Tuesday, April 18, 2017

PDMP Success and Doctor Shopping

Reuters reported in February that we are losing "91 Americans" per day to overdose. Interestingly, "since 1999, deaths from prescription opioids have quadrupled," and coincidentally so "have sales of opioids, including the painkillers oxycodone (Oxycontin) and hydrocodone (Vicodin)." This is not news. Overdose is a serious national issue.

The Reuters story goes on to describe that mandatory checking of prescription drug monitoring program (PDMP) databases reduces the "odds of doctor-shopping for opioid pain relievers." Generally, "doctor-shopping" refers to seeking a physician that will accede to the wishes of a patient. Doctor accommodation could be driven by a variety of factors including expedience, compassion, or profit. But the perception is that a patient may travel from physician to physician seeking one that will fulfill the patient's wishes.

This Reuters article highlights a recently published study by the "Substance Abuse and Mental Health Service Administration in Rockville, Maryland." According to the study, every state except Missouri has implemented a prescription-drug monitoring programs (PDMP). But, WorkCompCentral reported recently that Missouri seems to be making progress toward enacting this requirement. 

PDMPs are "state-run electronic databases designed to track prescribing of controlled substances." In the process of tracking the prescriptions, they also help "to identify people at high risk of using opioids for nonmedical purposes." Florida has had a PDMP for several years and has seen progress from the program. Other states are also seeing progress, and making adjustments to take advantage of the PDMP concept. 

The programs are categorized as "mandatory programs" and voluntary. The mandatory programs require physicians to check the database before prescribing potentially dangerous medications. Florida has a PDMP, but doctors are not required to check it prior to writing a prescription. Despite this, anecdotally it appears that pharmacists are checking the database prior to filling scripts. 

I am troubled anytime I see a discussion of prescriptions for "nonmedical purposes." That seems oxymoronic to me. Why is a doctor prescribing for "nonmedical purposes?" Doctors practice medicine, their purposes should be medical. This oxymoronic reverence is similar to statements recently voiced in regards to Ohio's efforts to stem overdose death. Ohio has legislation that bars "clinics that prescribe or dispense opioids without any legitimate purposes." Call me old fashioned, but I think that "legitimate purposes" would be a foundation of medicine generally. 

We have reached a point where medical doctors must be legislatively told to only medicate for "legitimate purposes," and not for "nonmedical purposes." That seems disappointing at best. Perhaps this is something that requires explanation, and perhaps some reader might respond and explain the reason for doctors prescribing life-threatening drugs for "nonmedical purposes." Would it make people safer if doctors writing such "nonmedical" prescriptions were simply removed from the marketplace?

Reuters reported that this Maryland study demonstrated that "in states where physicians were required to check an electronic database before writing an opioid prescription, the odds that two or more doctors would be giving pain relievers for nonmedical purposes to a single patient were reduced by 80 percent." This is a very persuasive statistic. There are effects demonstrated in non-mandatory states also. The study documented that voluntary program states saw a decrease of "doctor shopping" of 56% attributed to the PDMP.

Reuters reports that PDMPs result in the avoidance of 10 overdose deaths per day. The greatest success in decreasing death occurs in states with "the most robust" PDMP systems, and the systems in which information regarding prescriptions is most frequently updated and checked. Ten overdoses per day equated to 3,650 American lives saved annually.

There are those who believe that PDMP efforts successfully limit access to prescription opioids, but they are concerned that this success may drive users to illicit street drugs such as Heroin. Those street drugs are not supervised or limited by any physician or pharmacist observation or interaction. The cited study results did not support that fear. It contrarily "found that PDMPs did not lead to an increase in people starting to use heroin."

The gist of the study and the story is that PDMPs are a promising tool in the effort to address overdose and death issues. However, some caution that "they aren’t a panacea.” One doctor who treats the effects of opioid addiction counsels that "we really need a comprehensive approach. It isn’t one thing that will help get us out of the opioid epidemic.” So, there has to be a combination of efforts if the drug overdose pandemic is to end. But, it appears that the PDMP process is a step in the right direction, particularly for the 10 people who will live today as a result. 

Perhaps the greatest success will come from continued attention to the issue of overdose death. More education, greater awareness, and further discussion cannot hurt the cause and it might just save someone's life.

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