So welcome back. Today, we're going to talk about prescription drug monitoring programs. This is a part of the course where we are going to talk a lot about interventions and effective strategies for addressing the opioid epidemic. The good news is that we have a lot of information, a lot of evidence that can inform how we move forward and address this. One of the things that I want to emphasize as we start down this series of sessions is the importance of thinking comprehensively about this problem. We want to make sure that our interventions consider the ways in which we can address the supply of prescription opioids, so that we're not dispensing too many opioids to people who could be treated through other means. We want to make sure that we are capturing information about the opioids that we're prescribing so that that can be used to inform educational efforts, to inform enforcement efforts, and to by enlarge provide us with a good indication of the prescribing that's happening so that we can best monitor how the supply is relating to the epidemic outcomes of interest such as opioid overdose deaths. We also want to be very mindful of making sure that we have the appropriate and effective supports in place for people who are ready to enter treatment and who are working toward recovery, which oftentimes will be a lifetime of investment in terms of getting to a place where they are able to be comfortable, productive, happy members of society that are not tethered to opioids, which is often what happens when opioid use disorders are in full force. So the importance of considering the range of opportunities that we have to intervene effectively in addressing the opioid epidemic is extremely important, and today's session is the first of several discussions that we'll have about opportunities to intervene effectively to address opioid overdose deaths in the United States. So with that in mind, let's move forward and talk about how prescription drug monitoring programs are part of the solution. So first off, what is a prescription drug monitoring program? They're also referred to PDMPs or PMPs, they go by a couple of different names. But the important thing is to remember that this is a system in which prescribers and pharmacists can input information into a centralized database that is organized at the state level so that other users can use that information to understand trends that are happening at the population level, but also at an individual patient level understand what an individual person is being prescribed, and that can inform future prescribing decisions as well as opportunities for intervention and treatment. So PDMPs are a law in all 50 states at this point as well as the District of Columbia and Guam. So we have good coverage throughout this country with regard to the use of this tool. The important thing about PDMPs to understand is that they provide prescribers and pharmacists with the real important opportunity to understand what is being prescribed to individuals and what is being prescribed in different communities within their jurisdiction. So you might say, "Well, why are we worried about prescription opioids at this point in time?" What I'm hearing about on the news, what I'm seeing in conversations with friends and family is all about the illicit opioids. It's not so much about the opioids that are being prescribed in clinics anymore. Certainly, what we've seen in the past few years is a dramatic and alarming uptick in the role of illicit opioids in overdose deaths. We talked about that in a previous session with Dr. Josh Sharfstein when he reviewed the data on this issue. So certainly, illicit opioids like heroin and fentanyl laced heroin are important to understand with regard to why we're experiencing the very high numbers of deaths in this country. But what I also want to emphasize right now is the continuing role that prescription opioids play and the overdose deaths that we're seeing. The slide that you see here includes a graph that tells that story well. So certainly, you can see how those illicit opioids, the heroine and fentanyl are increasing dramatically, and they have been increasing dramatically over the past few years. That's something that we unquestionably want to pay attention to and that we want to intervene with where there are opportunities. But I want you to also note that prescription opioids remain an important cause of death when we're looking at who's dying from opioids in this country. So while the alarm and attention to illicit sources of opioids is important because of their recent rise, we don't want to lose sight of the very important role that prescription opioids still play in overdose deaths in this country. Perhaps even more importantly, there are for many of the people who are currently using substances like heroin. What we hear from them through research is that for the overwhelming majority of people who are currently experiencing opioid use disorders, who are currently using heroin, what we know from them is that those use patterns often start in the clinic. So often their first opioid exposure is with the prescription opioid. So for that reason as well, we want to make sure that we're continuing to pay attention to the medical supply of opioids, and we want to make sure that we are using the tools available to best intervene with prescription opioids while also learning how to effectively intervene and address the illicit supply of opioids as well. So what about PDMPs? Why are they a focus of our talk here today? Well, prescription drug monitoring programs allow physicians, allow pharmacists to better understand what's happening with the prescriptions that are being issued in this country. What we see when we look at the data, when we look at evaluations of prescription drug monitoring programs in this country is that there's a general association between the use of prescription drug monitoring programs and what we see in terms of the number of and rate of opioids prescribed. So generally, what we have learned from our studies of PDMPs is that when clinicians have the ability to check with their patients before prescribing to see their history of prescribing, that can inform their decision-making with regard to current prescribing, and what we see is that that generally leads to reductions in the amount of opioids that are being prescribed. So clinicians and prescribers are looking at these data and making different decisions about how they're going to use opioids in the course of treatment for pain. What we also know however is that despite being in place in all 50 states, it takes more than just a law on the books for clinicians to