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Association of the Use of a Mandatory Prescription Drug Monitoring Program With Prescribing Practices for Patients Undergoing Elective Surgery

Educational Objective To identify to what extent a mandatory prescription drug monitoring program (PDMP) changes practices.
1 Credit CME
Key Points

Question  How does mandatory use of a prescription drug monitoring program change the prescribing practices for patients undergoing elective general surgery?

Findings  In this pre-post cohort study of 1057 patients, prescribing practices were compared before and after New Hampshire legislation mandating the use of a prescription drug monitoring program that took effect January 1, 2017. There was no significant change in the rate of opioid prescriptions written or the mean number of pills prescribed.

Meaning  It seems that efforts to curb overprescribing of opioids should be evidence based and should show clinical benefit prior to mandatory implementation, and that patients undergoing elective surgical procedures should be considered differently when developing opioid legislation.

Abstract

Importance  Most states have adopted the routine use of a prescription drug monitoring program (PDMP) to curb overprescribing of opioids. The American College of Surgeons promotes the use of these programs as a “guiding principle to curb the opioid epidemic.” However, there is a paucity of data on the effects of the use of these programs for surgical patient populations.

Objective  To determine the association of the mandatory use of a PDMP with the opioid prescribing practices for patients undergoing general surgery.

Design, Setting, and Participants  A prospective observational cohort study was conducted at an academic hospital in New Hampshire among 1057 patients undergoing representative elective general surgical procedures from July 1, 2016, to June 30, 2017.

Exposures  New state legislation mandated the use of a PDMP and opioid risk-assessment tool for all patients receiving an outpatient opioid prescription in New Hampshire beginning January 1, 2017. The electronic medical prescribing system was modified to facilitate and support compliance with the new requirements.

Main Outcomes and Measures  Change in opioid prescribing practices after January 1, 2017, and time to complete PDMP requirements.

Results  Among the 1057 patients (569 women [53.8%] and 488 men [46.2%]; mean [SD] age, 56.8 [15.4] years), the percentage of patients prescribed opioids after surgery did not decrease significantly (429 of 536 [80.0%] before the new requirements vs 401 of 521 [77.0%] after the requirements; P = .29). The mean number of opioid pills prescribed decreased from 30.8 to 24.0 (22.1%) in the 6 months prior to the mandatory PDMP requirement; the rate of decrease was actually less (from 22.8 to 21.9 pills [3.9%]) in the 6 months after the legislation. These new requirements did not identify any high-risk patients who subsequently were not prescribed opioids. The query and opioid abuse risk calculator together took a median time of 7 minutes (range, 2-17 minutes) to complete.

Conclusions and Relevance  A mandatory PDMP query requirement was not significantly associated with the overall rate of opioid prescribing or the mean number of pills prescribed for patients undergoing general surgical procedures. In no cases was a high-risk patient identified, leading to avoidance of an opioid prescription. A PDMP can be a useful adjunct in certain settings, but this study found that it did not have the intended effect in a population undergoing elective surgical procedures. Legislative efforts to mandate PDMP use should be targeted to populations in which benefit can be demonstrated.

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Article Information

Accepted for Publication: May 13, 2018.

Corresponding Author: Richard J. Barth Jr, MD, Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756 (richard.j.barth.jr@hitchcock.org).

Published Online: August 22, 2018. doi:10.1001/jamasurg.2018.2666

Author Contributions: Dr Barth had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Stucke, Mathis, Hill, Barth.

Acquisition, analysis, or interpretation of data: Stucke, Kelly, Mathis, Barth.

Drafting of the manuscript: Stucke, Mathis, Barth.

Critical revision of the manuscript for important intellectual content: Stucke, Kelly, Hill, Barth.

Statistical analysis: Stucke, Kelly, Mathis.

Administrative, technical, or material support: Mathis.

Supervision: Mathis, Hill, Barth.

Conflict of Interest Disclosures: None reported.

