Yulin Chu, N.P.

Addiction, overdoses and deaths involving nonmedical prescription drug use, especially narcotic pain relievers, have risen dramatically over the last decade (Prescription Drug Monitoring Program Center of Excellence at Brandeis [PDMPCE], 2014).  In 2010, drug related poisonings were the leading cause of death due to unintentional injuries in the US. The number of overdose deaths involving prescription opioids has more than tripled since 1999; in 2010 these deaths were greater than those involving heroin and cocaine combined. A study estimated that in 2006 the total cost in the US of nonmedical use of prescription opioids was $53.4 billion (PDMPCE, 2014).Research and accumulated evidences strongly suggest that Prescription Monitoring Program (PMP) serves essential functions in combating the prescription drug abuse epidemic. As of July 2014, 49 states and one territory had passed legislation authorizing a PMP, and 48 states had an operating PMP (PDMPCE, 2014).

The application of scientific findings to clinical practice is the function of a rapidly expanding field of science known as translational science (Grady, 2010).  Translational science provides the means to apply the knowledge derived from basic healthcare research to interventions that improve health. In nursing, NPs should take the leadership roles in translating the current research findings that suggested PMP is effective in improving healthcare, reducing doctor shopping, inappropriate prescribing, drug diversion and prescription fraud, into nursing interventions to facilitate PMP implementation and improve healthcare outcomes.

In this paper, all aspects of the evidence using PMP will be addressed. A translation plan and the informatics role of NPs in this translation process will be proposed based on the evidence analysis. Finally, the identified main ideas and the major benefits of this translation science project will be concluded and summarized.

The Essential Role of PMP
The PMP is a prescription monitoring program to checking on the distribution of the prescription drugs when writing prescriptions for schedule II, III, and IV controlled substances (Department of Heath, 2014). It utilizes computer network technology and is based on e-prescribing to connect all registered prescribers to all pharmacies in statewide database. The PMP collects prescription data on controlled dangerous substances and human growth hormone dispensed in outpatient settings and by out-of-state pharmacies dispensing into the state (PDMP CE, 2014).  The PMP administrator follows up with HIPAA rules and keeps patient information strictly confidential.  Patient information in the program is intended to supplement an evaluation of a patient, confirm a patient’s drug abuse history, or document compliance with a therapeutic regimen. A prescriber can review PMP data to see if other prescribers have already given a patient a similar medicine or a medication that might cause a serious adverse drug reaction. When prescribers or pharmacists identify a patient as potentially having an issue of concern regarding drug use, they are encouraged to help the patient locate assistance and take any other action the prescriber or pharmacist deems appropriate – stopping to prescribe or refusing to fill a prescription based on a concern of addiction (NJDCA, 2015).  The PMP will be secure and easily accessible by practitioners and pharmacists, allowing them to view their patients’ controlled substance history in 24 hours/ a day and 7 days/ a week (Montgomery, 2012).

Evidences on PMP Effectiveness
The PMP enhanced information to practitioners and pharmacists in timely manner. It requires all prescriptions to be electronically transmitted, which improves safeguards for the distribution of specific prescription drugs that are prone to abuse.  It also stimulates stakeholders’ (clinicians’) responsibility to manage medication and to educate their patients about safe taking of prescription drugs, as well as increases public awareness regarding pain management and highly-addictive drug’s control (Montgomery, 2012).

Improving clinical decision-making
A PMP can add accuracy to providers’ clinical judgments to determine the requirements for prescription. A study of medical providers in Ohio ER found that 41% of those given PMP data altered their prescribing of multiple simultaneous narcotics. Of those providers, 61% prescribed no narcotics or fewer narcotics than originally planned (PDMPCE, 2014). A survey of medical professionals reported: Over 90% reported prescribing had fewer controlled substances, and over 50% of these respondent cited viewing PMP data as the main reason for this change (PDMPCE, 2014). In California, 74% of responders to a survey indicated that they had changed their prescribing practices as a result of using PMP, and 91% rated the effectiveness of PMP in maintaining the care of their patient as good to excellent (PDMPCE, 2014).

