Mandate letters increase use of prescription monitoring programs

Mandate letters increased clinicians’ engagement in prescription monitoring programs, which may result in safer prescribing of opioids, a study published in Health Affairs found.

According to CDC data, opioids accounted for 74.8% of all drug overdose deaths in 2020. Higher rates of opioid prescribing are associated with long-term opioid misuse, Adam Sacarny, PhD, an assistant professor of health policy and management at the University of Columbia Mailman School of Public Health, and colleagues wrote.

The opioid crisis in the United States is expected to worsen by 2025, according to previous research. To help combat the crisis, prescription monitoring programs (PMPs) were developed to facilitate safer opioid prescribing. PMPs are electronic databases that include information on patient prescription history and controlled substances.

“By facilitating access to medication records, PMPs may be particularly well-suited to helping prevent co-prescriptions from multiple clinicians, a common occurrence that further increases overdose risk,” Sacarny and colleagues wrote.

The researchers collaborated with the Minnesota Board of Pharmacy to determine whether mandate letters could both increase PMP usage and reduce potentially harmful opioid prescribing.

The study tested three interventions, which included:

• a mandate letter reminding physicians of state requirements to check the PMP before prescribing opioids;
• an information letter listing the risks of co-prescribing, the names of up to five patients with co-prescriptions from November 2020 to February 2021 and action steps that include recommendations to monitor patients and limit co-prescribing; and
• a letter that combined content of both the mandate and information letters.

The study pool consisted of 12,000 clinicians who prescribed opioids with benzodiazepines or gabapentinoids. They were randomly assigned into one of the three intervention arms — 3,000 each — or a control arm. Among the total participants, 60.6% were physicians, with most being primary care physicians.

During the 60 days leading up to the first letter, 49.7% of clinicians searched the PMP, while 69.2% had a PMP account.

Sacarny and colleagues found that during the 60-day post-intervention period, 51.3% of clinicians in the control arm searched the PMP. Across all three intervention arms, PMP search rates rose 3 percentage points compared with the control arm.

The mandate letter and information letter resulted in an 8.7% and 7.8% increase in PMP searches, respectively, compared with the control arm.

The mandate letter was also associated with a 2.1 percentage point increase in PMP accounts, while the information letter was associated with an increase of 1.7 percentage points.

“These effects persisted for at least 8 months,” Sacarny and colleagues wrote.

The researchers noted that the efficacy of the mandate letter “may reflect its strong language describing a new legal requirement to check the PMP when prescribing opioids.”

“This letter could have provided new information to clinicians who had previously been

unaware of the mandate. For those already aware of the mandate, the letter could have made it more salient and changed their views on its enforcement,” they wrote.

Additionally, Sacarny and colleagues pointed out that while the letters did not result in significant changes in prescribing, the increased engagement among clinicians and the letters’ cost-effectiveness should be considered by policymakers.

“Taken together, these findings highlight the promise of simple, low-cost letters to facilitate better-informed prescribing,” they concluded.

References:

• Death rate maps & graphs. https://www.cdc.gov/drugoverdose/deaths/index.html. Accessed Jan. 9, 2023.
• New randomized trial shows simple letters promote better-informed opioid prescribing. https://www.eurekalert.org/news-releases/975708. Published Jan. 9, 2023. Accessed Jan. 9, 2023.
• Sacarny A, et al. Health Aff. 2023;doi:10.1377/hlthaff.2022.00859.