make use of PDMPs. So what we've seen over the years is great variation among the states with regard to how they write laws about PDMPs, whether they mandate prescribers to register for the PDMPs, whether they mandate users, the prescribers to use the PDMPs. So those are just a couple of ways in which PDMP laws vary across the states. Not surprisingly, we see differences based on those variations in terms of how many prescribers register, how frequently they use the PDMP, and then subsequent prescribing rates for opioids as well. So while there's still a lot that we need to understand about PDMPs, we do generally see strong evidence that having access to information about a patient's history of controlled substance prescriptions is information that is helpful and useful in the clinical contexts when making decisions about how to treat pain. So one matter that I do want to be clear here about is a nuance to those data, which is that we do see that when the supply of prescription opioids is restricted through policy measures such as PDMP use, what we do see is that patients who are currently using opioids oftentimes will still need those opioids and without appropriate intervention, without appropriate access to treatment or tapering of those medications, we do need to be concerned about those patients going to illicit supplies. So the importance of a comprehensive approach that we talked about at the introduction to this module is very important. If we're going to undertake actions that will deliberately restrict the supply of an addictive substance like opioids, we need to be very careful and very deliberate that we are also forward thinking with regard to those policies and put in place interventions and supports that will allow that restriction and supply to translate into healthy, appropriate, lower use of opioids on the part of patients who are currently prescribed those medications. So again, this is just one example of why it's incredibly important to think of our interventions in this area as complementary and the importance of thinking comprehensively because oftentimes, if we take action on one end of the supply chain or in one aspect of this problem, it's going to have implications for other aspects of the issue. We don't want to be in a position where our efforts to restrict supply through clinical means negatively affects what we are seeing in the illicit market. That's certainly one lesson that has come out of our efforts in terms of addressing the oversupply of prescription opioids that has occurred over the past couple of decades in this country and is now generally recognized as an oversupply issue that needs to be addressed and we're in the process of correcting. But comprehensively, addressing the problem so that we can sort of foresee and deal with likely outcomes of that restriction are an important aspect of how we need to be thinking about this issue. So I want to draw from a couple of resources that the Centers for Disease Control and Prevention has made available. These are infographics that are available on their website. For those of you who are interested in learning more or talking with others about the overdose problem in this country, CDC has a wealth of resources that are available free of charge and that do a great job of really visualizing some of the aspects of the opioid overdose problem. So here's one that I thought would be useful to our conversation today, that really emphasizes several aspects of the prescription opioid problem. Again, making that point that although we're hearing a lot about the importance of the illicit market and the growing role that heroin and fentanyl are playing in the overdose deaths that are plaguing our country, prescription opioids remain an important part of this problem and we can't lose sight of that. Again, here is from my perspective, some very useful visuals as to why that is the case. So we see that by enlarge, when we look at the aggregate data, that prescription opioids are being prescribed to patients for too many days. There are too many prescriptions that continue to be written even with the interventions that we're seeing, and that those prescriptions often time are written at too higher dose. So people who are presenting for pain are on average receiving more medications than they need for a longer periods of time. That is a concern when we think about the current state of this epidemic. Having too much medicines in our homes, in our communities means that we're having extra pills that are available to be taken, stolen from communities, and that can be that starting point for opioid use disorders that are so important to the public health conversation and our nation today. So again, prescription opioids, while they have been addressed through many means, through clinical interventions, we still need to pay attention to how prescription opioids are being prescribed in clinics and continue to work with providers and systems to figure out ways to better address the supply of opioids so that they are targeted to the patients who need them, given in appropriate doses, and given at lengths that are appropriate for the problem that they're presenting for. I also want to take a moment to just emphasize that in the context of this discussion about all the challenges that we face with a large supply of prescription opioids, it's very important to remember that for some people, prescription opioids are the right treatment choice. That for some people, this is not only the right choice, but really the only option that they have for treating their pain. So one of the challenges that we have when we're talking about how to address the oversupply of prescription opioids in our society is to recognize that a balance need to happen, that there are people, there are patients with medical conditions that prescription opioids are advised. In fact, this is the medication that allows them to get through the daily functions of life. I want to make sure that we keep that in mind, that prescription opioids aren't always the wrong choice. In fact, there are many instances in which they are absolutely the right choice but we need to be deliberate and clear about the patient populations and the particular conditions for which opioids are the right choice. So we can imagine that some number of these 1,000 people per day who are presenting to emergency rooms for complications regarding opioids are people who were prescribed those opioids and didn't understand or chose not to follow the directions of their prescriber, but also some number of those people are those who obtained those prescription opioids without the medical advice of their prescribers. So