including (a) that micro-betting is related to severe problem gambling and impulsivity, (b) frequent participation of high school students in fantasy sports relates to a higher risk of gambling problems, and (c) special control should be exerted on youth regarding access to websites of fantasy football for protecting them of harm.

Discrepancies Between the Electronic Medical Record and Website Access to the Prescription Drug Monitoring Program

The US opioid crisis has affected many patients across the age spectrum. Yet little has been reported on the effects of this crisis on cancer patients. Prescription drug monitoring programs have emerged as potential tools to mitigate risks of opioid prescribing, but they are not without limitations. We present a case of missing opioid prescriptions on EMR integrated PDMP versus the web based PDMP. A full review of PDMP integration is needed to identify gaps as these pose a significant patient safety issue.

Health-care practitioner use of prescription drug monitoring programs in clinical practice in Australia: A qualitative study

INTRODUCTION

Prescription drug monitoring programs (PDMP) are electronic databases used by prescribers and pharmacists to monitor the use of high-risk prescription medications subject to extramedical use. This study aimed to explore how Australian pharmacists and prescribers are using PDMPs in practice and to gain an understanding of barriers to tool use, as well as practitioner recommendations to increase tool usability and uptake.

METHODS

Semi-structured interviews were conducted with pharmacists and prescribers who use a PDMP (n = 21). The interviews were audio-recorded, transcribed and thematically analysed.

RESULTS

The four themes that emerged were: (i) PDMP notifications combined with practitioner clinical judgement guide PDMP usability; (ii) practitioners use PDMPs to facilitate patient and practitioner communication; (iii) workflow systems integration impacts tool usability; and (iv) optimising PDMP information and data access including practitioner-tool engagement to improve tool uptake and usability.

DISCUSSION AND CONCLUSIONS

Practitioners appreciate the value of PDMP information support for clinical decisions and patient communication. However, they also acknowledge the challenges to tool use and recommend improvements including enhanced workflow, systems integration, optimisation of tool information and national data sharing. Practitioners provide an important perspective on PDMP use in clinical practice. The findings can be drawn on by PDMP administrators to improve tool usefulness. Consequently, this may lead to an increase in practitioner PDMP use and optimise the delivery of quality patient care.

Barriers and facilitators related to healthcare practitioner use of real time prescription monitoring tools in Australia

Introduction

Real time prescription monitoring tools have been implemented in Australia to address the growing concerns of drug misuse, drug-related mortality and morbidity. The objective of this pilot study is to investigate the barriers and facilitators related to healthcare practitioner use of real time prescription monitoring tools.

Methods

An online survey was distributed to Australian prescribers and pharmacists who use a real time prescription monitoring tool. Data analysis included descriptive statistics, chi-square tests and multivariate logistic regression analyses.

Results

A total of 102 questionnaires were analyzed. Practitioners mainly agreed that the tool was easy to use (n = 64; 66.7%) and access (n = 56; 57.7%), and the data was easy to interpret (n = 77; 79.4%). Over half agreed that they wanted training to guide clinical actions (n = 52; 55.9%) and clinical guidelines or guidance on what to do with the RTPM findings (n = 51; 54.8%). Prescribers were more likely to report difficulties with workplace access to a computer or the internet (n = 7; 21.2%) compared with pharmacists (n = 6; 9.2%; p = 0.037). Practitioners working in community settings (n = 59; 57.9%; p = 0.022) and those with 1-10 years practice experience (n = 45; 44.2%; p = 0.036) were more likely to want training to guide clinical actions in response to RTPM information.

Conclusion

This is the first known study to investigate the barriers and facilitators related to practitioner use of RTPM tools in Australia. The results from this study can inform further research to gain an understanding of healthcare practitioners use of RTPM tools, and how to minimize barriers and optimize use for the essential delivery of quality healthcare.

Between Care and Control: Examining Surveillance Practices in Harm Reduction

As harm reduction programs and services proliferate, people who use drugs (PWUD) are increasingly subjected to surveillance through the collection of their personal information, systematic observation, and other means. The data generated from these practices are frequently repurposed across various institutional sites for clinical, evaluative, epidemiological, and administrative uses. Rationales provided for increased surveillance include the more effective provision of care, service optimization, risk stratification, and efficiency in resource allocation. With this in mind, our reflective essay draws on empirical analysis of work within harm reduction services and movements to reflect critically on the impacts and implications of surveillance expansion. While we argue that many surveillance practices are not inherently problematic or harmful, the unchecked expansion of surveillance under a banner of health and harm reduction may contribute to decreased uptake of services, rationing and conditionalities tied to service access, the potential deepening of health disparities amongst some PWUD, and an overlay of health and criminal-legal systems. In this context, surveillance relies on the enlistment of a range of therapeutic actors and reflects the permeable boundary between care and control. We thus call for a broader critical dialogue within harm reduction on the problems and potential impacts posed by surveillance in service settings, the end to data sharing of health information with law enforcement and other criminal legal actors, and deference to the stated need among PWUD for meaningful anonymity when accessing harm reduction and health services.

