Does the program change opioid prescribing or patient outcomes?

Dec. 19, 2017

Story and photo by Nadir Balba

The OHSU School of Medicine's Paper of the Month for November 2017 is "Association of Prescription Drug Monitoring Program Use with Opioid Prescribing and Health Outcomes: a Comparison of Program Users and Non-Users" published in the Journal of Pain. This project was led by Richard Deyo, M.D., M.P.H., professor of family medicine, OHSU School of Medicine, who focuses on evidence-based medicine.

Its authors in descending order are, Dr. Deyo, Sara Hallvik, M.P.H., and Christi Hildebran, L.M.S.W., both from HealthInsight Oregon; Miguel Marino, Ph.D., and Rachel Springer, M.P.H., both from OHSU's Department of Family Medicine; Jessica Irvine, M.S., a consultant from the Propeller Management firm; Nicole O'Kane, Pharm.D., from HealthInsight Oregon; Joshua Van Otterloo, M.S.P.H., and Dagan Wright, Ph.D., both from the Injury and Violence Prevention Program for the State of Oregon; Gillian Leichtling from HealthInsight Oregon, Lisa Millet, M.S.H., from the Injury and Violence Prevention Program; Jody Carson, M.S.W., from HealthInsight Oregon, Wayne Wakeland, Ph.D., from Portland State University's Department of Systems Sciences; and Dennis McCarty, Ph.D., from the OHSU-PSU School of Public Health, with an appointment in the OHSU School of Medicine's Department of Psychiatry.

Fighting back against the opioid epidemic

Prescription opioid use in the United States has dramatically increased over the past two decades, and with it so have opioid-related overdoses, mortality, hospitalizations, and addiction treatment. It has been estimated that 64,000 people overdosed on opioid pain relievers in 2016 or about one every eight minutes. This rapid increase in prescription and non-prescription opioid drug use, known as the opioid epidemic, has been exceptionally difficult to combat. One response enacted by many states, including Oregon, has been the creation of Internet-based prescription drug monitoring programs, or PDMPs, which track outpatient prescriptions for controlled drugs including opioids. However, registering to use Oregon's PDMP is completely voluntary for clinicians and the effect of using the program had not been examined. The goal of this study was to evaluate Oregon's PDMP between 2011 and 2014 by comparing prescribing patterns and patient outcomes from clinicians who did, or did not, register to use the system.

Unclear effects from previous studies

Previous research on the effectiveness of statewide PDMPs have shown mixed results with some studies demonstrating critical changes in opioid prescription, while others reporting little or no change. There are also conflicting results between studies examining PDMP's effects on overdose risk, hospitalizations and mortality. Many of these studies relied on comparisons between states with and without such programs or prescribing patterns before and after PDMP implementation. 

Dr. Deyo argues that many of these analyses do not account for state-to-state variations in program design, and do not consider other confounding influences such as updated medical literature, new clinical guidelines, shifting insurance coverage policies, increased media reports and other general changes in public policy. The team decided there was a clear need to compare registrant clinicians to non-registrants in order to accurately measure the program's effect in Oregon.

Declining rates, but with a catch

What the team found was a statewide decline in several measures of opioid prescribing, including inappropriate prescriptions per person. However, the study found few differences between PDMP registrants and non-registrants, with registered clinicians actually having slightly higher prescription rates overall. There were virtually no differences in patients receiving high-risk prescriptions, which include high-dose prescriptions, overlapping opioid and sedative prescriptions, inappropriate prescriptions and prescriptions from multiple providers. Among clinicians who registered for the PDMP, frequent users and infrequent users showed similar changes in prescribing patterns and patient overdose events. What these analyses demonstrate is that opioid prescriptions declined statewide after implementing the PDMP, but registrants didn't exhibit greater declines than non-registrants.

These results were surprising and contrary to the team's overall hypothesis. Mary Heinricher, Ph.D., associate dean for basic research, OHSU School of Medicine, was equally stunned by the results and the implications of the study. "The prescription drug monitoring program has been a widely promoted tool in efforts to control the opioid epidemic. The authors' observation that providers using the PDMP did not change their prescribing behavior was not what everyone would have predicted and certainly suggests that the effectiveness of these programs needs closer examination."

Moving forward

The team hopes to build on this research and focus on implementing and rigorously evaluating PDMP refinements, including the development of best practices for clinicians in using PDMP data. 

New PDMP improvements might include the use of prescriber "dashboards" that help identify high-risk patients based on unusual prescription patterns. Other possible refinements include proactive alerts for clinicians, integration of PDMP data into electronic medical records and mandatory registration into the program. 

Previous research from this team has also indicated that clinicians vary widely in how they harness the benefits of registering with the PDMP, including the frequency of PDMP use, their responses to the data and how they discuss issues regarding opioid use with their patients. The team suggests better clinician training in using PDMP so that it may have a greater impact in the future.

Resources

• Read the paper

Citation

Deyo, Richard A., Sara E. Hallvik, Christi Hildebran, Miguel Marino, Rachel Springer, Jessica M. Irvine, Nicole O'Kane et al. "Association of prescription drug monitoring program use with opioid prescribing and health outcomes: a comparison of program users and non-users." The Journal of Pain (2017).

More Published Papers

• Previous School of Medicine Papers of the Month
• Recent OHSU published papers

Pictured above, from left to right: Dennis McCarty, Rachel Springer, Miguel Marino, Rick Deyo, Christi Hildebran.