Prescription Drug Monitoring Programs - PDMP Center of Excellence

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Prescription Drug Monitoring Programs: An Assessment of the Evidence for Best Practices 40the federal certification to accept and enroll users in their PDMPs, thus saving the prescriber fromduplicative authentication procedures and expediting the PDMP enrollment procedure. This kind ofstudy is urgent as e-‐prescribing of controlled substances is expected to advance quickly, especially asNew York State has passed a 2012 statute mandating e-‐prescribing of controlled substances within a fewyears.Barriers to adoption: Barriers to streamlining certification and enrollment processing include lack ofsecure online information systems that can replace in-‐person notarization as a means to authenticateapplicants. In particular, the need exists to explore federal certification of prescribers to issue electronicprescriptions for controlled substances, as a shortcut in state authentication systems.SummaryRationale: Streamlined certification and enrollment processes may increase enrollment and utilization.Evidence of effectiveness: Accumulated experience, key stakeholder perceptions.Current adoption status: A few states have explored various steps in streamlining enrollment.Barriers to adoption: Lack of information systems and validated processes that would facilitatecertification and enrollment, including possible use of federal certification of prescribers for electronicprescribing.4. Mandate enrollmentRationale: In most states with operational PDMPs, enrollment and utilization are voluntary. This makesit necessary for states to conduct recruitment campaigns to increase awareness of the PDMP and induceprescribers and pharmacists to enroll (see 2. Conduct recruitment campaigns, above). Such campaignscan be expensive, resource-‐intensive, and time-‐consuming; PDMP administrators frequently report thatcampaigns fail to produce high rates of participation. Another option, not yet widely adopted butgaining in prevalence, is to make enrollment in a PDMP mandatory for certain user groups, such asprescribers and dispensers (NAMSDL, 2012a).Evidence of effectiveness: The effectiveness of prescriber-‐‐ and pharmacist-‐mandated enrollment inproducing greater utilization of PDMPs needs to be assessed, taking into account any unintendedconsequences, such as resistance on the part of some doctors to a perceived regulatory burden and/orinfringement on their autonomy, or the inability of enrollment and certification systems to handle a surgeof applications. One PDMP has expressed concern about a legislative mandate for enrollment because itmay not provide funding for processing applications. Examining states’ experience could shed light onwhether mandates are more successful than voluntary campaigns in producing high rates of enrollmentand utilization, and if so, which ancillary systems and policies enable successful mandates. Utah, with arelatively small number of prescribers, has been able to implement mandated enrollment using itsadvanced health management information system. How and whether larger and less technologicallyadvanced states could carry out such a mandate are open questions needing investigation.Current adoption status: Since 2007, Arizona has required that practitioners who possess a registrationunder the U.S. Controlled Substances Act must also be registered with the PDMP. Utah has recently (July
Prescription Drug Monitoring Programs: An Assessment of the Evidence for Best Practices 412010) mandated that prescribers join its PDMP, making enrollment a prerequisite for practitioners torenew their federal or state licenses to prescribe controlled substances. More than 90 percent of thosewith licenses to prescribe controlled substances in Utah are now enrolled in its PDMP (personalcommunication from Utah PDMP administrator). Similarly, Minnesota requires PDMP enrollment forpharmacists as a precondition for license renewal, and in Louisiana, recent legislation requires themedical directors of pain clinics to enroll in and use the PDMP. Kentucky, New Hampshire, Tennessee, andMassachusetts have passed laws in 2012 mandating registration and use of the PDMP by prescribers(NAMDSL, 2012a and 2012b, communication with Massachusetts PDMP). A New York 2012 statute (the“I-‐Stop” Program Bill #39, introduced in June 2012) mandates use of the PDMP prior to prescribing ordispensing controlled substances, with limited exceptions—effectively mandating enrollment as well. A2012 Massachusetts statute mandates that all prescribers of controlled substances enroll in the PDMPprogram over a three-‐year period as they establish or renew their state controlled substancesregistrations. Maine requires registration but not utilization.Barriers to adoption: Barriers to mandating PDMP enrollment include the need for possibly significantrevisions in PDMP legislation and regulations, possible opposition from provider groups wary of stateintrusion on medical practice, and lack of funding and other program resources to supportimplementation. A facilitating factor might include the perception that prescriber use of a PDMP isbecoming a “duty of care,” given its role in promoting safe prescribing, especially as online PDMPreports become available to practitioners. 5 This suggests that public and provider education about thevalue of PDMP data for medical practice might help build support for enrollment mandates, should aconsensus emerge that they constitute a best practice for building PDMP participation. See Section V.Summary and Recommendations for further discussion of mandates to enroll in and use PDMPs.SummaryRationale: Mandating enrollment may increase provider utilization of a PDMP.Evidence of effectiveness: Accumulated experience, key stakeholder perceptions.Current adoption status: A few states mandate enrollment.Barriers to adoption: Need for legislative/regulatory change, provider resistance to mandates, and lackof program resources to implement mandate.C. Approaches to increasing utilizationLike enrollment, actual use of the PDMP—such as requesting a report via fax or accessing an onlinedatabase – is optional for prescribers and pharmacists in most states. This raises the question of whichstrategies work best to increase voluntary utilization by registered users and the further question ofwhether mandating the use of a PDMP might constitute a best or promising practice. Even in states with5Concerns among doctors that they would become legally liable for failure to consult the PDMP could perhaps beoffset by reductions in malpractice insurance premiums for physicians who integrate use of the PDMP into theirpractices (see 5. Institute financial incentives, below).
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