A Novel Approach to PDMP Reporting: Adapting Opioid Quality Measures to PDMP Data

OBJECTIVE

The SUPPORT Act provided resources for developing prescription drug monitoring programs (PDMPs) capable of reporting on four specific opioid quality measures. Therefore, the objective of this pilot study was to map, test, and adapt these claims-based opioid quality measures specified for health plan performance to PDMP data for state-level performance.

MATERIALS AND METHODS

Maryland PDMP and claims from Maryland Medicaid beneficiaries continuously enrolled from April 1, 2019, to March 31, 2020.

RESULTS

The measure rates as specified using claims data are closely aligned with the measure rates when mapped and adapted to PDMP data. The Concurrent Use of Opioids and Benzodiazepines measure rates were 14.49% and 15.31%, the OHD rates were 12.44% and 13.54%, the OHDMP rates were 0.01% and 0.40%, and the Use of Opioids from Multiple Providers in Persons Without Cancer rates were 0.12% and 3.03% for the claims-based and adapted measures, respectively.

DISCUSSION

This is a novel application that may be replicated in other states to support quality improvement and can have a measurable effect on stemming the drug abuse epidemic.

CONCLUSIONS

This will facilitate data sharing of the opioid quality measure reporting within the Maryland PDMP and stakeholders responsible for caring for Maryland Medicaid beneficiaries. Owing to the encouragement by the Centers for Medicare and Medicaid Services, other states' PDMPs may require the adaptation of these measures. This will open the door for innovative state-level policy and practice interventions. The quantification of outcomes related to these measures will inform our learning healthcare system and help support the Quintuple Aim.

Evaluating State-Level Prescription Drug Monitoring Program (PDMP) and Pill Mill Effects on Opioid Consumption in Pharmaceutical Supply Chain

The opioid crisis in the United States has had devastating effects on communities across the country, leading many states to pass legislation that limits the prescription of opioid medications in an effort to reduce the number of overdose deaths. This study evaluates the impact of two categories of PDMP and Pill Mill regulations on the supply of opioid prescriptions at the level of dispensers and distributors (excluding manufacturers) using ARCOS data. The study uses a difference-in-difference method with a two-way fixed design to analyze the data. The study finds that both of the regulations are associated with reductions in the volume of opioid distribution. However, the study reveals that these regulations may have unintended consequences, such as shifting the distribution of controlled substances to neighboring states. For example, in Tennessee, the implementation of Operational PDMP regulations reduces the in-state distribution of opioid drugs by 3.36% (95% CI, 2.37 to 4.3), while the out-of-state distribution to Georgia, which did not have effective PDMP regulations in place, increases by 16.93% (95% CI, 16.42 to 17.44). Our studies emphasize that policymakers should consider the potential for unintended distribution shifts of opioid drugs to neighboring states with laxer regulations as well as varying impacts on different dispenser types.

How do patient, pharmacist and medication characteristics and prescription drug monitoring program alerts influence pharmacists' decisions to dispense opioids? A randomised controlled factorial experiment

BACKGROUND

Prescription drug monitoring programs (PDMP) are electronic databases that track the prescribing and dispensing of high-risk medicines such as opioids. They have the ability to provide clinicians with alerts, which identify medication-related risks, and are used to help inform decisions to supply. This study aimed to determine to what extent patient, pharmacist, and medication related characteristics and PDMP alerts influence decisions to dispense opioids and take other action, using a randomised controlled factorial design.

METHODS

Pharmacists completed an online factorial experiment, comprising six randomly generated vignettes, describing a hypothetical pharmacy patient. Pharmacists ranked the likelihood of dispensing an opioid prescription and indicated other actions, if any, they would make. Mixed-effects linear and logistical models were used to examine the association between the vignette (patient, medication and alerts), and pharmacist characteristics and the likelihood to dispense and take other actions.