Reducing doctor shopping
The new system (PMP) substantially decreased opportunities for “doctor shoppers” to illegally obtain prescriptions from multiple practitioners (Montgomery, 2012). A study in New York State’s PMP found that in the next year’s inspection of the program, prescribing of benzodiazepines to patients suspected of drug diversion fell by 95% as measured by insurance claim data. Following initiation of the Arkansas PMP in 2013, the number of individuals meeting a threshold for doctor shopping fell from 114 to 31. It also showed the similar results in Florida, Virginia, Ohio, New York, and in Tennessee (PDMPCE, 2014).

Impact on controlled substance availability
A national evaluation comparing states with and without PMP found that proactive PMP was associated with slower growth in the per capita availability of prescription pain relievers and stimulants. Another similar study reported that PMP had decreases in the amount of opioid shipments. In many states, the numbers of prescriptions and doses of pain killers have dropped as utilization of PMP has increased (PDMPCE, 2014).

Improved Health Outcomes Associated with PMP
The PMP is a tool for the prescriber and the pharmacist – it gives a more complete picture of a patient’s pharmacy history with controlled substances and allows healthcare providers to take the best care of patients and achieve the very best outcome of care (Montgomery, 2012).

Decreasing drug-related deaths and treatment admissions
Following the implementation of PMP, drug-related deaths have declined: in Florida, fell by 18% in 2011-2012; in Washington State, down 27% from 2008-2012. Some states reported that proactive PMP was associated with dropping of the ER visits for drug overdoses. A national evaluation comparing states with and without PMP found that proactive PMP was associated with lower rates of treatment admissions for drug abuse (PDMPCE, 2014).

Dropping drug and medical costs
After New York State instituted its triplicate prescription program in 1988, the estimated saving due to the decline in benzodiazepine prescribing for Medicaid program in 1989-1990 was $27 million. Blue Cross Blue Shield of Virginia estimated saving $333, 418 in drug and medical claims by restricting 100 clients to one pharmacy who had been receiving multiple narcotic prescriptions from 5 or more sources over a 90-day period (PDMPCE, 2014).
 
Reducing diversion and drug investigation times
Because PMP data tracks filled prescriptions from all sources, it is a great source for the identification of such clients for drug diversion and reduces the time and expenses related to drug investigation. A study of diversion rates for prescription opioids in Florida found significant declines for several drugs, including oxycodone, methadone and morphine, after the implementation of the State’s PMP (PDMPCE, 2014).

Stimulating abstinence and facilitating patient-centred care
Drug courts in Kentucky use PMP data to help monitor abstinence from prescription drugs, helping clients achieve sobriety and stability. In addition, it is more comfortable checking a PMP report than mandating urine drug screening, which can result in disruption of the patient-doctor relationship (Katz MH, 2010). Furthermore, patients’ awareness of the PMP database may lead them to provide true information, which would stimulate patients’ engagement of care and enhance the patient-provider relationship (Islam & McRae, 2014).

Translating PMP Evidences to Advanced Practice
A major role for nursing informatics is translational research, which performs evidence to practice research concentrating on the dissemination and implementation of best practices in prevention and treatment in communities (Clinical and Translational Science Institute [CTSI], n.d.).  As NPs, we should identify the factors that serve as barriers and facilitators to translation, develop intervention and implementation strategies to increase translation, and evaluate the impact of strategies to increase translation of evidence in the care (CTSI, n.d.)
 
Translation process analysis
According to the Donabedian model, information about quality of care can be drawn from three categories: structure, process, and outcomes (Donabedian, 1988). Structure describes the context in which care is delivered, including hospital buildings, staff, financing, and equipment.  Process denotes the transactions between patients and providers throughout the delivery of healthcare. Outcome refers to the effects of healthcare on the health status of patients and populations, which is the most important indicators of quality of care and serves as the primary goal of healthcare (Donabedian, 1988).

