Transcript Use of PDMP to Improve Patient Care and Outcomes – O`Kane

Use of Prescription Drug Monitoring Programs
to Improve Patient Care and Outcomes
Nicole O’Kane, PharmD
Clinical Director
Acumentra Health
May 30, 2015
Disclosure Statement
I have no relevant, real or apparent personal
or professional financial relationships with
proprietary entities that produce health care
goods and services.
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Agenda
1. Background
2. Who uses the Oregon PDMP?
3. When and how do Oregon prescribers
use the PDMP?
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Acumentra Health
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Portland-based nonprofit consulting firm,
dedicated to improving quality, safety, and
effectiveness of health care
Collaborate with practitioners in all care
settings, and with purchasers, communitybased organizations, professional
associations, policy makers, and consumers
www.acumentra.org
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Oregon Prescription Drug Monitoring
Program (PDMP)
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•
Goal to improve health and public safety
Pharmacies submit data weekly
Includes data for all controlled substance
prescriptions dispensed to Oregon residents
Oregon-licensed providers, pharmacists, and
their staff can get authorization to access the
web-based information to manage patient
treatments
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A Socio-Ecological Model for Behavior
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Background
• PDMPs increasingly used for public
health: reduce drug abuse, improve
patient safety
• Many clinicians who prescribe
controlled drugs do not use PDMPs
• Little is known about clinician responses
to PDMP information
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Oregon Pain Guidance: Five-Step Approach
with Chronic Complex Non-Cancer Pain
1.
2.
3.
4.
5.
Practice assessment
Patient assessment
Non-opioid treatments
Patient reassessment
Follow-up visits
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Use of Prescription Monitoring Programs
to Improve Patient Care and Outcomes
•
5-year grant (2012‒2017) to study
effectiveness of the Oregon Prescription
Drug Monitoring Program as a clinical
decision tool for prescribers of controlled
substance medications
Supported by the National Institutes of Health, National Institute for
Drug Abuse through Grant # 1 R01 DA031208-01A1, and by the
National Center for Research Resources and the National Center for
Advancing Translational Sciences, through grant UL1RR024140
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Research Partnership
• Acumentra Health
• Oregon Health Authority
• Principal investigator Richard A. Deyo,
MD, MPH, Oregon Health & Sciences
University
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Study Aims
AIM 1:
Determine the prevalence and characteristics
of PDMP users and non-users
AIM 2:
Determine how providers use PDMP data;
formulate recommendations for clinical guidelines
AIM 3:
Determine whether use of PDMP improves patient
outcomes and reduces apparent diversion/abuse
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5000
Cumulative Number of System Accounts
4500
Cumulative System Accounts
4000
3500
3000
2500
Delegates
MD / DO
NP / CNS-PP / PA
DDS/DMD
RPh
2000
1500
1000
500
0
*Delegates were granted
access starting in Q1 2014
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2011 2012 2012 2012 2012 2013 2013 2013 2013 2014 2014 2014 2014
Calendar Quarter
1600
New System Accounts
Number of New System Accounts
1400
1200
1000
Delegates
MD/DO
NP / CNS-PP / PA
DDS/DMD
RPh
800
600
400
*Delegates were
granted access
starting in Q1 2014
200
0
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2011 2012 2012 2012 2012 2013 2013 2013 2013 2014 2014 2014 2014
Calendar Quarter
120000
Total Queries by Discipline
Total Number of System Queries
100000
80000
Delegates
MD (PA, DO)
NP / CNS-PP
DDS/DMD
RPh
60000
40000
*Delegates were
granted access starting
in Q1 2014
20000
0
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
2012 2012 2012 2012 2013 2013 2013 2013 2014 2014 2014 2014
Calendar Quarter
Number of Users Submitting Queries
5000
Number of Users Submitting Queries
Delegates
4500
MD (PA, DO)
4000
NP / CNS-PP
DDS/DMD
In 2012 - 2013, unique users
were counted monthly (and
summed quarterly)
3500
3000
RPh
In 2014, unique users
were counted quarterly
2500
2000
1500
1000
* Delegates were granted access
starting in Q1 2014
500
0
Q3
2012
Q4
2012
Q1
2013
Q2
2013
Q3
2013
Q4
2013
Calendar Quarter
Q1
2014
Q2
2014
Q3
2014
Q4
2014
2014 Oregon PDMP Annual Report
• Only 42% of prescribers who write
prescriptions for scheduled drugs have
a PDMP account
• Of the 4,000 most frequent prescribers
of scheduled drugs, only 66% have a
PDMP account
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How Providers Use PDMP
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Surveyed a sample of all Oregon clinicians
with DEA license
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Randomly selected 650 frequent users
(>1 query per month)
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Of 358 frequent users who returned a survey,
212 agreed to a follow-up interview
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Follow-up telephone interviews (n=33)
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Interview Participants
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Survey Results: Topics for Learning
1. Workflow
2. Communication
3. Decision-Making
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Workflow Topics
• When do providers
check PDMP?
