The U.S. is in the midst of an opioid crisis. Deaths from prescription painkiller overdoses have quadrupled since 1999. To combat the epidemic, 49 states1 and Washington, D.C., have built computer systems intended to detect when people try to get multiple prescriptions, either for their own use or to sell illegally. The prescription drug monitoring programs, or PDMPs, track patients who already have prescriptions for controlled substances and can alert prescribers if someone appears to be “doctor-shopping.” The problem? They often go neglected by physicians.
Now advocates want stricter laws that require doctors to use the databases. Currently just seven states mandate that prescribers check the systems before giving patients opioids in all circumstances. More require them to get patients' prescription history only if they suspect abuse. There's no reliable data on how often doctors use PDMPs, but evidence from such states as New York, Tennessee, and Kentucky show that they are used much more frequently when the law requires it.
Gary Mendell is among those pushing for the change. He founded an advocacy group called Shatterproof after his son Brian, who had struggled with drug addiction, committed suicide in 2011 at age 25. Mendell, a former hotel executive, said the government needs to respond to the opioid crisis with the urgency of an epidemic such as Ebola or Zika. “Human beings take time to change,” he said. "This will change over the next two decades unless there’s urgency to it.”
Doctors say passing a law to make people use the databases won't solve the problem. "When they are fully funded, integrated into [electronic health records], and when they provide accurate, relevant, and real-time data, they can provide helpful clinical information,” said Steven J. Stack, president of the American Medical Association, in a statement. "While some PDMPs can do this, many cannot." The doctors group “strongly supports” using the systems, Stack said, but they’re "only one piece of a much larger puzzle" to end the opioid crisis.
“There are a tremendous number of barriers that have to be overcome for PDMPs to be used regularly at the point of care,” said Caleb Alexander, co-director of the Center for Drug Safety & Effectiveness at the Johns Hopkins Bloomberg School of Public Health. He signed on to a recent report from Shatterproof calling for mandatory use of PDMPs.
For example, requiring prescribers to log on with a separate username and password is “a nonstarter” at many hospitals, Alexander said. Even if the prescribing history is integrated into the software doctors already use, it has to be delivered at the right time and in a format that doctors understand. "I think mandated use is long overdue, although the programs have to be usable enough so that it’s reasonable to mandate them,” Alexander said.
New guidelines from the Centers for Disease Control call for doctors to consult PDMPs "to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose.” They’re just one part of a renewed national strategy to reduce opioid abuse. Every state but Missouri has authorized a PDMP, and the evidence in favor of the systems is growing, said Cindy Reilly, director of the prescription drug abuse project at the Pew Charitable Trusts.
Just getting prescribers enrolled to use the systems can be a challenge. In 23 states, fewer than half of the people registered with the Drug Enforcement Agency to prescribe controlled substances were enrolled in the PDMP in 2014, according to forthcoming research from Pew.
There are some steps Reilly said states can take to make the systems function better. Allowing prescribers to delegate checking the patient’s prescription history to other staff members can ease the burden on doctors in a rush. Likewise, the PDMPs should be linked seamlessly to electronic health records. The software should be able to alert doctors to risky patterns and deliver the information in a meaningful, easy-to-understand way. While states are progressively improving their systems, Reilly said, “it’s a slow-moving train.”
Mendell says the current pace is unacceptable. “If this were Ebola, and the government thought that 30,000 people might die this year from Ebola, I don’t believe you would see evidence-based solutions and recommendations that would be implemented over the next decade,” he said. "I believe you would see solutions implemented in weeks."