RESULTS

241 pharmacists were included in the analysis (n = 1353 vignettes). The PDMP alert for high dose and multiple prescriber episodes were significant predicators of reduced likelihood to dispense, with a respective 2.73- and 4.1-unit decrease in likelihood to dispense (p < 0.001). Alerts had the strongest association with other actions such as contacting the prescriber, talking to the patient and recommending naloxone, though patient and medication characteristics including age, opioid dose, benzodiazepine use and co-morbidity were also associated with increased odds of engaging in some actions.

CONCLUSION

PDMP alerts were the most significant predictor of reduced likelihood to dispense and were associated with the greatest odds of taking other actions. Well-established risk factors such as high dose and high-risk drug combinations, in the absence of PDMP alerts, were associated with some actions, though to a lesser degree than PDMP alerts. These findings have significant policy implications and suggest PDMP alerts are a greater driver of decisions to dispense opioids and take other actions, compared with other known clinical risk factors.

Patient experiences of prescription drug monitoring programs: a qualitative analysis from an Australian pharmaceutical helpline

BACKGROUND

Prescription Drug Monitoring Programs (PDMP) are electronic databases that are used to track and monitor the prescribing and dispensing of controlled substances, such as opioid analgesics and benzodiazepines. PDMP have been used widely throughout North America and have recently been implemented in Australia. Several unintended harms have been associated with PDMP in North America, including increased stigma, discrimination, and dismissal from care for patients prescribed these medications.

AIMS

This study aimed to better understand how people who use prescription medications extramedically and their loved ones give meaning to their consumption and their treatment experiences and concerns in the context of a newly implemented real-time PDMP in Victoria, Australia.

METHOD

Nineteen audio recordings of telephone calls made to the PDMP Pharmaceutical Helpline were transcribed and thematically analysed.

RESULTS

Patients and their families were hopeful that PDMP would stop the extra medical use of medications. However, many were deeply concerned about how they would cope with withdrawal or life stressors without the support these medications afforded. Patients reported experiences of stigma and strained therapeutic relationships associated with PDMP implementation.

CONCLUSION

PDMP have the potential to both assist and harm patients whose prescription medication use has been identified as 'risky' by the PDMP. The findings from this study suggest that clear and open communication, as well as reflection on unconscious bias and stigma may assist healthcare providers to facilitate better patient experiences and outcomes in the context of prescription medication dependence.

The effects of opioid policy changes on transitions from prescription opioids to heroin, fentanyl and injection drug use: a qualitative analysis

BACKGROUND

Beginning in the 1990s, nonmedical use of prescription opioids (POs) became a major public health crisis. In response to rising rates of opioid dependence and fatal poisonings, measures were instituted to decrease the prescription, diversion, and nonmedical use of POs including prescription drug monitoring programs (PDMPs), pain clinic laws, prescription duration limits, disciplining doctors who prescribed an excessive number of POs, and the advent of abuse deterrent formulations of POs. This paper explores the unintended effects of these policies in the descriptions of why people who use opioids transitioned from PO to injection or heroin/fentanyl use.

METHODS

We conducted 148 in-depth-interviews with people who use prescription opioids nonmedically, fentanyl or heroin from a rural, urban and suburban area in three states, Connecticut, Kentucky and Wisconsin. Interviews with people who use opioids (PWUO) focused on how they initiated their opioid use and any transitions they made from PO use to heroin, fentanyl or injection drug use.

RESULTS

The majority of participants reported initiating use with POs, which they used for medical or nonmedical purposes. They described needing to take more POs or switched to heroin or fentanyl as their tolerance increased. As more policies were passed to limit opioid prescribing, participants noticed that doctors were less likely to prescribe or refill POs. This led to scarcity of POs on the street which accelerated the switch to heroin or fentanyl. These transitions likely increased risk of overdose and HIV/HCV infection.

CONCLUSIONS

A careful analysis of how and why people say they transitioned from PO to heroin or fentanyl reveals many unintended harms of policy changes to prevent overprescribing and diversion. Results highlight the importance of mitigating harms that resulted from policy changes.

Provider perspectives and experiences following the integration of the prescription drug monitoring program into the electronic health record

Prescription drug monitoring programs (PDMPs) are a public health tool for prescribers and pharmacists to monitor controlled substance use at the patient level. The objectives of this study were to (1) assess attitudes about the PDMP and perceived changes in experience and decision-making following integration into the electronic health record (EHR), and (2) identify barriers to optimal PDMP use and user recommendations for improvement. This descriptive study used an electronic survey to obtain feedback from prescribers and pharmacists at a single academic medical center. Descriptive statistics were calculated, and textual data were analyzed. Of 1480 PDMP users 208 responded (14.1%). Responses demonstrated the integration of the PDMP into the EHR simplified log-in and access to PDMP information resulting in more frequent access and perceived improvement of care quality. Barriers included technical issues accessing the PDMP within the EHR and the lack of integration of other state PDMPs. Overall, the benefit of integrating the PDMP into the EHR was positive but largely limited to streamlining log-in and patient selection. Recommendations for improvement include addressing technological issues and education on PDMP interpretation and integrating new features that may modify prescribing, referral, and co-prescribing behaviors.

