Lawrence Greenblatt, MD

Primary care physicians will find a number of important messages in Landau et al’s study.  The authors surveyed physicians and advanced practice providers in one ED with a focused tool looking at the provider’s impression of their patient’s perceived need for opioid analgesic therapy and their level of concern about drug abuse and/or diversion. The ED is in Pennsylvania, a state which has mandated use of their prescription drug monitoring program prior to prescribing opioids or benzodiazepines. The fact that providers changed their prescribing decision in 11 of 103 encounters is a significant number in my opinion, and Landau, et al conclude that review of these data “rarely” influences prescribing decisions around opioid therapy. When a decision was reversed, more often clinicians were reassured by the Prescription Drug Monitoring Program data and made a decision to prescribe an opioid rather than modifying their initial decision to prescribe opioid therapy because the Prescription Drug Monitoring Program data raised concern for opioid misuse, abuse, or diversion.    

However, we should be careful not to believe that routine use of the prescription drug monitoring program does not have great value. This would be analogous to concluding that vaccines don’t have much impact in children after studying unvaccinated children who are part of a larger population where vaccination rates are high. Prescription drug monitoring programs have very effectively reduced a dangerous behavior — “doctor shopping” — to obtain opioids for misuse or abuse. A previous study, “Legislative Impact on [Prescription Drug Monitoring Program] Utilization, Perceptions, and Prescriber Behavior in Kentucky” found that when prescription drug monitoring programs are in routine use, individuals quickly become aware that this strategy will no longer be effective in obtaining opioids and therefore stop doing it. To think that ED providers, on the front line of acute pain management and opioid-seeking for misuse and abuse don't see benefit from using the system fails to recognize its role in reducing this risky behavior.

Based on Landau and colleagues’ findings, PCPs should recognize that they continue to play an essential role in combatting the opioid epidemic by routine use of their state’s prescription drug monitoring program both prior to initial prescribing and routinely during ongoing opioid therapy.

Also noteworthy in the Pain Medicine study is the finding that 35% of emergency clinicians did not endorse feeling at least somewhat comfortable in referring individuals with evidence of opioid misuse or abuse for treatment. Given the growing illicit opioid epidemic and the reality that these individuals interact rarely with the health system, providers need to be trained and supported to take advantage of any opportunity to counsel and refer. PCPs must develop communication skills and be able to provide brief counseling and referral to treatment in their community. Even better would be to obtain training in buprenorphine management and offer this treatment, coupled with counseling where indicated, to patients who attend their practice and are diagnosed with opioid use disorder.

Further reading: Prescription Drug Monitoring Program Training and Technical Assistance Center. Legislative Impact on [Prescription Drug Monitoring Program] Utilization, Perceptions, and Prescriber Behavior in Kentucky.  http://www.pdmpassist.org/pdf/TTAC_Webinar_KY_HB1_Study_20150930.pdf Accessed June 4, 2018.