AMA Asks more Docs to Check PDMPs

Thursday, July 30, 2015 | 0

The American Medical Association, one of the largest and most influential health care organizations in the country, is swinging its weight against opioid abuse by asking more doctors to use prescription drug-monitoring databases.

The AMA convened a task force to combat opioid abuse last year and released its first recommendations on Wednesday. The task force began by encouraging doctors across the country to participate in state prescription drug-monitoring programs — a tool many have lauded for the ability to stop injured workers and others from doctor shopping to obtain opioids.

PDMPs offer a database that tracks which patients have what prescriptions from which doctors and when those prescriptions are filled. Pharmacists and law enforcement officials are the most common database watchers, but in some states, prescribers are required to check the databases before they write a prescription for a Schedule II opioid. In doing so, a prescriber can see if that patient has already received a prescription from another doctor.

However, prescribers in about half the states aren’t required to check a PDMP before writing a prescription. And the data suggests that when prescribers aren’t required to check the database, they usually don’t. In Kentucky, university researchers found that only 27.5% of prescribers in the state were even registered with the PDMP in 2009 when checking the database wasn’t mandatory.

“Generally, what we see is that less than 30% of prescribers in a state will be using a PDMP if there's no requirement to use it,” said Bob Twillman, executive director of the American Academy of Pain Management.

Twillman praised the AMA for its efforts and said it was a good idea to focus on PDMPs. However, the association is treading a tricky path for doctors. In states where legislators have proposed making it mandatory for prescribers to check the database, physicians have fought back and cited inconvenience in being forced to use the sometimes clunky technology.

Twillman said he believes in prescriber mandates — to a point. For instance, he said it makes sense to require a prescriber to check the database before writing a first prescription for a patient. That serves the purpose of finding doctor shoppers. But some states go further than that, requiring prescribers to check the database every time they write a prescription for a patient.

“Every time? I think that's overkill,” he said. “The vast majority of patients don’t abuse their medications.”

The AMA task force’s recommendations earned praise from those involved in the workers’ compensation industry as well. Bruce Wood, a lobbyist for the American Insurance Association, said PDMP laws should go even further than Twillman suggested.

“We believe that requiring physicians to register and requiring physicians to check the database, virtually in all circumstances when prescribing narcotics, is essential to reducing the incentives to overprescribe and reducing the incentives for doctor shopping,” Wood said.

Wood said PDMPs have been proven to be more effective when they do require prescriber participation. He pointed to Kentucky, which saw skyrocketing usage when the state began requiring physicians to use the database in 2012.

“The number of requests from physicians in Kentucky went up 650% — 650%! Absolutely astounding,” Wood said.

Phil Walls, chief clinical officer for the pharmacy benefit manager MyMatrixx, said he’s happy that the AMA has taken a step toward using its influence to get physicians to use PDMPs.

However, he said, the association is late to the party. States and specialty medical societies have begun adopting guidelines urging prescribers to be more careful when prescribing opioids, physicians have cut back on their reliance on the drugs and the Food and Drug Administration used its “Risk Evaluation and Mitigation Strategies” program to encourage the development of abuse-resistant opioids.

“The opioid epidemic has taken a turn over the last few years. Thanks to things like the FDA’s REMS program, thanks to these PDMP databases, we're seeing a decrease in the use of prescription opioids,” he said.

The country has turned around, even in the past five years, in terms of its tone on opioid prescriptions, he said. When he attended an FDA hearing on the subject five years ago, Walls said many doctors said they didn’t see a problem with opioids, despite a growing number of addicts.

“So step one was getting doctors on board just to recognize that, 'Hey we have a problem and part of it is overprescribing,'” Walls said.

And yet, he said, more needs to be done. Now that doctors are prescribing fewer opioids, the Centers for Disease Control and Prevention has suggested that many painkiller addicts are turning to heroin. So he said there needs to be more focus on addiction treatment, not only for opioid addicts that have come from the workers’ compensation system and other places in the health care industry, but for those who have moved on to other drugs.

Patrice Harris, the chair-elect of the AMA, said the task force plans to get to that issue as well. After setting up efforts to reach out to physicians and encourage them to use state PDMPs, she said the task force plans to focus on three areas:

• Expanding access to addiction treatment centers.
• Improving the availability of naloxone, a drug that counteracts opioid overdoses.
• Removing the stigma around pain management so as to make patients feel more comfortable with seeking treatment.

Through it all, she said, the task force will look to educate prescribers, possibly through continuing education courses.

But the task force wanted to look at PDMPs first for a couple of reasons. For one, she said, they have multiple uses for prescribers. On top of identifying doctor-shopping patients, she said the databases allow prescribers to alert physicians to other drugs the patient is taking. For instance, if the patient is taking benzodiazepines, that can increase the risk of overdose.

Secondly, she said, she hopes that the increased focus will lead to improvements in state PDMPs. While she said the AMA supports state-specific systems, the variability between states has sometimes created difficulties for physicians who try to use the databases. One common problem is that the databases have trouble working with existing electronic health records that physicians have on file. So instead of being able to work in one program, they have to manually transfer information from one program to another.

Other problems include the databases only refreshing data once per week — which some suggest is too infrequent to catch doctor shoppers — and databases that don’t share information with other states.

“If I live by the border in West Virginia, it will be very important for me, probably, to have access to the PDMP in Kentucky,” Harris said.

Then there are states where PDMPs are not yet functional. Missouri is the only state in the nation not to have legislation enacted to establish a PDMP, but others have had trouble getting legislation-mandated databases up and running. In Pennsylvania, the state’s PDMP was supposed to be operational by June 1 of this year under the legislation’s mandatory timeline. But the system still isn’t running, according to Pennsylvania Department of Health spokesperson Wes Culp.

“The previous administration’s budget provided no money for operations,” Culp wrote in an email to WorkCompCentral.

Gov. Tom Wolf has, however, proposed $2.1 million for the PDMP in the next budget cycle, Culp said. That would be enough to get the system moving, and the Department of Health is moving to find a vendor to create the database.

The budget hasn’t yet been approved, Culp said, but the Department of Health has already put leadership for the program in place.

With more state PDMPs improving their operations, more physicians using them and more education available on appropriate prescribing practices, Harris said she hopes to see the health care industry find a state of moderation on opioids.

“We want to evolve to a system where those other options are available to everyone and there are a lot of tools in the toolbox and it really is right patient, right time, right treatment,” she said.