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Impact Evaluation of
Prescription Drug Monitoring Program
David Lambert, Ph.D.
March 2007
Executive Summary
Background and Overview
An
alarming increase in the abuse of prescription drugs in
In
developing the Maine PMP, state policymakers and stakeholders wanted the
program to be used as a public health and clinical intervention tool and not
be used as a law enforcement tool, as it is in most other states with a PMP.
This strong public health orientation is reflected in the programs goals, which
are to:
·
curb
illicit use of prescription drugs in
·
give
prescribers an added tool in patient care;
·
get
patients who are addicted into proper treatment;
·
help
reduce prescription drug overdoses;
·
ensure
that those who need strong prescription drugs receive them.
The implementation of the PMP proceeded smoothly, with 350 prescribers
and 66 dispensers registering for the program by summer 2005. Prescribers
received and used threshold reports and requested and used patient history
reports to monitor patients’ use of prescription drugs. Data confidentiality was maintained in an
exemplary manner. The main recommendation by prescribers and dispensers was to
have access to more “real time” information from the PMP database, which would
allow and enhance the proactive management of patients. The launch of OSA’s WEB
Portal, planned for the first quarter of 2006, held much promise to provide
improved access.
For the PMP to be able to meet its longer term goals of reducing the
abuse of prescription drugs, and the consequence of this abuse, more
prescribers will need to continue to register for and use the PMP database. The
“tipping point” would be a sizeable portion, if not a majority, of the 6,139
clinicians in Maine registered to prescribe medication, particularly primary
care and emergency department clinicians, who are likely to see new patients
requesting prescriptions to control pain.
This
study examines the following questions to see if the PMP has begun to achieve
the impacts, which if sustained, are likely to result in reducing prescription
drug abuse and overdoses:
·
Following
its implementation, has the PMP been expanded and refined as planned?
·
Which
prescribers are using the PMP? Is the PMP growing in the regions of the state
where it is most needed?
·
Has
the PMP given prescribers a useful tool in patient care?
·
Has
patient care improved as a result of the PMP?
·
What
are the collateral effects of the PMP on other programs and regulatory
activities in
·
Have
there been any adverse or unintended consequences of the PMP?
·
Has
the abuse of prescription drugs in
Data were used from
four sources to examine these questions:
·
Survey of prescribers who have
registered in the PMP system.
·
Survey of dispensers who submit data to
the program.
·
Key stakeholder interviews with OSA staff,
members of the PMP Advisory and Clinical Advisory Committees, and heads of
professional licensing boards.
·
Secondary
data analysis of standard and special reports, queries from the PMP database
and aggregate data trends from the public-use databases.
Findings
The
PMP program has grown steadily since clinicians began registering for the
program in January 2005, with over 1,000 prescribers registering for the
program by October 2006. The largest growth occurred after an on-line WEB
Portal became available in March 2006. Prescribers are joining the program
throughout
The
PMP program has been successfully implemented and grown almost exactly as
planned and has the wide support of stakeholders and the vast majority of
participating prescribers and dispensers. The program has met / is meeting its
goals to (1) give prescribers an added tool in patient care; (2) get patients who are
addicted into proper treatment; and (3) ensure that those who need strong
prescription drugs receive them. If the PMP program continues to grow, it
appears to be on track to meet its other two goals to (4) curb the illicit use
of prescription drugs in
The PMP has significant potential
to benefit other agencies and regulatory bodies in
The PMP has maintained very
productive, but confidential, relations with state medical licensing boards. If
a licensing board wants information about a member there must be a formal,
notarized request. Licensing board directors and PMP staff report that there
have generally been only a relatively few number of requests for information
from each Board and that these requests have been met professionally,
discretely, and in a timely manner.
Recommendations
To help promote the
further growth and appropriate use of the PMP, OSA might consider the following
recommendations.
In
developing the Maine PMP, state policymakers and stakeholders identified a
strong preference that the program be used as a public health and clinical intervention
tool to reduce the illicit use of prescription drugs and not be used as
a law enforcement tool, as it is in a number of other states with a PMP funded
under the Harold Rogers Program. The strong public health orientation of
·
curb
illicit use of prescription drugs in
·
give
prescribers an added tool in patient care;
·
get
patients who are addicted into proper treatment;
·
help
reduce prescription drug overdoses;
·
ensure
that those who need strong prescription drugs receive them.
The
·
Prescribers
receiving Threshold Reports and requesting Patient History Reports had used
them to help clarify whether patients were “doctor shopping” or using
prescription medications appropriately.
·
Prescribers
and dispensers were enthusiastic about the planned availability of an on-line
web-portal (scheduled for implementation in early 2006) that would allow close
to “real-time” access to information.
·
Early concerns
over patient confidentiality, the potential use of PMP data by law enforcement,
and a potential “chilling effect“ (in which concerns over confidentiality would
constrain the number of prescriptions written) had not materialized.
·
Major
stakeholders (including The Maine Medical Association and the Maine Osteopathic
Association) were pleased with how the PMP had developed and optimistic about
what it might accomplish.
The
study noted that the PMP would need to continue to increase the number of
registered prescribers actively using the program and its database; maintain
its exemplary record of data security and confidentiality; reduce the time
between when information was requested and received; and maintain and enhance
the public health function of the PMP. The study, incorporating the advice of
PMP policymakers and stakeholders, recommended that the PMP program begin to
consider longer-term issues of sustainability and how the impact of the
program might be monitored and assessed over time.
The
Maine Office of Substance Abuse contracted with the
II.
