Optimal Implementation of Prescription Drug Monitoring Programs in the Emergency Department

Factors associated with prescription drug monitoring program utilisation: a cross-sectional survey of community pharmacists

BACKGROUND

Prescription drug monitoring programs (PDMP) are databases which collect prescribing and dispensing information for high-risk medicines, and are one approach to mitigate prescription opioid-related risks.

AIM

To examine correlates of PDMP use under voluntary and mandatory conditions, among a representative sample of community pharmacists in Victoria, Australia.

METHOD

An online anonymous survey was conducted and collected data in relation to pharmacist and pharmacy characteristics, comfort in performing certain tasks, PDMP training and the frequency of PDMP use under voluntary and mandatory conditions. Multivariate logistic regression models were performed to determine the effect of each covariate on voluntary and mandatory PDMP use.

RESULTS

In total, 265 pharmacists participated (response rate 47%). Under voluntary conditions, a quarter of pharmacists (24.9%) used the PDMP all the time, while half (51.7%) used the PDMP all of the time, once mandated. Pharmacies that stocked naloxone (OR: 1.96; 95% CI 1.11-3.45) and pharmacists that had attended formal PDMP training (OR: 1.78; 95% CI 1.05-3.05), were significantly associated with regular PDMP use under voluntary conditions. Under mandatory conditions, increased odds of PDMP use were associated with pharmacies that stocked naloxone (OR: 1.88; 95% CI 1.06-3.34). Pharmacists working in regional and rural areas had significantly lower odds (OR: 0.35; 95% CI 0.20-0.63) of always using the PDMP, as did pharmacists with > 15 years' experience (OR: 0.24; 95% CI 0.11-0.51) once use was mandated.

CONCLUSION

Given that PDMP utilisation was slower or less regular amongst pharmacists located in regional and rural areas, pharmacists with more years of experience and those not already supplying naloxone, targeted training aimed at these sub-populations may be beneficial.

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.

Optimization of Prescription Drug Monitoring Program to Overcome Opioid Epidemic in West Virginia

The development of the Prescription Drug Monitoring Program (PDMP) led to an innovation in the healthcare organization system (HCOs). The PDMP system has been utilized in different states at various organizational levels in an effort to achieve improved health outcomes, reduce the number of prescription drug overdoses, and lighten the economic burden that follows. However, during the implementation of PDMP, there were several barriers and limitations that were discovered. Those barriers impeded the process of utilization of PDMP, such as the complex user interface and lack of training for healthcare providers. The purpose of this paper was to examine the advances and limitations in the utilization and implementation of PDMP in the US healthcare industry and develop strategies for effective use of PDMP in West Virginia.

The qualitative part of this paper was a literature review. The paper referred to several peer-reviewed studies and research articles from several reliable resources, which were reached by databases or Google Scholar. A total of 44 articles were reviewed for this study.

The implementation of the PDMP was influenced by benefits and barriers. This article reviewed several studies in general that demonstrated positive outcomes from the implementation of PDMP, including a reduced number of prescription drug overdoses, coordinated care for patients, and improved health outcomes. However, the barriers and limitations were not neglected, which mainly include integration of PDMP into the electronic health record (EHR) system, lack of training for the providers, and lack of basic standards for the use of PDMP.

Although the new health reforms encouraged the adaption of PDMP among providers, data reporting and data interpretation still remain major concerns for assessing the health outcomes of PDMP implementation.

Evaluation of Interventions to Reduce Opioid Prescribing for Patients Discharged From the Emergency Department: A Systematic Review and Meta-analysis

Importance

Limiting opioid overprescribing in the emergency department (ED) may be associated with decreases in diversion and misuse.

Objective

To review and analyze interventions designed to reduce the rate of opioid prescriptions or the quantity prescribed for pain in adults discharged from the ED.

Data Sources

MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Controlled Register of Trials databases and the gray literature were searched from inception to May 15, 2020, with an updated search performed March 6, 2021.

Study Selection

Intervention studies aimed at reducing opioid prescribing at ED discharge were first screened using titles and abstracts. The full text of the remaining citations was then evaluated against inclusion and exclusion criteria by 2 independent reviewers.

Data Extraction and Synthesis

Data were extracted independently by 2 reviewers who also assessed the risk of bias. Authors were contacted for missing data. The main meta-analysis was accompanied by intervention category subgroup analyses. All meta-analyses used random-effects models, and heterogeneity was quantified using I2 values.

Main Outcomes and Measures

The primary outcome was the variation in opioid prescription rate and/or prescribed quantity associated with the interventions. Effect sizes were computed separately for interrupted time series (ITS) studies.

