Prescriber Mandates in Prescription Drug Monitoring Programs

To address the crisis of opioid misuse, abuse, and overdose, every state but Missouri has implemented a prescription drug monitoring program (PDMP) that collects data from retail pharmacies on all dispensed controlled substances. PDMPs can help prescribers identify patients who might misuse or divert controlled substances, as well as patients who need substance abuse treatment.

Despite the promise of PDMPs, actual use by prescribers remained low until recent years. A national survey in 2014 found that 53% of primary care physicians had ever used their state’s PDMP and many did not use it routinely. Many states have now mandated that prescribers register to become authorized users and/or that prescribers use the PDMP (that is, query the system) at the point of care. Typically, mandates of registration apply to all prescribers of controlled substances; in contrast, mandates of use vary in the drug classes, clinical settings, or clinical circumstances to which they apply.

What are the effects of these state PDMP mandates? A new Health Affairs study by CHERISH pilot grantee, Dr. Yuhua Bao, and colleagues at the University of Kentucky (Dr. Hefei Wen) and at Weill Cornell Medical College (Drs. Bruce Schackman and Brandon Aden) evaluates the effect of mandates on opioid prescriptions received by Medicaid enrollees, a population with a heightened prevalence of prescription opioid misuse and overdose. They found that PDMP mandates of any kind implemented between 2011 and 2014 were associated with a 9-10% reduction in the use of Schedule II opioids by Medicaid enrollees compared to states without mandates. Schedule II opioids are a class of opioids with the greatest potential for misuse and dependence and accounted for 70% of all opioids received by Medicaid enrollees.

Contrary to a common belief that just requiring prescribers to register would have limited effects, the researchers found that these reductions were largely attributable to mandates of registration. Mandates of use, either alone or in combination with a mandate of registration, were not associated with (incremental) reductions in Schedule II opioid prescriptions received. The authors estimate that if every state adopted a mandate of registration, Medicaid programs nationwide could improve prescribing practices and save more than $166 million on Schedule II opioids annually.

This evidence supports the adoption of mandates of registration in all states as an effective and relatively low-cost strategy to enhance prescriber participation in PDMPs. The added value of mandating use needs further evaluation as more states adopt stronger and more comprehensive mandates of use in recent years. Also, these policies should be considered in light of their potential unintended consequences, such as excessive infringement of prescriber autonomy. While enforcement of mandates of registration is relatively low-cost (for example, it can be paired with prescriber license renewal), enforcing mandates of use will be costly if not impossible. Adoption of PDMP prescriber mandates calls for thoughtful balances among their potential benefits, prescriber buy-in, time burden, privacy and confidentiality concerns around substance use, and other considerations.