Context
and Scope of Study
An
alarming increase in the abuse of prescription drugs in
Prescription
Drug Monitoring Programs in other states, funded by the U.S. Department of
Justice, offered an opportunity and a model to address
A consensus emerged that a prescription monitoring program should be
used as a public health and clinical intervention tool to reduce the illicit
use of prescription drugs.
Under the
leadership of Maine’s Office of Substance Abuse and with the participation and
support of Maine’s medical community, pharmacies, attorney general’s office,
department of licensure and regulation, and other stakeholders a working
consensus was formed for how Maine’s Prescription Monitoring Program should
work to support this goal. The passage of the Bill in 2003 (on the third try
before the Maine Legislature) creating the Prescription Monitoring Program,
gave the Office of Substance Abuse the authority to develop the program, but did not authorize a state expenditure. To
be implemented, the program would need to secure external funding, which it did
in October 2003. Many data confidentiality issues
were addressed in the enabling legislation creating the PMP.[ii] In
administering the PMP, OSA is designated as a “health oversight agency” under
HIPAA.
The implementation of the PMP proceeded smoothly, with 350 prescribers
and 66 dispensers registering for the program by summer 2005 (Lambert 2006).
Prescribers received and used threshold reports and requested and used patient
history reports to monitor patients’ use of prescription drugs. Data confidentiality had been maintained in an
exemplary manner. The main concern of (and recommendation by) prescribers and
dispensers was to have access to more “real time” information from the PMP
database, which would allow for proactive management for patients. The launch
of OSA’s WEB Portal, planned for the first quarter of 2006, held much promise
to provide such improved access. For the PMP to be able to meet its longer term
goals of reducing the abuse of prescription drugs, and the consequence of this
abuse, more prescribers would need to continue to register for and use the PMP database.
What is not known is how many and what
type(s) of prescribers among the 6,139 Drug Enforcement Agency registrants in
This
study examines the following questions to see if the PMP has begun to achieve
the impacts, which if sustained, are likely to result in longer term outcomes
of reducing prescription drug abuse and overdoses:
III.
Methods
and Approach
This impact evaluation is based
on data from four sources:
Prescriber and
Dispenser Surveys:
Surveys were mailed in August 2006 to all
prescribers and to all dispensers who had registered for the PMP. A
second mailing of the surveys was sent out in October 2006 to prescribers and
dispensers not responding to the initial mailing, or who had registered for the
program since the first mailing. A total
of 354 out of 968 prescribers (36.6 percent) and 34 out of 102 dispensers (33.3
percent) mailed back completed surveys. The response rates for the prescriber
and the dispenser surveys are similar to those obtained in the surveys
conducted for the implementation evaluation (38.9 percent and 31.8 percent
respectively). The geographic locations
(county) and medical specialties of prescribers responding to our survey are very
similar to the geographic and specialty distributions of all prescribers
registered for the PMP database. We are confident that the answers from
prescribers are reflective of registered prescribers throughout
Stakeholder
Surveys: Interviews were conducted with PMP staff, advisory and medical
committee staff, contractors, and members of health professional licensing boards
to gain additional perspective on how the program was developing, and whether,
when, and how one might expect the PMP to impact the rate and consequence of
prescription drug abuse. Interviews with heads of licensing boards and other
agencies explored whether they were receiving a collateral benefit from the PMP
Program and what the potential for such benefits in the future might be.
Information from the stakeholder interviews is incorporated or noted, where
appropriate, in different sections of the report. The names of stakeholders are
withheld to protect confidentiality.
Secondary Data
Analysis: The PMP database was queried to
generate information on the number and distribution of threshold and patient
history reports. To protect confidentiality, these queries were conducted by
PMP staff, at the request of the researchers of this report. Public health
databases in the public domain were also queried to report trend information on
prescription drug abuse and its consequences in
Approach:
As the Maine PMP grows and matures, it should reduce the prevalence and
consequence of prescription drug abuse in
IV.
Findings
Expansion and Growth of the PMP
Program
Central
to the growth and success of the PMP Program is the active involvement of
prescribers and dispensers in using the data available from the program.
Prescribers receive data about their patients in one of two ways: (1) through a
Threshold Report sent to them by the PMP Program indicating that a patient has
a “suspicious number of prescriptions filled in a certain time period”; (2) by
requesting a Patient History Report on one of their patients. To be able to
request a patient history report, a prescriber must register with the PMP
Program. Dispensers are not sent a Threshold Report (although notified
prescribers may contact them about a particular patient), but may register and
request Patient History Reports.
At
the time the implementation study was conducted in summer 2005 –one year after
the PMP program was implemented – 350 prescribers had registered to use the PMP
database. The vast majority of these prescribers were familiar or very familiar
with the program; the most common way they had learned about the program was
through a mailing (40 percent), an information pamphlet (24 percent), or a professional
association (21 percent). Just under half had requested a Patient History
Report; sixty-one percent not having requested a patient history report
expected to do so within the next six months. Most prescribers receiving
threshold and patient history reports found them useful and had been able to
clarify whether or not their patients were using prescriptions properly or
improperly. The major issue prescribers had with the system was being able to
access data on a more timely or “real-time” basis when the patient was in the
clinical setting. To meet its longer
term goals, the PMP will need to continue to increase the number of registered
prescribers actively using the program. It
is important, as the program matures, for PMP policymakers and stakeholders to
have a better sense of which types (specialties) of prescribers are registering
and using the program.
Outreach to
Prescribers and Dispensers: Since
Table 1. Number of PMP trainings provided by OSA, January 1, 2004-
|
Period |
Dispenser Trainings |
Prescriber Trainings |
Licensing |
Law Enfo |