 Routine versus triggered
by “red flag” or suspicion
 New Rx/patient versus
existing patient
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Results: Workflow
• Inconsistent use of routine PDMP checks
 Some emergency and procedural
specialists check routinely when
controlled substance is requested; others
rely on red flags such as patient behavior
 Many PCPs check routinely with new
patients; for ongoing monitoring with
existing patients, some rely on red flags
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Quotes: Routine vs. Triggered Checks
“If somebody immediately starts negotiating their
pain medicine or telling me they’ve lost a
prescription and/or they’re new to town ― and
usually they would say several of those things ―
that’s clearly a red flag. But it wouldn’t even take
something that overt. If they’re hinting at…they’re
low on their medication, and it’s the weekend and
they haven’t been able to get in with their doctor,
that’s all it usually takes to prompt me to consider
or just go ahead and use the Prescription Drug
Monitoring Program.”
– Emergency Room Physician
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Quotes: Routine vs. Triggered Checks
“I started trying to be less discriminating. If pain
is the issue and if I think pain medications are
going to be a question, I’ve tried to start doing it
almost across the board with those people
before I walk into the room. I’m not going to try
to pick and choose so much, I’m going to try to
do it on most if not all of the people I’m seeing.”
– Emergency Room Physician
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Quotes: New vs. Existing Patients
“The new patient that's coming in asking for opiates
is going to get at least checked immediately. With
existing patients, it will depend on the situation. If I
see them frequently wanting medications, maybe
after the first or second time, I'll check them. It
really depends on what they're asking for. It
depends on the feel that I’m getting from the
patient. I don’t have a thing I do for every patient.”
– Primary Care Clinician
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Communication Topics
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Ways in which providers discuss
worrisome reports with patients
Policies or guidelines that
influence checking the PDMP
and/or prescribing
Ways in which providers
discuss PDMP information to
assess patient medication
compliance and ongoing care
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Quotes: Ways Providers Discuss
Worrisome Reports with Patients
• Openly discussing and sharing PDMP
results with the patient
“For me, it’s a chance to be hopefully less
judgmental…and an opportunity to broach the
topic. And in an objective, non-judgmental way, to
say, ‘Look at this: you’re 20 years old and I see
you’ve gotten 160 Vicodin over the last month.’”
– Emergency Room Physician
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Quotes: Ways Providers Discuss
Worrisome Reports with Patients
• Withholding PDMP results and keeping
them a secret
“It’s a cat and mouse thing. I keep it secret as
much as possible because it’s better used if it’s
kept quiet. I can catch the patient unaware…It’s
much better for me to have information and I
can discover things that are happening. You
have to be a bit of a detective.”
– Primary Care Physician
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Quotes: Ways Providers Discuss
Worrisome Reports with Patients
• Avoid discussing PDMP results with the
patient
“I never confront them with the evidence from
the PDMP. I write it up in the chart, so the chart
indicates 18 prescriptions for controlled
substances, from six providers over the last
year…I’ll flag his chart as drug seeking and that
will be his number one diagnosis.”
– Primary Care Physician
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Quotes: Policies or Guidelines That Influence
Checking the PDMP and/or Prescribing
• Discussing PDMP as part of agency policy
or guideline
“I tell them that as part of our clinic policy, I
need to log in and see if they’re getting these
prescriptions from another prescriber. It also
helps me to tell them about the policy, the
contract that we will have them sign if they start
getting them long-term from us.”
‒ Primary Care Clinician
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Quotes: PDMP Information Communicated as
a Tool to Assess Patient Medication Usage
• Discussing PDMP results routinely as
part of the visit
“I communicate much of the time that, ‘It looks
like you’ve been filling your Ambien about two
weeks late, so it looks like you haven’t been
using it every night. What have you been doing
to help yourself sleep on the nights that you
don’t take it?’”
‒ Psychiatrist
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Decision-Making Topics
•
Prescribing decisions in light of worrisome
PDMP profile
 New/episodic patients
 Existing patients
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Referrals
 Emergency/procedural specialist referral to PCP
 Referral to behavioral health provider
•
Discharge from care
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Results: Prescribing and New Patients
•
Clinicians generally won’t prescribe for
new patient with worrisome profile
 Some PCPs/clinics had policies against
prescribing at first visit or until specific
conditions met
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Clinicians will prescribe for verifiable acute
condition (e.g., broken bone) regardless
 Emergency and procedural specialists
generally won’t prescribe for chronic pain
conditions unless authorized by PCP
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Quotes: New Patients
“I just say, ‘I see you’ve gotten multiple scripts
filled from multiple providers. I just need to look
into this some more, and I’ll see you back in X
amount of time, hopefully when I’ve gotten the
records, and we can figure out what else we’re
going to do for your anxiety or pain management.’”