Results

Sixty-three unique studies were included in the review, and 45 studies had sufficient data to be included in the meta-analysis. A statistically significant reduction in the opioid prescription rate was observed for both ITS (6-month step change, -22.61%; 95% CI, -30.70% to -14.52%) and other (odds ratio, 0.56; 95% CI, 0.45-0.70) study designs. No statistically significant reduction in prescribed opioid quantities was observed for ITS studies (6-month step change, -8.64%; 95% CI, -17.48% to 0.20%), but a small, statistically significant reduction was observed for other study designs (standardized mean difference, -0.30; 95% CI, -0.51 to -0.09). For ITS studies, education, policies, and guideline interventions (6-month step change, -33.31%; 95% CI, -39.67% to -26.94%) were better at reducing the opioid prescription rate compared with prescription drug monitoring programs and laws (6-month step change, -11.18%; 95% CI, -22.34% to -0.03%). Most intervention categories did not reduce prescribed opioid quantities. Insufficient data were available on patient-centered outcomes such as pain relief or patients' satisfaction.

Conclusions and Relevance

This systematic review and meta-analysis found that most interventions reduced the opioid prescription rate but not the prescribed opioid quantity for ED-discharged patients. More studies on patient-centered outcomes and using novel approaches to reduce the opioid quantity per prescription are needed.

Trial Registration

PROSPERO Identifier: CRD42020187251.

Effect of a Prescription Drug Monitoring Program on Emergency Department Opioid Prescribing

INTRODUCTION

Our goal was to determine whether implementation of a prescription drug monitoring program (PDMP) altered emergency department (ED) opioid prescription rates overall and in patients of different pain severities.

METHODS

We conducted this single-center, retrospective review at an academic ED. The study examined patients discharged from the ED who received opioid prescriptions, before and after the state's implementation of a PDMP (August 25, 2016). The monthly rate was a ratio of the patients given ≥ 1 opioid prescription to the ED patients with a numeric pain rating scale (NPRS) > 0. We performed an interrupted time series analysis on each demographic.

RESULTS

The overall ED opioid prescription rate decreased from 51.3% (95% confidence interval [Cl], 50.4%-52.2%) to 47.9% (95% Cl, 47.0%-48.7%). For males, this decreased from 51.1% to 46.7% (P < 0.0001), while in females it did not significantly change (51.6% to 49.7% [P = 0.0529]). For those with mild pain, the rate increased from 27.5% to 34.3% (P < 0.0001), while for those with moderate pain, it did not significantly change (42.8% to 43.5% [P = 0.5924]). For those with severe pain, the rate decreased from 66.1% to 59.6% (P < 0.0001).

CONCLUSION

We found that PDMP implementation was associated with an overall decrease in opioid prescription rates, and that patients with mild pain were prescribed opioids more often while severe pain patients were prescribed opioids less often.

Barriers and facilitators to PDMP IS Success in the US: A systematic review

INTRODUCTION

Prescription Drug Monitoring Programs (PDMP) help prevent prescription drug misuse and promote appropriate pain management. Despite these benefits and PDMP mandates in most states, PDMPs face challenges that hinder their success. This paper uses the Delone and McLean Information Success (IS) Model to review the current literature for barriers and facilitators to PDMP quality, use, intention to use and user satisfaction in the United States (U.S.).

MATERIAL AND METHODS

Scopus, PubMed and Embase databases were searched due to their relevance to information technology, education and research.

RESULTS

There were 142 and 183 barriers and facilitators, respectively, found in 44 peer reviewed articles. Barriers to PDMP quality, use and user satisfaction include lack of interstate data sharing, access difficulties, lack of time, inability to delegate access, lack of knowledge or awareness of the PMDP, and lack of EHR integration. Facilitators to PDMP quality, use and user satisfaction include interstate data connections, real-time data updates, EHR integration, and access delegation.

DISCUSSION

Interstate data sharing, EHR integration and expanding access to delegates were common themes found. Some results were found to be contradictory such as mandating use.

CONCLUSION

PDMP users can use these findings to assess current barriers to PDMP success in the U.S. and draw possible solutions from the list of facilitators. Practitioners should consider the context of their state and organization when determining which facilitators would most promote PDMP IS success. Combining facilitators may be the best route to PDMP IS success in certain situations.

Self-reported sleep disturbance in ambulance attendances for suicidal ideation and attempted suicide between 2012 and 2017

BACKGROUND

Sleep disturbances are among the top-ten warning signs for suicide, however there has been limited investigation of the relationship between these variables in acute presentations, particularly community settings. We examined ambulance attendances for suicide ideation and attempt to explore the role of sleep and co-morbid factors (mental health symptoms, attendance time, and alcohol and benzodiazepine use).

METHODS

Coded clinical records from Ambulance Victoria for the period 1 January 2012 to 30 June 2017 were analysed.

RESULTS

Paramedics attended 97,198 cases of suicidal ideation or suicide attempt during the study period. Just over half (56.4%) of these were for suicidal ideation, and 43.6% were for attempted suicide. Depression symptomology-related attendances were more common than those for anxiety and despite a lower proportion of both sleep and current anxiety-related symptoms, benzodiazepine use was significantly more common in attendances for suicide attempts (25.9%) than for ideation (2.2%). Co-morbid benzodiazepine use was associated with attempted suicide (OR: 10.37 (10.04-10.72), in a hierarchical regression model.

LIMITATIONS

Data represent self-report/paramedic observation only, and do include validated measures of sleep or drug use. Sleep disturbance is likely under recorded in ambulance attendances given the primary role of paramedics is to stabilise patients, and minimise risk of harm during transport.

