Thursday, January 15, 2015

PMPs Are Inadequate to the Task

By Doug Brockway
January 15, 2015

A bit of background to make sure we’re on the same or similar pages.  Especially accelerating in the past few years, opioid abuse, the over use of prescription pain killers, has become a major economic and health issue in the US and a major cause of death.

Opiates, which are crucial to alleviating pain for many patients have been mismanaged and misused to our shared loss.  There are many places to get numbers.  Here’s a fairly net summary from The Incidental Economist, Austin Frackt[1].

In the summary Frackt makes two points key to this post:
  • Most opiate overdose deaths and growth in them can be traced back to prescriptions: “4 in 5 of people today who start using heroin began their opioid addiction on prescription opioids.” Clamping down on the supply of heroin alone will not address the problem.
  • U.S. clinicians “write more prescriptions for opiate painkillers each year than there are adults in the United States.”
A common and concerning trope is that average citizens are often prescribed opiates in large or refillable dosages after injury.  This often leads to dependencies.  When the prescriptions run out and/or the costs get out of hand, the much more available and cheaper street drugs, mostly heroin, become the outlet for the addict’s need.  From here we move to petty crime to support the addiction and death from misuse and overdose (see chart above).

Much has been and must continue to be done to help people recover from their addictions.  In terms of preventing them in the first place, besides public awareness, education, training within the medical, policing and treatment communities, the tool that is almost universally cited as an aide to prevention is something called a Prescription Monitoring Program (PMP). 

Operating on a state-by-state basis in almost all states PMPs require pharmacists to record into the system the data/time of fulfilling a prescription for Schedule II or III drugs (opiates), the name of the patient, who picked up the prescription, the name of the doctor, and key data about the prescription itself.

Once the data are in the PMP then doctors have the opportunity to, increasingly they are required to, look at the PMP data base to see if the patient has outstanding, repeated or high numbers of opiate prescriptions prior to writing a new one.  Similarly, the pharmacist can see the same information to help guide if a prescription should be filled based on patterns implied in the PMP data.  In this way PMPs have shown some effect in reducing “casual” or “unthoughtful” prescription of opiates, but the effect is minor compared to what should be[2].

Especially given the size and scope of the epidemic, the nature of the death and destruction that opiate addiction brings with it, Prescription Monitoring Programs as currently structured are inadequate to the task.  PMPs’ significant shortcomings include:

  • ·    The Fox is in the PMP Henhouse - When doctors and/or pharmacists are involved in the fraud the PMP is not a defense. This is a major failing of relying on PMPs.  Although very few doctors participate in scams, if, as the Boston DEA’s SAC Ferguson says, “there are too many rogue doctors and pharmacists” then we are not being diligent enough if we ask rogue doctors and pharmacists to check on themselves
  • ·    Prevention Effectiveness Requires Transactional Consistency - PMP data is subject to error in the interpretation by myriad independent physicians and pharmacists each applying their individual interpretations and doing it with different levels of diligence each time
  • ·    Design Prescription Monitoring for Operability - PMPs oblige doctors and pharmacists to examine a data base, manually, with each patient, causing delay, frustration and cost in the office. It’s as if when buying clothes at a retailer the sales clerk stops the sale to check your credit score
  • ·    Closing the In-state PMP Loop - With PMPs data are only collected for prescriptions filled, not prescriptions written.  The PMP cannot detect potential diversion prior to dispensing.  You can see doctor after doctor for at least a week before anyone notices
  • ·    In Opiate Abuse Prevention, PMP Timelinessis Godliness - PMP data are collected monthly, or at best in some states weekly.  This is not sufficient to capture diversion, which can be done intraday with patients getting prescriptions from multiple doctors and filling them at multiple pharmacies in very short periods of time
  • ·    State-by-State Doctor Shopping Prevention Silos - Because they vary, technically, by state, and because laws governing their data and use are written without sharing across state lines in mind, PMPs do not operate across state lines.  Multiple prescriptions can be written in one state and a very short time later, often minutes, filled in a nearby state with no-one the wiser.

Opiate addiction and its health and related effects is particularly destructive to people, families and communities.  Nationwide groups, towns, counties and states are trying to stem and turn the tide.  PMPs as structured are not adequate to the task.  Fortunately, there are methods to do the checking for the doctor not by the doctor, operate without new office technology and very little process change for doctors, capture prescription writing and dispensing, operate in real time, and operate across state lines.

[1] If you have the time I strongly urge you to read the insightful conversation between Harold Pollack and Keith Humphreys that Frackt links to
[2] Perhaps this is only the Hawthorne Effect where the act of looking itself changes the behavior, not the analysis of the doctor or pharmacist

1 comment:

  1. Here is a perfect example of the issue. This doctor was in a direct conspiracy with a drug dealer:

    No PMP will catch this. They do not capture prescription writing, can't establish that the patient EVER saw the doctor, can't establish that the patient saw the pharmacist in person.