The structure could involve a PMP database that is filled out with the patients’ medical history and the current controlled drug prescriptions. The NPs should look at the whole picture of the patient’s prescription status (structure) and make clinical judgment and improve the quality of care (process).  By utilizing PMP, NPs can identify patients who are receiving multiple legitimate prescriptions but are at risk of complications from polypharmacy. The outcomes are to evaluate the efficacy of PMP implementation and improved care, which may include increased patient safety as decreased controlled substance abuse, reduced cost as dropping of drug diversion, and facilitated patient-centred care as stimulated abstinence.

Evidence analysis
The studies showed the above pros but also the following cons of PMP:

The chilling effect could also lead to increased prescribing of alternate medications (substitution effect). For example, in 1989, New York State added benzodiazepines restriction but increased other sedatives prescribing in the same time (Islam & McRae, 2014).

Patient concerns about refusal to prescription and its consequences. Patients who are questioned about substance use and then excluded from an expected treatment may feel embarrassed or abandoned.  This may negatively impact on service rapport and trust. There is a concern that this refusal could eventually push some patients into the illicit market. For instance, the opioid abuse crackdown in Florida has been followed by increased use of heroin, and overdose presentation in the emergency department (Islam & McRae, 2014).

The abuse of prescription drugs is a multifaceted problem and needs collaboration of various stakeholders. It is more of a public health issue than anything else, and requires a public health focus – as opposed to a strictly law-enforcement focus. However, in some settings, PMP is seen as a tool of the police rather than an important component of patient safety, which should be the primary purpose of health care (Islam & McRae, 2014).

In order to encouraging physicians and NPs to use PMP, we should make the databases more convenient that include real-time data provision, easy recovery of forgotten passwords and easy navigation to the web portal (Islam & McRae, 2014).
 
Despite some unintended consequences of PMP, it continues growing and developing today.  Continued improvements in information technology may work as a catalyst in PMP proliferation.  In advanced nursing practice, we should not only use PMP ourselves but also provide education and training of PMP to our patients, peers, and all nurses. In addition, advocating public awareness, increasing access to addiction treatment and recovery, providing appropriate enforcement through healthcare administration, together, may accelerate the acceptance and help realize the full benefits of PMP (Islam & McRae, 2014).

In conclusion, PMP has essential role to monitor prescription distribution. Research continues support the efficacy of PMP with improved healthcare outcomes. To translate these evidences, NPs should take leadership role to identify the barriers and facilitators of the PMP implementation, educate patients and peers to utilizing PMP, and improve patient-centred care.
 
References
Clinical and Translational Science Institute (CTSI). (n.d.).  What is clinical and translational science? Retrieved from https://accelerate.ucsf.edu/about/clinical-and-translational
Department of Heath. (2014). I-STOP/PMP – Internet system for tracking over-prescribing – prescription monitoring program. New York State. Retrieved from https://www.health.ny.gov/professionals/narcotic/prescription_monitoring/
Donabedian, A. (1988). The quality of care: How can it be assessed? JAM: The Journal of the American Medical Association, 121 (11), 1145–1150. doi:10.1001/jama.1988.03410120089033
Grady, P (2010). Translation research and nursing science. Nursing Outlook, 58 (3), 164-166. doi:10.1016/j.outlook.2010.01.001
Islam, M. M. & McRae, I.  (2014). An inevitable wave of prescription drug monitoring programs in the context of prescription opioids: pros, cons and tensions. BMC pharmacology and toxicology, 15(46), 1-7. Retrieve from http://www.biomedcentral.com/2050-6511/15/46
Katz MH.  (2010). Long-term opioid treatment of nonmalignant pain: A believer loses his faith. Archives of Internal Medicine, 170(16), 1422–1424.
Montgomery, V. (2012). New I-STOP law to help state fight prescription drug abuse. NY Senator Homepage. Retrieved from http://www.nysenate.gov/press-release/new-i-stop-law-help-state-fight-prescription-drug-abuse
New Jersey Division of Consumer Affairs [NJDCA]. (2015). NJ prescription monitoring program. Retrieved from http://www.njconsumeraffairs.gov/pmp/
Prescription Drug Monitoring Program Center of Excellence at Brandeis (PDMPCE). (2014). Briefing on PDMP Effectiveness, 3rd ed. Retrieved from www.pdmpexcellence.org