The Opioid Crisis: A Multidisciplinary Perspective on Effective Management - Episode 13
Experts share insights on how they have utilized Prescription Monitoring Programs to combat the opioid crisis and improve the safety of prescribed opioids.
Peter Salgo, MD: Let’s take a look at the overall picture: the 10,000-foot view, if you want. There are prescription monitoring programs in clinical practices; how does that fit in? Where does naloxone fit in with that? Jeremy, do you want to start on that?
Jeremy Adler, DMSc, PA-C, DFAAPA: The PDMPs [prescription drug monitoring programs] are certainly important tools. I found them to be much more of an educational tool, useful for good decision-making in patient care. We have already talked today about how so many of these individuals abusing opioids are getting them illicitly. The PDMPs do not monitor illicit opioids or diverted opioids. We cannot see that; but what these programs can do is show us, certainly, if a patient is receiving opioids from more than 1 source and what they are receiving. Often, we find that the PDMPs are even more important when identifying drugs that we know have significant comorbidity with concomitant use, like benzodiazepines; that is the class for which we look.
We use the PDMPs as a way to assess risk, put together plans for our patients, and know when to give naloxone. In California, where I practice, we have—as Theresa already mentioned—legal requirements to offer naloxone if a patient is taking an opioid and benzodiazepine. Certainly, if we see through the PDMPs that they are on a benzodiazepine, then that, for us, is an immediate indication to offer naloxone. I think it is an important part of this equation.
Peter Salgo, MD: Riddle me this, Batman: if there are PDMPs out there—and PDMPs actually are not only a good idea, but they are required by the law in lots of places—I’m encouraged by that, until I hear Jeff. Jeff and Joshua say that opioid overdoses are skyrocketing. How do you reconcile these 2 things?
Charles Argoff, MD: The point that was just made by Dr Adler, or Jeremy, was that we are not going to catch the people who are using opioids illicitly merely by looking at the PDMP, which is why, as we discussed earlier, we cannot put every difficult situation involving opioids into the same bucket. There are people for whom we are trying to optimize the use of opioids in the proper setting who are being prescribed, monitored, and cared for, and we have some more control of that. We do not have as much control over the hardcore drug misuser, or the illicit drug user, and we certainly want to make their experience as safe as possible, we don’t want them to die either, but we do not have the same control, and we are not going to see what they do.
Jeffrey Bratberg, PharmD, FAPhA: I would even go one step further: if you are not required to talk about naloxone when prescribing opioids—and yes, you may be utilizing all those of those referral techniques—if that patient is unable to tell Dr Lynch in the ED [emergency department] that she is taking Suboxone, how many people are going to reveal their cocaine, fentanyl, or occasional heroin use? How many are going to reveal that, whether they are taking opiates or not? Again, we are skilled clinicians; we’ll find out about that and compassionate clinicians will ask about that, but the stigma against illegal drugs is so strong that if the patient decided to seek care, there is going to be an even bigger barrier for them to reveal that. This is why I think naloxone should be universal; we should just say we recommend this everybody. PDMPs are just a tool to recognize that.
Theresa Mallick-Searle, MS, RN-BC, ANP-BC: It needs to be out in the community. One other thing I want to add to Jeremy’s discussion about the PDMP, think about these patients. We want to make sure the patients are safe. We want to make sure they are not doctor shopping, that they are not getting 2 prescriptions for every 1, and that they’re not using it with benzodiazepines. Think of those patients who are diverting. This comes back to the number of opiates that might be out there and how important it is to have the knowledge out in the community about the safe use of naloxone for inadvertent overdoses for patients who are using prescription opiates recreationally.
Peter Salgo, MD: What I hear everybody saying is that the PDMP is a great idea. People change their prescribing practices and have done so over time based on what they see in the PDMP. But it does not cover this enormous pool of nonprescribed opiates, and that pool of nonprescribed opiates is associated with an enormous death risk. The only way to attack this is to not only to give naloxone to people you are prescribing opiates to, but to give it to everybody, because there is a pool out there of people illicitly using opioids that you will never see, that you cannot find. That pool of people is not on the state registry. The only way you hit that is to hit everybody across the board, or am I missing the point?
Charles Argoff, MD: You made the point about how widely available naloxone is in New York state and Rhode Island with that pharmacy, so it is easy to get, and you want to make people want to be as safe as possible. You want to make that into a cool thing. Let’s be cool. We also may want to utilize other resources when evaluating people, like urine drug screening. We have not talked about that. You want to trust and verify your information, and you can use other ancillary measures when assessing someone. We want people to become comfortable under all circumstances with trying to be safe.
Joshua Lynch, DO, EMT-P, FAAEM, FACEP: One other use of the PDMP that we have not talked about, and what I and a lot of emergency physicians also use it for: we print out the report and instead of taking the “I got you,” angle, I take it right into the room and sit down with the patient. I print out 2 copies and give the patient one and I look at the other, and we talk about how this is dangerous, we discuss what is going on here. It may be that the patient has had multiple addresses down or 50 prescriptions in the last 3 months. What is going on here? That acknowledges that the prescriptions mean a lot of opioids are going out into the community, but we also need to talk about the patient getting into treatment or if there is an opportunity for naloxone. We have identified many patients who come in looking for pain medication; we print out the PDMP report and we have a serious discussion that takes us in a totally different direction. Hopefully, this discussion can end up with the patient getting into treatment, getting onto MAT [medication-assisted treatment], or both. That is a less used opportunity to maximize what the PDMP can give us.
Jeffrey Bratberg, PharmD, FAPhA: I would say that the PDMP can be a double-edged sword, and it should be used as a conversation starter to meet people where they are. People do not reveal all of the illegal things that they do because society has labeled them as illegal; they are shameful about it and many health care professionals have not dealt well with patients who have revealed that. I love that approach—use the PDMP, approach them with it, and say, “What can we do? Where are you at?” As Theresa said, we should ask why the patient is diverting. We should say, “It looks like there is a pattern. Are you using your opioids? Your urine opioid screen is negative and yet you have been prescribed these things. I am not trying to accuse you of anything. I want to help you.” We need to go back to that initial point: where are we at?
Transcript Edited for Clarity