Every state except Missouri has functioning prescription drug monitoring programs that collect data from pharmacies on all dispensed controlled substances.
In view of rising opioid abuse and overdose deaths, St Louis County took the reins to establish Missouri’s first prescription drug monitoring program since legislators in Missouri were unable to devise a statewide program.
The St. Louis County Prescription Drug Monitoring Program (PDMP) -- the Phelps County Commission voted to join on Thursday, August 9 -- monitors the prescribing and dispensing of schedule II-V controlled substances to help in the identification and prevention of prescribing rates that cause prescription misuse and abuse, according to Emily Varner, of St. Louis County PDMP, who originally pitched the program to the Phelps County Commission on July 31, 2018.
Before Phelps County officially joins the monitoring program the county will have to enact an ordinance authorizing participation in the PDMP and sign a User Agreement with St. Louis County, where all prescriptions dispensed within Phelps County must be reported to the St. Louis County PDMP, including mail-order prescriptions.
This remains the case for every jurisdiction with PDMP legislation, according to Varner, because the St. Louis County Department of Health operates the PDMP on behalf of all of the participating jurisdictions, and it is up to each jurisdiction to include an enforcement clause.
St. Louis County states that in-compliant pharmacies face a punishment of up to a year in jail or a $1,000 fine or both, said Varner, yet other jurisdictions in the PDMP have no enforcement clause.
The PDMP was initially implemented April 25, 2017, in St. Louis County and is intended to track habits of both prescribers and patients, but the effectiveness of PDMPs vary because some states mandate its use while others don’t, including The St. Louis County PDMP where prescribers within the participating jurisdictions aren't forced to check the PDMP before writing a prescription.
“Pharmacies do have to submit the information to the PDMP, but no one has to use it as far as clinical care,” said Varner, which raised the question from Presiding Phelps County Commissioner, Randy Verkamp, if pharmacies or practitioners can be held liable for not checking the PDMP for drug interactions with prescriptions.
The question of liability, and if action can be taken against prescribers writing scripts without checking the PDMP or pharmacists filling a prescription where an adverse drug interaction happens, and they chose not to use the PDMP to look at the patient's medical history, is not the St. Louis County PDMP’s place to regulate.
“It’s a tool for health care providers, but we are not going to come after a provider for using or not using the PDMP,” said Varner. “We as a local government agency can’t regulate patient care as the statewide boards can.”
However, prescribers are encouraged to use the PDMP, said Varner. But whether PDMP use can truly impact the opioid crisis is yet to be determined, and Varner notes that it will never be expected that every single patient is searched through the PDMP before a script is filled.
“In July (2018) we are running a little over 4,000 patient searches per day,” said Varner, while there are 12,856 approved users in the system.
A 2017 study by University of Texas Health Science Center at San Antonio and Northwestern researchers found PDMP use effects remain varied because using the PDMP before writing a prescription for opioids may be mandatory or optional.
States also vary in the responsibility they place upon providers for any adverse outcomes associated with misuse or abuse by their patients, where the St. Louis County PDMP imposes no liability upon providers as a result of being a government agency and not having the wherewithal a statewide board has in regulating patient care.
As a result of the study, researchers found that the timeliness and accuracy of PDMP data vary considerably across states, as does the frequency and consistency of use by providers.
Researchers found an underlying link between the use of PDMPs and a reduction of misuse and diversion. Further, many of the programs provide a detailed prescribing history of a patient over the duration of three months.
While the use of PDMPs reduces the number of opioids prescribed within a state, the researchers noted many issues that PDMPs could impact, primarily, the ‘chilling effect,’ which could strip patients of necessary pain medications causing long-term consequences.
Further, even when opioid prescriptions were reduced, the researchers found that it didn’t minimize overdose mortality rates in states overall. The presence of a PDMP helped to slow the increase in rates of misuse but did not achieve reductions in all-around abuse.
Prescribers, therefore, are an essential link in addressing the current epidemic of overdose deaths and substance use disorders. The challenge is to develop and implement systems that help prescribers identify potential cases of misuse or diversion, while still allowing appropriate prescribing of opioids for pain control, the researchers concluded.
The St. Louis County PDMP is a step in the right direction according to Varner who acknowledges that The PDMP is not alone going to solve the problem of the increasing number of overdose deaths in recent years from opioid misuse.
When it comes to the ‘chilling effect,' she points out there is always a chance that the PDMP will cause a provider to stop patient care or not to fill a script, but that is something the PDMP recommends against.
“We don’t want the PDMP used against patients; it’s a prevention tool, to help prevent opioid abuse,” said Varner.
With Phelps County voting to join the PDMP, healthcare providers will soon be able to search any county participating in the program for information on patients.
The program provides alerts for providers that the online system generates if a patient has three or more prescribers or three or more pharmacies they use to fill prescriptions, which will show up in the patient report for anyone authorized to accesses the information.
The PDMP system shows prescription history, prescribers who write prescriptions for the patient and any dispensaries that fill the prescriptions across every jurisdiction that is part of the PDMP system.
The alert section will also allow authorized users to see the past six months of how many prescribers and pharmacies a patient has, and even up to two years of history, except Phelps County doesn’t have enough data for the extent of two years of patient history, according to Varner.
“It will take a long time to see the decrease since it’s been generations and generations that have affected the opioid epidemic,” concluded Varner. “This is one tool that can provide a resource to help with abuse of prescriptions in Phelps County."