– Primary Care Clinician
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Quotes: New Patients
“I’ll bring the PDMP report back with me and I’ll
say, ‘I want to get clear on the information we
discussed. You told me you take a Vicodin once in
a while, but I have access to your prescription
history and when I looked it up, I see you’re getting
a regular prescription for this many from Dr. Soand-So, and that’s more than once in a while. So I
want you to know before we do treatment, I will not
be able to prescribe you any narcotics in addition
to what you're already getting.’”
– Dentist
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Survey Results: Prescribing and
Existing Patients
• Some clinicians discontinue ongoing Rx
automatically at worrisome profile
 Violation of medication agreement
•
For some, depends on patient circumstances
 If continue Rx: revisit medication agreement,
more frequent monitoring, shorten refill/visit
schedule, behavioral health visit
•
If discontinue Rx: some taper, others do not
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Quotes: Existing Patients
“If they’ve gone to other prescribers, I’ve found
it’s most commonly dentists and they don’t think
of it as the same thing…I am aware of the kind
of mistakes that people make, but when
somebody has been to an ER three times in the
last month and hasn’t told me, and got
prescriptions every time, I simply say, ‘That’s a
violation and I can no longer prescribe for you.’”
– Primary Care Clinician
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Quotes: Existing Patients
“It depends on their history and the risk of addiction
and abuse. We do a risk evaluation when they first
come in, so they’re either a mild, moderate, or highrisk patient. If they’re a high-risk patient and
something happens, then it’s a lot more severe
what I do. If they’re a moderate or low-risk patient,
chances are I might not be as controlling. I might
just say ‘Okay, you did this ― now we’re reiterating
that this is our policy. You can’t do this again.’ Then
I’ll watch their drug monitoring program a lot closer
and maybe do urine drug screens more frequently.”
– Primary Care Clinician
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Survey Results: Referral and Discharge
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Some emergency and procedural specialists
refer patient to primary prescriber/PCP, or
may contact PCP to ask about prescribing
PCPs and clinicians who provide ongoing
prescribing had varied responses
 Some may discharge if worrisome report;
others will not
 Most offer referrals and/or alternatives
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Quotes: Referral to PCP/Pain Specialist
“If I feel like they have a legitimate reason for
wanting more, sometimes I will call their
medical doctor or whoever’s been prescribing
all the other pain medicine, and talk to them to
see if they feel comfortable with me giving the
patient more, or ask them if the patient has a
legitimate reason for being out.”
– Dentist
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Quotes: Referral to PCP/Pain Specialist
“We are not going to manage medications,
narcotics at least, for long periods of time. So
when I get into situations like that, I would
rather refer them to somebody that is better
suited to handle a longer-term situation. Or if I
think that they’re going to be a problem,
somebody that needs to be monitored a little
more closely with urine drug screens and things
like that.”
– Surgical Specialist
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Quotes: Discharge
“Usually the people I choose to discharge from my clinic
are the ones who have been getting narcotics multiple
other places and haven’t been honest with me.”
– Primary Care Clinician
“You have to be a really bad person to get discharged
from our practice…I think as clinicians, a lot of times we
hide behind the Hippocratic Oath or behind this side
that we don't want to hurt anybody. Well, we already got
all those patients on these medications. It's best that
you work with them to turn the ship.”
– Primary Care Clinician
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Conclusions: Workflow
• Routine use of PDMP vs. triggered by
red flags
 Some emergency and procedural specialists
do not check routinely
 Some PCPs check routinely only with new
patients; for ongoing monitoring, rely on red
flags
• Need for guidance:
 What policies or guidelines support optimal
use of PDMP?
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Conclusions: Communication
• Some discuss PDMP results openly;
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others hold back PDMP results to unearth
patient dishonesty
Need for guidance:
 What works best in engaging patient?
 What should be the role of episodic providers
in discussing concerns with patient?
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Conclusions: Decision-Making
• Clinicians are not likely to prescribe for
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new patients with worrisome profile
Decisions related to existing patients are
varied
Need for guidance:
 For existing patients, when to taper,
discontinue, or continue prescription?
 What is the optimal care related to discharge
in response to a worrisome profile?
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Recommended Next Steps
1. Understand when it is optimal for
providers to access PDMP
2. Understand how the various ways of
communicating PDMP results may
affect provider-patient relationship and
ongoing patient engagement
3. Understand how clinic policies or
guidelines may affect provider actions
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Contact Information
Nicole O’Kane, PharmD
Acumentra Health
[email protected]
Project Funding:
National Institute on Drug Abuse, 1R01DA031208-01A1
For more information, please visit:
http://www.acumentra.org/PDMP/
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