Prescription History Before Opioid Overdose Death: PDMP Data and Responsible Prescribing

Abstract

Introduction:As the opioid epidemic continues, state legislatures and clinicians increasingly utilize Prescription Drug Monitoring Programs (PDMPs). These programs record dates prescribed and filled for all controlled substances, attempting to identify high-risk prescribing. The aims of this study were to (i) examine data from individuals who died of accidental opioid overdose and (ii) compare differences between those with prescriptions documented in Kentucky's PDMP with individuals without recorded prescriptions. Methods: This was a retrospective, observational cohort study conducted in Jefferson County, Kentucky. We reviewed records for all opioid overdose death subjects from 2017 and 2018, cross-referencing with prescriptions in Kentucky's PDMP (Kentucky All Schedule Prescription Electronic Reporting System [KASPER]) back to 2014. We performed χ 2 analyses for categorical variable comparisons and a separate univariate analysis for age. Results: Of the 575 individuals who died of accidental opioid overdose in Jefferson County during the study period, 379 (65.9%) had prescriptions documented in KASPER. Individuals had a high prevalence of fentanyl on postmortem toxicology. Only one individual had postmortem toxicology positive for buprenorphine, a medication for opioid use disorder (MOUD).Several subjects experienced what we termed see-saw MOUD prescribing (prescriptions alternating between MOUD and other controlled substances including full agonists), and multiple prescriptions were apparently written and/or filled for deceased subjects. Conclusions: Review of PDMP data in deceased patients can prevent unnecessary opioid prescribing and optimize clinical practice. Buprenorphine may have a protective effect in opioid dependence, but access must be consistent. Providers should be aware of see-saw MOUD prescribing and understand the effects on patient care. In response to the prescriptions filled for deceased individuals, legislators could enact a policy such as Void All Prescriptions or VAP alerts to cancel all prescriptions for individuals who have died, reducing drug diversion. It is vital that providers routinely use PDMP data along with counseling and other treatment strategies to optimize patient care.

Mapping the research addressing prescription drug monitoring programs: A scoping review

“…The extracted data from the included studies were then classified into main conceptual categories and summarised to align with the scoping review objective and research questions. The data extraction results are presented in Tables S1 and S2 [18–166], Supporting Information.…”

“…The most frequently reported theme was opioid prescribing trends (65%) that explored the association between PDMP effectiveness and outcome measures such as opioid volume, morphine milligram equivalents and number of opioid prescriptions. Other opioid‐related themes also ranked high with misuse, hospitalisation and emergency department visits featured in 45 studies (29%) [5,9,18,19,21,27,29,33–35,39,43,46,47,53,55,59–63,65,71,73,74,80,98–100,103–105,107,119,121,123,127,129,144,155,156,158,160,162,163], opioid overdose in 33 studies (22%) [5,9,21,32,34,35,41–43,47,53,55,59,62,63,73,76,84,86,99,105,107,116–118,121,123,129,140,142,155,156,163], and opioid mortality and morbidity in 29 studies (19%) [5,9,21,43,48,59,62,73,78,105,107,116,118,123,142]. The association between opioid‐related outcomes and PDMP characteristics were explored in 38 studies (25%).…”

“…Almost one-third of the studies (30%) described PDMPs as a risk mitigation tool. The clinical practice implications included improving prescribing practices (18%), supporting clinical decision making (12%) [21,31,47,51,55,58,60,71,74,80,100,112,114,119,126,135,140,143,150] and optimising clinical practice (9%). A minority of studies discussed how information from PDMPs facilitate drug misuse education with patients (8%) and health-care professional collaboration (6%).…”

Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis

“…After the second prescription is sent, they either have another colleague waiting there, or go to retrieve the medication themselves. Patients may avoid the Prescription Drug Monitoring Program (PDMP) flags or warnings at the pharmacy by filling these duplicate prescriptions the same day (pharmacies report to the PDMP every 24 h) [ 14 , 15 ]. Similarly, patients may and avoid insurance billing errors or flags by paying cash or utilizing coupons.…”

Impact of CancelRx on Discontinuation of Controlled Substance Prescriptions

“…Additionally, by filling the prescription the same day, these patients avoid Prescription Drug Monitoring Program (PDMP) flags or warnings at the pharmacy (pharmacy reporting to the PDMP is reported every 24 hours). 10,11 In these scenarios, even if the prescriber delegates a clinic staff member to contact the first pharmacy to cancel the original prescription, it may be too late when the patient’s representative is already there to retrieve the medication as soon as it is filled.…”