Attention deficit/hyperactivity disorder in adults: A case study

Attention-Deficit/Hyperactivity Disorder (ADHD) is often misdiagnosed or mistreated in adults because it is often thought of as a childhood problem. If a child is diagnosed and treated for the disorder, it often persists into adulthood. In adult ADHD, the symptoms may be comorbid or mimic other conditions making diagnosis and treatment difficult. Adults with ADHD require an in-depth assessment for proper diagnosis and treatment. The presentation and treatment of adults with ADHD can be complex and often requires interdisciplinary care. Mental health and non-mental health providers often overlook the disorder or feel uncomfortable treating adults with ADHD. The purpose of this manuscript is to discuss the diagnosis and management of adults with ADHD.

Development and validation of a risk-score model for opioid overdose using a national claims database

Opioid overdose can be serious adverse effects of opioid analgesics. Thus, several strategies to mitigate risk and reduce the harm of opioid overdose have been developed. However, despite a marked increase in opioid analgesic consumption in Korea, there have been no tools predicting the risk of opioid overdose in the Korean population. Using the national claims database of the Korean population, we identified patients who were incidentally prescribed non-injectable opioid analgesic (NIOA) at least once from 2017 to 2018 (N = 1,752,380). Among them, 866 cases of opioid overdose occurred, and per case, four controls were selected. Patients were randomly allocated to the development (80%) and validation (20%) cohort. Thirteen predictive variables were selected via logistic regression modelling, and a risk-score was assigned for each predictor. Our model showed good performance with c-statistics of 0.84 in the validation cohort. The developed risk score model is the first tool to identify high-risk patients for opioid overdose in Korea. It is expected to be applicable in the clinical setting and useful as a national level surveillance tool due to the easily calculable and identifiable predictors available from the claims database.

Mapping the research addressing prescription drug monitoring programs: A scoping review

ISSUES

Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice.

APPROACH

A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021.

KEY FINDINGS

A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use.

IMPLICATIONS

Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement.

CONCLUSION

Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.

Key considerations for the implementation of clinically focused Prescription Drug Monitoring Programs to avoid unintended consequences

Prescription Drug Monitoring Programs (PDMP) are electronic databases that are used to track and monitor the prescribing and dispensing of controlled substances, including opioid analgesics and benzodiazepines. PDMP have been widely implemented throughout North America and are currently being introduced in Australia and some parts of Europe. PDMP were originally developed by and for law enforcement, however many jurisdictions have now shifted use toward clinical care and harm reduction through early identification of prescription dependence and extra-medical use, and to ensure appropriate supply of controlled substances to the community through monitoring health care provider prescribing and dispensing patterns (Deloitte, 2018; Picco et al., 2021a; CDC, 2021a, U.S Department of Justice, 2018). Clinically-motivated PDMP highlight medication-related risk, based on the patient's prescribing and dispensing history. Health care professionals can use this information to aid or inform clinical decision-making and provide opportunities for intervention and treatment (Deloitte, 2018) . However, a number of harms have been associated with the use of PDMP, including increased stigma and discrimination, untreated pain and mental illness, and denial of appropriate health care for those identified as 'high risk'. In this article we examine these harms and potential mitigating factors. We conclude with some suggestions and future directions for research to address some of the current uncertainties regarding PDMP use. We highlight the need for mixed methods research to better understand the personal impacts of PDMP policy on the populations they were designed to aid.

Satisfactory Pain Management With Minimal Opioid Use After Arthroscopic Rotator Cuff Repair

PURPOSE

To evaluate patient use of opioids following arthroscopic rotator cuff repair, including the number of days and number of pills when used in combination with non-opioid medications and to determine whether patients were satisfied with their pain management and if variables such as age, sex, body mass index, duration of symptoms, anticipation of postoperative pain, preoperative opioid consumption, size of the rotator cuff tear, or anxiety/depression affected pain management.

METHODS

This was a prospective cohort study of 117 prospectively enrolled patients older than the age of 18 years undergoing primary arthroscopic rotator cuff repair. All patients completed preoperative and 2-week postoperative questionnaires to assess their pain and satisfaction with pain management. Univariate and multivariate analyses were performed to evaluate the association of patient characteristics with satisfaction of pain control and amount/duration of opioids postoperatively.