References
1.
Paulozzi  LJ, Mack  KA, Hockenberry  JM.  Variation among states in prescribing of opioid pain relievers and benzodiazepines—United States, 2012.  J Safety Res. 2014;51:125-129. doi:10.1016/j.jsr.2014.09.001PubMedGoogle ScholarCrossref
2.
Centers for Disease Control and Prevention. Number and age-adjusted rates of drug-poisoning deaths involving opioid analgesics and heroin: United States, 1999-2014. https://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000-2014.pdf. Accessed August 20, 2017.
3.
Compton  WM, Jones  CM, Baldwin  GT.  Relationship between nonmedical prescription-opioid use and heroin use.  N Engl J Med. 2016;374(2):154-163. doi:10.1056/NEJMra1508490PubMedGoogle ScholarCrossref
4.
Dart  RC, Surratt  HL, Cicero  TJ,  et al.  Trends in opioid analgesic abuse and mortality in the United States.  N Engl J Med. 2015;372(3):241-248. doi:10.1056/NEJMsa1406143PubMedGoogle ScholarCrossref
5.
Lev  R, Lee  O, Petro  S,  et al.  Who is prescribing controlled medications to patients who die of prescription drug abuse?  Am J Emerg Med. 2016;34(1):30-35. doi:10.1016/j.ajem.2015.09.003PubMedGoogle ScholarCrossref
6.
Maxwell  JC.  The prescription drug epidemic in the United States: a perfect storm.  Drug Alcohol Rev. 2011;30(3):264-270. doi:10.1111/j.1465-3362.2011.00291.xPubMedGoogle ScholarCrossref
7.
Manchikanti  L, Singh  A.  Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids.  Pain Physician. 2008;11(2)(suppl):S63-S88.PubMedGoogle Scholar
8.
Manchikanti  L, Helm  S  II, Fellows  B,  et al.  Opioid epidemic in the United States.  Pain Physician. 2012;15(3)(suppl):ES9-ES38.PubMedGoogle Scholar
9.
Califf  RM, Woodcock  J, Ostroff  S.  A proactive response to prescription opioid abuse.  N Engl J Med. 2016;374(15):1480-1485. doi:10.1056/NEJMsr1601307PubMedGoogle ScholarCrossref
10.
Hill  MV, McMahon  ML, Stucke  RS, Barth  RJ  Jr.  Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures.  Ann Surg. 2017;265(4):709-714. doi:10.1097/SLA.0000000000001993PubMedGoogle ScholarCrossref
11.
Hill  MV, Stucke  RS, McMahon  ML, Beeman  JL, Barth  RJ  Jr.  An educational intervention decreases opioid prescribing after general surgical operations.  Ann Surg. 2018;267(3):468-472.PubMedGoogle ScholarCrossref
12.
Bateman  BT, Cole  NM, Maeda  A,  et al.  Patterns of opioid prescription and use after cesarean delivery.  Obstet Gynecol. 2017;130(1):29-35. doi:10.1097/AOG.0000000000002093PubMedGoogle ScholarCrossref
13.
Osmundson  SS, Schornack  LA, Grasch  JL, Zuckerwise  LC, Young  JL, Richardson  MG.  Post discharge opioid use after cesarean delivery.  Obstet Gynecol. 2017;130(1):36-41. doi:10.1097/AOG.0000000000002095PubMedGoogle ScholarCrossref
14.
Kim  N, Matzon  JL, Abboudi  J,  et al.  A prospective evaluation of opioid utilization after upper-extremity surgical procedures: identifying consumption patterns and determining prescribing guidelines.  J Bone Joint Surg Am. 2016;98(20):e89. doi:10.2106/JBJS.15.00614PubMedGoogle ScholarCrossref
15.
Kumar  K, Gulotta  LV, Dines  JS,  et al.  Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits.  Am J Sports Med. 2017;45(3):636-641. doi:10.1177/0363546517693665PubMedGoogle ScholarCrossref
16.
Rodgers  J, Cunningham  K, Fitzgerald  K, Finnerty  E.  Opioid consumption following outpatient upper extremity surgery.  J Hand Surg Am. 2012;37(4):645-650. doi:10.1016/j.jhsa.2012.01.035PubMedGoogle ScholarCrossref
17.
Bates  C, Laciak  R, Southwick  A, Bishoff  J.  Overprescription of postoperative narcotics: a look at postoperative pain medication delivery, consumption and disposal in urological practice.  J Urol. 2011;185(2):551-555. doi:10.1016/j.juro.2010.09.088PubMedGoogle ScholarCrossref
18.
Hill  MV, Stucke  RS, Billmeier  SE, Kelly  JL, Barth  RJ  Jr.  Guideline for discharge opioid prescriptions after inpatient general surgical procedures.  J Am Coll Surg. 2018;226(6):996-1003. doi:10.1016/j.jamcollsurg.2017.10.012PubMedGoogle ScholarCrossref
19.
American College of Surgeons. Statement on the opioid abuse epidemic. https://www.facs.org/about-acs/statements/100-opioid-abuse. Published August 2, 2017. Accessed August 2, 2017.
20.
Johnson  H, Paulozzi  L, Porucznik  C, Mack  K, Herter  B; Hal Johnson Consulting and Division of Disease Control and Health Promotion, Florida Department of Health.  Decline in drug overdose deaths after state policy changes—Florida, 2010-2012.  MMWR Morb Mortal Wkly Rep. 2014;63(26):569-574.PubMedGoogle Scholar
