As states grapple with the growing problem of prescription drug misuse and abuse, many are turning to prescription drug monitoring programs (PDMPs) to prevent the misuse of potentially addictive drugs. One of these states is Kentucky. Since launching its PDMP in 1999, Kentucky has seen its ranking among states with the highest nonmedical use of prescription painkillers drop from second to thirty-first place, reflecting a drop that officials attribute largely to its monitoring program.
The overarching goals of PDMPs are to facilitate appropriate prescribing practices and prevent prescription drug misuse and diversion. They accomplish this by collecting information provided by pharmacies on the controlled substances they dispense. This information includes the patient’s personal information, the name of the medical practitioner doing the prescribing, the dispenser, the type of medication, and the dosage. Medical practitioners are then encouraged—and in some states required—to access this information, collected in a centralized database, prior to writing a prescription for a potentially addictive drug. This process can help practitioners determine whether or not a patient is seeking the drug for a legitimate medical condition. For example, a search might reveal that an individual has obtained prescriptions for a potentially addictive drug from five or more practitioners within the past three months—an indication that the individual may be using the drug for nonmedical purposes or selling it to others (known as diversion).
Some states also use PDMP data to strengthen related prevention initiatives. For example, law enforcement officials often use PDMP data to inform investigations into suspected drug diversion, avoiding the need to visit every pharmacy in the area to obtain individual prescription records. State health officials can also use aggregated PDMP data (data stripped of identifying information) to determine patterns of drug dispensing within communities. By pinpointing areas with high levels of drug dispensing—often correlated with higher rates of prescription drug misuse—officials can target communities with the greatest need for prevention and treatment services.
According to Peter Kreiner, principal investigator for the PDMP Center of Excellence at Brandeis University, Kentucky’s PDMP, the Kentucky All Schedule Prescription Electronic Reporting (KASPER) System, is regarded by many as a “gold standard” for state PDMPs. He attributes this to three primary factors: legislation that mandates physician and pharmacy compliance; ongoing innovativeness, such as improvements in timeliness of data reporting; and high levels of ongoing cooperation among key stakeholders.
For PDMPs to be effective, medical practitioners and pharmacies need to use them. In Kentucky, use is required. In July 2012, the state implemented legislation that requires practitioners and pharmacists to register with KASPER. Before prescribing a potentially addictive drug, practitioners are required to obtain a KASPER report on the patient’s controlled substance prescription history. The law also mandates that practitioners review a patient’s treatment plan at regular intervals and before issuing additional controlled substance prescriptions or refills. Pharmacies are required to report every controlled substance prescription they dispense.
Physicians in Kentucky agree that KASPER has helped them make better prescribing decisions. Participants in a 2010 survey of physicians indicated that KASPER reports were an aid to clinical practice, with 70% of respondents judging them “very” or “somewhat” important in helping them decide which drug to prescribe a patient. Ninety percent of respondents also indicated that they had “refused to prescribe or dispense a controlled substance based on the information contained in a KASPER report.”
The speed and regularity with which data are updated also contributes to KASPER’s utility. According to Kreiner and other experts, physicians need as close to “real-time” data as possible to get the full picture of when and how their patients are using potentially addictive prescription drugs. He explains: “A single patient, fraudulently seeking pain medication, can visit several hospital emergency departments within a single 24-hour period. Across the nation, most pharmacies in states with PDMPs are required to report the prescriptions they dispense within 14 days. Kentucky has cut this reporting time in half by requiring pharmacies to report their prescriptions within a week.” And a new rule will go into effect that will require pharmacies to submit their reports within one business day.
Finally, ongoing, high-level support from the governor’s office, legislature, and other key stakeholders has been critical to KASPER’s success, according to David Hopkins, KASPER Program Manager for the Kentucky Cabinet for Health and Family Services. From the beginning, efforts were made to reach out to stakeholders, including doctors, pharmacies, professional licensing boards, law enforcement, judges, and others; many of these groups played important roles in raising awareness about KASPER. For example, the Kentucky Board of Medical Licensure and the Kentucky Office of Drug Control Policy are instrumental in providing training to physicians in how to use KASPER and in promoting the database’s value to clinical practice.
According to Connie Smith, Branch Manager for the Substance Abuse Prevention Program with the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities, such stakeholder buy-in was also critical for addressing initial concerns about the monitoring program—such as fears that a data breach could potentially expose patients’ personally identifiable information, or worries that a PDMP would have a chilling effect on physicians’ willingness to prescribe potentially addictive drugs to patients who had a legitimate medical need. “We learned that we needed to engage all stakeholders in building and maintaining consensus for how KASPER would be implemented and operate,” says Smith. “We also learned how important it is to make the public aware of KASPER and of the data safeguards that are in place. People need to know their data are safe.”
Value to Public Health
The data produced by PDMPs have enormous value to public health officials and policymakers responsible for allocating resources for prevention and treatment. In the past, policymakers were often forced to rely on federal data, which could be four to six years old by the time they were disseminated, says Nick Peiper, Epidemiologist and Project Director of the Kentucky State Epidemiological Outcomes Workgroup (SEOW), which evaluates KASPER data as part of its data surveillance efforts. Officials relying on PDMP data can be confident that they are making decisions based on what’s happening now, not what happened six years ago.
In addition, Kentucky prevention officials frequently use KASPER data to monitor the scope of the prescription drug problem across the state, and in its various regions, and to tailor their prevention efforts to the needs of these regions. “We knew we had a prescription drug problem, but before KASPER, we didn’t know where the problem was,” explains Smith, who is also co-chair of the Kentucky SEOW. “Now, we know where it is, we know how much is going on. And we can pinpoint the hotspots. Not every region has a problem, but because of KASPER and other epidemiological information, we can now pinpoint those regions that do have problems.”
Currently, KASPER data only includes prescriptions dispensed within the state. Hopkins and Kreiner agree that an important next step for KASPER, as well as for other PDMPs, is to establish protocols and agreements for sharing data across state lines, particularly with neighboring states. Doing so could help to identify and prevent people from crossing state borders to obtain potentially addictive prescription drugs for fraudulent purposes.
KASPER is a work in progress, Hopkins says, but it has already made a difference. “KASPER has helped increase awareness by doctors of the need for more review of the potentially addicting substances their patients are receiving,” he says. “And in some cases, this may lead them to prescribe fewer potentially addictive medications in the first place.”
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