RESULTS

Patients required a median of 18 opioid pain pills or 135 morphine milligram equivalents (interquartiles, 6-35 pills) postoperatively over 6.9 ± 5.1 days. In total, 65% of patients took opioid pain medications for 7 days or fewer. On postoperative day 2, patients reported a VAS pain score of 6.6 ± 2.8 and at the 2-week postoperative visit, mean visual analog scale pain score was 3.5 ± 2.5. Differences in age, sex, body mass index, duration of symptoms, anticipation of postoperative pain, preoperative 2-item Patient Health Questionnaire, 2-item Pain Self-Efficacy Questionnaire, current opioid use, and surgical characteristics had no effect on, or association with, satisfaction with pain management postoperatively.

CONCLUSIONS

Following arthroscopic rotator cuff repair, patients can achieve satisfactory pain control using a multimodal approach with a median of 18 opioid pills (range 6-35 pills) over 6.9 ± 5.1 days when used in combination with non-opioid pain medications. Overall, 74.4% of patients were satisfied with their postoperative pain management.

LEVEL OF EVIDENCE

Level II; Prospective cohort study.

How prescription drug monitoring programs influence clinical decision-making: A mixed methods systematic review and meta-analysis

BACKGROUND

Opioid prescribing, for chronic non-cancer pain, has increased substantially in the past two decades and is associated with significant harms. Various public health approaches have been adopted to address these harms including the implementation of prescription drug monitoring programs (PDMPs). This systematic review aims to identify how PDMP use influences healthcare providers' clinical decision-making.

METHODS

Six databases were searched for literature up until April 2021. Empirical studies were included, with no restrictions placed on year, location, language or study design. Thematic analysis of the identified articles was conducted and where possible, meta-analyses were conducted using a random effect model in Stata.

RESULTS

Forty-one articles related to 39 studies were included. All studies were conducted in the United States, published between 2005 and 2021 and most (n = 28) related to one state-level PDMP. PDMP utilisation influenced healthcare providers' clinical decision-making across seven broad themes: (i) the supply of controlled substances, (ii) refusal to prescribe or treat, (iii) risk mitigation strategies, (iv) communication, (v) education and counselling, (vi) referrals and care coordination and (vii) stigma.

CONCLUSIONS

PDMP use influenced healthcare providers' clinical decision-making, resulting in both intended and unintended outcomes for patients. PDMPs are a public health initiative designed to reduce harms associated with increased opioid prescribing, yet their use is associated with multiple unintended outcomes. Targeted research is needed to understand the impact of healthcare providers' clinical decision-making after PDMP utilisation, and the clinical outcomes for patients identified through these tools.

"Doctor and pharmacy shopping": A fading signal for prescription opioid use monitoring?

BACKGROUND

The term "doctor and pharmacy shopping" colloquially describes patients with high multiple provider episodes (MPEs)-a threshold count of distinct prescribers and/or pharmacies involved in prescription fulfillment. Opioid-related MPEs are implicated in the global opioid crisis and heavily monitored by government databases such as U.S. state prescription drug monitoring programs (PDMPs). We applied a widely-used MPE definition to examine U.S. trends from a large, commercially-insured population from 2010 to 2017. Further, we examined the proportion of enrollees identified as "doctor shoppers" with evidence of a cancer diagnosis to examine the risk of false positives.

METHODS

Using a large, commercially-insured population, we identified patients with opioid-related MPEs: opioid prescriptions (Schedule II-V, no buprenorphine) filled from ≥5 prescribers AND ≥ 5 pharmacies within the past 90 days ("5x5x90d"). Quarterly rates per 100,000 enrollees (two specifications) were calculated between 2010 and 2017. We examined the trend in a recently published all-payer, 7 state cohort from the U.S. Centers for Disease Control and Prevention for comparison. Cancer-related ICD-9/10-CM codes were used.

RESULTS

Quarterly MPE rates declined by approximately 73 % from 18.2-4.9 per 100,000 enrollee population with controlled substance prescriptions. In 2017, nearly one fifth of these commercially-insured enrollees identified by the 5x5x90d algorithm were diagnosed with cancer. Approximately 8% of this sample included patients with ≥ 1 buprenorphine prescriptions.

CONCLUSIONS

Opioid "shopping" flags are a long-standing but rapidly fading PDMP signal. To avoid unintended consequences, such as identifying legitimate medical encounters requiring high healthcare utilization or opioid treatment, while maintaining vigilance, more nuanced and sophisticated approaches are needed.