Protocol: mixed-methods study to evaluate implementation, enforcement, and outcomes of U.S. state laws intended to curb high-risk opioid prescribing

McGinty, Emma E.; Stuart, Elizabeth A.; Alexander, G. Caleb; Barry, Colleen L.; Bicket, Mark C.; Rutkow, Lainie

doi:10.1186/s13012-018-0719-8

Cited by 26 publications

(19 citation statements)

References 38 publications

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“… 17 However, these studies have not focused on how implementation factors such as monitoring and enforcement vary by state or how these differences may influence the perceived unintended consequences of the PDMP. 28 …”

Section: Introductionmentioning

confidence: 99%

Effects of Implementation and Enforcement Differences in Prescription Drug Monitoring Programs in 3 States: Connecticut, Kentucky, and Wisconsin

et al. 2021

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Background and aims: Prescription Drug Monitoring Programs (PDMPs) were designed to curb opioid misuse and diversion by tracking scheduled medications prescribed by medical providers and dispensed by pharmacies. The effects of PDMPs on opioid prescription, misuse and overdose rates have been mixed due in part to variability in states’ PDMPs and difficulties measuring this complexity, and a lack of attention to implementation and enforcement of PDMP components. The current study uses qualitative interviews with key informants from 3 states with different PDMPs, Connecticut, Kentucky and Wisconsin to explore differences in the characteristics of the PDMPs in each state; how they are implemented, monitored and enforced; and unintended negative consequences of these programs. Methods: We conducted in-depth interviews with key informants from each state representing the following sectors: PDMP and pain clinic regulation agencies, Medicaid programs, state licensing boards, pharmacies, emergency medicine departments, pain management clinics, first responders, drug courts, drug treatment programs, medication assisted treatment (MAT) providers, and harm reduction organizations. Interview guides explored participants’ experiences with and opinions of PDMPs according to their roles. Data analysis was conducted using a collaborative, constant comparison method. Results: While all 3 states had mandated registration and reporting requirements, the states differed in the implementation and enforcement of these and the extent to which provider prescribing was monitored. These, in turn, influenced how medical providers perceived the PDMP and changed how providers prescribed opioids. Unintended consequences of state PDMPs included under-prescribing for pain and “dumping” patients who were long term users of opioids or who had developed opioid use disorders and may explain the increase in illicit heroin or opioid use. Conclusion: State PDMPs with similar mandates may differ greatly in implementation and enforcement. These differences are important to consider when determining the effects of PDMPs on opioid misuse and overdose.

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Section: Introductionmentioning

confidence: 99%

Effects of Implementation and Enforcement Differences in Prescription Drug Monitoring Programs in 3 States: Connecticut, Kentucky, and Wisconsin

et al. 2021

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“…There may be state variations in the scope and stringency of each individual PDMP best practice adopted (e.g., a query mandate could apply broadly or only to new patients or certain prescriptions) and in whether and how states enforce PDMP mandates such as those for registration and access . If so, this might explain our finding that effect sizes did not necessarily increase with more comprehensive adoption of best practices.…”

Section: Discussionmentioning

confidence: 97%

Prescription drug monitoring programs: Assessing the association between “best practices” and opioid use in Medicare

Moyo

Simoni

Griffin

et al. 2019

Health Services Research

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Objective To estimate the impact of implementing prescription drug monitoring program (PDMP) best practices on prescription opioid use. Data Sources 2007–2012 Medicare claims for noncancer pain patients, and PDMP attributes from the Prescription Drug Abuse Policy System. Study Design We derived PDMP composite scores using the number of best practices adopted by states (range: 0‐14), classifying states as either no PDMP, low strength (0 < score < median), or high strength (score ≥ median). Using generalized linear models, we quantified the association between the PDMP score category and opioid use measures—overall and stratified by disability/age. Sensitivity analyses assessed the general Medicare sample regardless of pain diagnoses, individual PDMP characteristics, and compared GEE model findings to models with state fixed effects. Principal Findings Compared to non‐PDMP states, strong PDMP states had lower opioid cumulative doses (−296 mg; 95% CI: −512, −132), days supplied (−7.84; 95% CI: −10.6, −5.04), prescription fill rates (0.97; 95% CI: 0.95, 0.98), and mean daily doses (−2.31 mg; 95% CI: −3.14, −1.48) but greater prevalence of high opioid doses in disabled adults, whereas there was little or no change in older adults. Findings in states with weak PDMPs were substantively similar to those of strong PDMPs. Results from sensitivity analyses were mostly consistent with main findings except there was a null relationship with mean daily doses and high doses in models with state fixed effects. Conclusions Comprehensive or minimal adoption of PDMP best practices was associated with mostly comparable effects on Medicare beneficiaries’ opioid use; however, these effects were concentrated among nonelderly disabled adults.

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“…Various regulations have been enacted to reduce high-risk prescribing practices including mandatory Prescription Drug Monitoring Programs, caps on opioid prescribing which limit the dose and/or duration of prescriptions, and pill mill laws to prevent nonmedical opioid prescribing. However, the effectiveness of such USA state laws is currently under investigation [52]. In England, if every general practice prescribed highdose opioids at the same rate as the lowest decile of practices, a cost saving of £24.8 million and 543,000 fewer high-dose opioid prescriptions could be achieved in 6 months [5].…”

Section: Implications For Practice and Policymentioning

confidence: 99%

Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis

Richards

Mahtani

Muthee

et al. 2020

BMC Med

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Background: The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care. Methods:We conducted a systematic review of observational studies in high-income countries that used patientlevel primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. We pooled data on factors using random effects meta-analyses and reported relative risks (RR) or mean differences with 95% confidence intervals (CI) where appropriate. We also performed a number needed to harm (NNT H ) calculation on factors when applicable. Results:We included six studies with a total of 4,248,119 participants taking opioids, of whom 3.64% (n = 154,749) were taking high doses. The majority of included studies (n = 4) were conducted in the USA, one in Australia and one in the UK. The largest study (n = 4,046,275) was from the USA. Included studies were graded as having fair to good quality evidence. The co-prescription of benzodiazepines (RR 3.27, 95% CI 1.32 to 8.13, I 2 = 99.9%), depression (RR 1.38, 95% CI 1.27 to 1.51, I 2 = 0%), emergency department visits (RR 1.53, 95% CI 1.46 to 1.61, I 2 = 0%, NNT H 15, 95% CI 12 to 20), unemployment (RR 1.44, 95% CI 1.27 to 1.63, I 2 = 0%), and male gender (RR 1.21, 95% CI 1.14 to 1.28, I 2 = 78.6%) were significantly associated with the prescribing of high-dose opioids in primary care.Conclusions: High doses of opioids are associated with greater risks of harms. Associated factors such as the coprescription of benzodiazepines and depression identify priority areas that should be considered when selecting, identifying, and managing people taking high-dose opioids in primary care. Coordinated strategies and services that promote the safe prescribing of opioids are needed. Study registration: PROSPERO, CRD42018088057

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Protocol: mixed-methods study to evaluate implementation, enforcement, and outcomes of U.S. state laws intended to curb high-risk opioid prescribing

Cited by 26 publications

References 38 publications

Effects of Implementation and Enforcement Differences in Prescription Drug Monitoring Programs in 3 States: Connecticut, Kentucky, and Wisconsin

Effects of Implementation and Enforcement Differences in Prescription Drug Monitoring Programs in 3 States: Connecticut, Kentucky, and Wisconsin

Prescription drug monitoring programs: Assessing the association between “best practices” and opioid use in Medicare

Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis

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