there are lots of opportunity, lots of work that still needs to be done in order to assure that those prescriptions that are being released into the community are properly understood and are properly used by the people who are coming into contact with them. So I'd like to move from that overview of PDMPs and the important role that they play in terms of addressing the prescription side of the opioid supply in our society to talk about this series of recommendations that our group has come up with based on the evidence about PDMPs. So I have six recommendations that I like to review with you. Just as a reminder, these recommendations are provided in the Opioid Report, that is the accompanying reading for this course. In addition to the written text, there's recommendations that are provided here on these slides. There's also a rationale provided for each recommendation and detailed references. So any information that you want about the support for these recommendations is available in the full report that accompanies this course. So the first recommendation that I have listed here is to mandate prescriber, PDMP, registration, and use. So we've talked about what PDMPs are, why all 50 states, the District of Columbia and Guam have opted to include PDMPs as part of their laws for their states. We also know that without registration incentives and use registrations, clinicians use of PDMPs are much lower than if the law includes provisions requiring physicians and other prescribers to both register and use the PDMP. So that's an important addition to some state laws that we feel needs to be made in order to get toward that kind of comprehensive approach that we've talked about. Many states have mandatory registration and use policies written into their PDMP laws, but many states do not have those provisions included, and we recommend that states and do have those provisions as part of their PDMP law. We also recommend that PDMP data be used. So the importance, the value of this data for educating consumers, for educating prescribers, for educating the media about how prescriptions are being dispensed in this country, the trends and variation across states, is a valuable resource that we believe should be tapped for educational purposes as well as for law enforcement purposes. So allowing law enforcement to access PDMP data so that they can analyze those data, look at trends, and identify where illegal prescribing is happening or where additional investigation is needed, is another important and valuable use of PDMP data that we recommend states consider. Again, some states have these provisions where they allow their PDMP data to be used for education and enforcement purposes, but not all states do. We also see the importance of including in PDMP laws the ability of third party payers to access PDMP data. Access but with protections for privacy considerations. So again, there's a great investment that our country has made in collecting these data. Our clinicians or pharmacists are actively taking time to update and ensure that information included in the PDMP is accurate and is timely, and we believe that that data and all those efforts and resources are also quite valuable. So we're advocating for policies that maximize the use of those valuable data. Again, having third-party payers allowed appropriate access to those data, can help them be part of the mix in terms of reviewing prescriptions and considering ways in which their role as a payer can help to address over prescribing or prescribing that is ill-advised. So the fourth recommendations in this series, is to empower law enforcement and licensing boards for health professionals to really follow up on PDMP data, that suggests that certain prescribers or certain dispensers are at high risk for illicit activity. So PDMP data can provide information about who is prescribing at higher rates than their colleagues and who is dispensing at higher rates than their colleagues. There may be good reasons for these differentiations. But often times, it's good to invest in law enforcement resources to look further into these outliers and investigate what's happening. So allowing law enforcement to be a part of that data analysis process, is an important recommendation that gets back to maximizing the use of this important investment that we've made. We also recommend the importance of working with industry and state lawmakers to require that integration of PDMPS be part of how we're moving forward with electronic health records. So one of the things we know that can be a barrier to clinicians using PDMP, has to do with the ease with which they're able to access the information. Increasingly, we're seeing that electronic health records are a part of routine clinical practice. So strategies to integrate PDMP searches and PDMP information into that electronic health record system that is already part of clinical flows, is a very important strategy to easing the burden on clinicians for using this tool. So we want to think of ways to make sure that PDMPS are as easy as possible to use by the clinical providers who stand to be some of the most important consumers. Considering information flow and clinical flows in the context of electronic health records, is an important aspect of how we can make PDMP really fit in well to existing clinical practice. Finally the last recommendation that I'll share with you here, is the importance of engaging state health leadership to establish or enhance PDMP access across state lines. So as you can imagine, prescribing patterns for many patients don't stop at a state line. The importance of having PDMPS that can communicate with each other so that a provider in Maryland while checking the PDMP records and the prescribing history within the state, also has the ability to check the District of Columbia PDMP and the Pennsylvania PDMP, to make sure that when they are looking to that data to inform their clinical decision making about how best to address the pain that the patient is presenting for, they have the full amount of information that has been stored with regard to prescribing history. So encouraging that collaboration across state lines so that clinical providers can have access to that full history, is extremely important. Something again that many places are doing, but that we need to be more deliberate and comprehensive about. Thank you very much. That is the end of our module on Prescription Drug Monitoring Programs. I hope you've enjoyed this session, and if you have any questions or would like additional information, there's a wealth of information available in the full report. Thank you for your attention.