21.
Florida Department of Health. Electronic-Florida online reporting of controlled substances evaluation: 2012-2013 prescription drug monitoring program annual report. http://www.floridahealth.gov/statistics-and-data/e-forcse/news-reports/_documents/2012-2013pdmp-annual-report.pdf. Published December 1, 2013. Accessed August 20, 2017.
22.
Centers for Disease Control and Prevention. Trends in drug-poisoning deaths involving opioid analgesics and heroin: United States, 1999-2012. https://www.cdc.gov/nchs/data/hestat/drug_poisoning/drug_poisoning.htm. Updated December 2, 2014. Accessed August 20, 2017.
23.
Virginia Department of Health Professions. Virginia prescription monitoring program 2010 statistics. http://www.dhp.virginia.gov/dhp_programs/pmp/docs/ProgramStats/2010PMPStatsDec2010.pdf. Accessed August 20, 2017.
24.
Li  G, Brady  JE, Lang  BH, Giglio  J, Wunsch  H, DiMaggio  C.  Prescription drug monitoring and drug overdose mortality.  Inj Epidemiol. 2014;1(1):9. doi:10.1186/2197-1714-1-9PubMedGoogle ScholarCrossref
25.
Ali  MM, Dowd  WN, Classen  T, Mutter  R, Novak  SP.  Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: evidence from the National Survey of Drug Use and Health.  Addict Behav. 2017;69:65-77. doi:10.1016/j.addbeh.2017.01.011PubMedGoogle ScholarCrossref
26.
Beaudoin  FL, Banerjee  GN, Mello  MJ.  State-level and system-level opioid prescribing policies: the impact on provider practices and overdose deaths, a systematic review.  J Opioid Manag. 2016;12(2):109-118. doi:10.5055/jom.2016.0322PubMedGoogle ScholarCrossref
27.
Leichtling  GJ, Irvine  JM, Hildebran  C, Cohen  DJ, Hallvik  SE, Deyo  RA.  Clinicians’ use of prescription drug monitoring programs in clinical practice and decision-making.  Pain Med. 2017;18(6):1063-1069.PubMedGoogle Scholar
28.
Lin  DH, Lucas  E, Murimi  IB,  et al.  Physician attitudes and experiences with Maryland’s prescription drug monitoring program (PDMP).  Addiction. 2017;112(2):311-319. doi:10.1111/add.13620PubMedGoogle ScholarCrossref
29.
PDMP Center of Excellence, Brandeis University. Briefing on PDMP effectiveness. http://www.pdmpassist.org/pdf/COE_documents/Add_to_TTAC/Briefing%20on%20PDMP%20Effectiveness%203rd%20revision.pdf. Updated September 2014. Accessed August 20, 2017.
30.
Baehren  DF, Marco  CA, Droz  DE, Sinha  S, Callan  EM, Akpunonu  P.  A statewide prescription monitoring program affects emergency department prescribing behaviors.  Ann Emerg Med. 2010;56(1):19-23.e1, e3. doi:10.1016/j.annemergmed.2009.12.011PubMedGoogle ScholarCrossref
31.
Weiner  SG, Griggs  CA, Mitchell  PM,  et al.  Clinician impression versus prescription drug monitoring program criteria in the assessment of drug-seeking behavior in the emergency department.  Ann Emerg Med. 2013;62(4):281-289. doi:10.1016/j.annemergmed.2013.05.025PubMedGoogle ScholarCrossref
32.
Finley  EP, Garcia  A, Rosen  K, McGeary  D, Pugh  MJ, Potter  JS.  Evaluating the impact of prescription drug monitoring program implementation: a scoping review.  BMC Health Serv Res. 2017;17(1):420. doi:10.1186/s12913-017-2354-5PubMedGoogle ScholarCrossref
33.
Blum  CJ, Nelson  LS, Hoffman  RS.  A survey of physicians’ perspectives on the New York State mandatory prescription monitoring program.  J Subst Abuse Treat. 2016;70:35-43. doi:10.1016/j.jsat.2016.07.013PubMedGoogle ScholarCrossref
34.
Christino  MA, Matson  AP, Fischer  SA, Reinert  SE, Digiovanni  CW, Fadale  PD.  Paperwork versus patient care: a nationwide survey of residents’ perceptions of clinical documentation requirements and patient care.  J Grad Med Educ. 2013;5(4):600-604. doi:10.4300/JGME-D-12-00377.1PubMedGoogle ScholarCrossref
35.
Maund  E, McDaid  C, Rice  S, Wright  K, Jenkins  B, Woolacott  N.  Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review.  Br J Anaesth. 2011;106(3):292-297. doi:10.1093/bja/aeq406PubMedGoogle ScholarCrossref
36.
Elia  N, Lysakowski  C, Tramèr  MR.  Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone? meta-analyses of randomized trials.  Anesthesiology. 2005;103(6):1296-1304. doi:10.1097/00000542-200512000-00025PubMedGoogle ScholarCrossref
37.
Chou  R, Gordon  DB, de Leon-Casasola  OA,  et al.  Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council  [published correction appears in J Pain. 2016;17(4):508-510].  J Pain. 2016;17(2):131-157. doi:10.1016/j.jpain.2015.12.008PubMedGoogle ScholarCrossref
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