CONCLUSION

This study reports internationally unique data, and provides the first examination of ambulance coded clinical records for suicide ideation and attempt. Sleep disturbances had a unique role in these attendances, over and above common co-occurring factors including drug use and mental health diagnoses.

Barriers to Utilization of Prescription Drug Monitoring Programs Among Prescribing Physicians and Advanced Practice Registered Nurses at Veterans Health Administration Facilities in Oregon

Objective

To identify barriers to using state prescription drug monitoring programs (PDMPs) among prescribing physicians and advanced practice registered nurses across a variety of Veterans Health Administration (VA) settings in Oregon.

Design

In-person and telephone-based qualitative interviews and user experience assessments conducted with 25 VA prescribers in 2018 probed barriers to use of state PDMPs.

Setting

VA health care facilities in Oregon.

Subjects

Physicians (N = 11) and advanced practice registered nurses (N = 14) who prescribed scheduled medications, provided care to patients receiving opioids, and used PDMPs in their clinical practice. Prescribers were stationed at VA medical centers (N = 10) and community-based outpatient clinics (N = 15); medical specialties included primary care (N = 10), mental health (N = 9), and emergency medicine (N = 6).

Methods

User experience was analyzed using descriptive statistics. Qualitative interviews were analyzed using conventional content analysis methodology.

Results

The majority of physicians (64%) and advanced practice registered nurses (79%) rated PDMPs as “useful.” However, participants identified both organizational and software design issues as barriers to their efficient use of PDMPs. Organizational barriers included time constraints, clinical team members without access, and lack of clarity regarding the priority of querying PDMPs relative to other pressing clinical tasks. Design barriers included difficulties entering or remembering passwords, unreadable data formats, time-consuming program navigation, and inability to access patient information across state lines.

Conclusions

Physicians and advanced practice registered nurses across diverse VA settings reported that PDMPs are an important tool and contribute to patient safety. However, issues regarding organizational processes and software design impede optimal use of these resources.

Interstate data sharing of prescription drug monitoring programs and associated opioid prescriptions among patients with non-cancer chronic pain

All fifty states have implemented prescription drug monitoring programs (PDMPs) to reduce misuse and diversion of controlled drugs. Interstate PDMP data sharing has been called for by clinical practitioners, but evidence to support the effectiveness of PDMP data sharing is lacking. This study examined whether PDMP interstate data sharing with bordering states was associated with prescriptions of opioids. This was a cross-sectional study that included patients with non-cancer chronic pain from the 2014 National Ambulatory Medical Care Survey (weighted N = 66,198,751; unweighted N = 2846). Multinomial logistic regression was performed to examine the association between PDMP interstate data sharing status and patients' being prescribed opioids for pain treatment, controlling for covariates guided by the Eisenberg's model of physician decision-making. Findings indicated that patients residing in states with interstate PDMP data sharing with all or partial bordering states were not less likely to be prescribed opioids compared to those living in states without interstate data sharing. Other factors such as patient age, health insurance type, new patient status, and physician adoption of electronic medical records were associated with the likelihood of patients' being prescribed opioids. This study concluded that current practice of interstate PDMP data sharing with bordering states was not associated with patients' being prescribed opioids for non-cancer chronic pain treatment. Future studies and policy efforts that unravel technological, legal, and political barriers to reciprocal and equal interstate data sharing with bordering states should be warranted to inform PDMP redesign and in turn, augment overall PDMP effectiveness in reducing misuse of prescription opioids.

Emergency department provider and facility variation in opioid prescriptions for discharged patients

STUDY OBJECTIVE

To study the variation in opioid prescribing among emergency physicians and facilities for discharged adult ED patients.

METHODS

We conducted a retrospective analysis of ED visits from five U.S. hospitals between January and May 2014 using records from Data to Intelligence (D2i). We examined physician- and facility-level variation in opioid prescription rates for discharged ED patients. We calculated unadjusted opioid prescription rates at the physician and facility levels and used a multivariable mixed-effect logistic regression model to examine within-facility physician variation in opioid prescription adjusting for patient and situational factors including time of presentation, ED census, and physician workload.

RESULTS

In 47,304 visits across five EDs, median patient age was 40 years old (IQR 28,55), and 89% had some form of insurance. There were 17,098 (36%) ED discharges with at least one opioid prescription. The unadjusted facility-level opioid prescription rate ranged from 24%-46%. Among 253 ED physicians, the adjusted opioid prescription rate varied from 22%-76%. Increased physician workload is related to decreased odds of opioid prescription at ED discharge for the lowest (<3 patients) and moderate (6-9 patients) physician workload levels, while the association weakened with increasing levels of workload.

CONCLUSION

There was substantial physician and facility variation in opioid prescription for discharged adult ED patients. Emergency physicians were less likely to prescribe opioids when their workload was lower, and this effect diminished at high workload levels. Understanding situational and other factors that explain this variation is important given the rising U.S. opioid epidemic and the need for urgent intervention.