Final CAT                                                                                         Name: Ruthie Schreiber

PICO Rotation 7 Week 3

 

 

Clinical Question:

 

Prescription opioid abuse has unfortunately become a significant public health problem. Prescription drug monitoring programs (PDMP) are electronic databases that can track controlled substance prescriptions of individual patients as a means of combatting this issue. With the implementation of PDMPs, healthcare providers are able to access patient prescription history to inform future prescriptions and ultimately prevent drug abuse and overdose.

 

Search Question:

 

In adult patients prescribed opioids, are prescription drug monitoring programs an effective way to prevent drug overdose?

 

PICO search terms:

 

P	I	C	O
Adult patient	Prescription drug monitoring programs	No intervention	Decrease in non-fatal overdose
Opioid use	PDMP		Decrease in fatal overdose
Patient prescribed opioids	Prescription drug abuse prevention plan

 

 

 

Search tools and strategy used:

 

PubMed

 

            ~Prescription drug monitoring programs → 690 results

                        *Filter: meta-analysis, systematic review→ 14 results

                                    *Filter: 5 years publication date→ 12 results 

  

 

           ~ Prescription drug monitoring programs opioids→ 457 results

                      *Filter: meta-analysis, systematic review→ 11 results

                                 *Filter: 5 years publication date → 10 results

 

~Prescription drug monitoring programs overdose→188 results

                        *Filter: meta-analysis, systematic review→ 6 results

                                    *Filter: 5 years publication date→ 6 results 

 

 

Cochrane

 

            ~ Prescription drug monitoring programs → 168 results

                        *Filter: review → 4 results

 

~ Prescription drug monitoring programs overdose →8 results

                        *Filter: trials → 8 results

 

  

           

Google Scholar

 

~ Prescription drug monitoring programs opioids → 43,000 results

                        *Filter: since 2016→ 22,200 results

 

~ Prescription drug monitoring programs opioids overdose→ 25,000 results

                        *Filter: since 2016→ 17,300 results

 

 

 

 

 

In determining which articles to include for this miniCAT, it was important to find articles that were of the highest evidence available (i.e. systematic review or meta analysis) and to include studies that were conducted recently. I chose to include my specific articles due to their explicit relevance to both my PICO question and clinical scenario. Additionally, these articles are systematic reviews, which are of high-level evidence. Furthermore, these articles were recently published within the past couple years, making them pertinent and extremely up to date.

                                   

 

Articles Chosen:

 

• Fink DS, Schleimer JP, Sarvet A, et al. Association Between Prescription Drug Monitoring Programs and Nonfatal and Fatal Drug Overdoses: A Systematic Review. Ann Intern Med. 2018;168(11):783-790. doi:10.7326/M17-3074

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6015770/

 

Background

Prescription drug monitoring programs (PDMPs) are a key component of the president’s Prescription Drug Abuse Prevention Plan to prevent opioid overdoses in the United States.

Purpose

To examine whether PDMP implementation is associated with changes in nonfatal and fatal overdoses; identify features of programs differentially associated with those outcomes; and investigate any potential unintended consequences of the programs.

Data Sources

Eligible publications from MEDLINE, Current Contents Connect (Clarivate Analytics), Science Citation Index (Clarivate Analytics), Social Sciences Citation Index (Clarivate Analytics), and ProQuest Dissertations indexed through 27 December 2017 and additional studies from reference lists.

Study Selection

Observational studies (published in English) from U.S. states that examined an association between PDMP implementation and nonfatal or fatal overdoses.

Data Extraction

2 investigators independently extracted data from and rated the risk of bias (ROB) of studies by using established criteria. Consensus determinations involving all investigators were used to grade strength of evidence for each intervention.

Data Synthesis

Of 2661 records, 17 articles met the inclusion criteria. These articles examined PDMP implementation only (n = 8), program features only (n = 2), PDMP implementation and program features (n = 5), PDMP implementation with mandated provider review combined with pain clinic laws (n = 1), and PDMP robustness (n = 1). Evidence from 3 studies was insufficient to draw conclusions regarding an association between PDMP implementation and nonfatal overdoses. Low-strength evidence from 10 studies suggested a reduction in fatal overdoses with PDMP implementation. Program features associated with a decrease in overdose deaths included mandatory provider review, provider authorization to access PDMP data, frequency of reports, and monitoring of nonscheduled drugs. Three of 6 studies found an increase in heroin overdoses after PDMP implementation.

Limitation

Few studies, high ROB, and heterogeneous analytic methods and outcome measurement.

Conclusion

Evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient, as is evidence regarding positive associations between specific administrative features and successful programs. Some evidence showed unintended consequences. Research is needed to identify a set of “best practices” and complementary initiatives to address these consequences.

Primary Funding Source

National Institute on Drug Abuse and Bureau of Justice Assistance.

 

• Ponnapalli A, Grando A, Murcko A, Wertheim P. Systematic Literature Review of Prescription Drug Monitoring Programs. AMIA Annu Symp Proc. 2018;2018:1478-1487. Published 2018 Dec 5.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371270/

 

Abstract

Prescription opioid abuse has become a serious national problem. To respond to the opioid epidemic, states have implemented prescription drug monitoring programs (PDMPs) to monitor and reduce opioid abuse. We conducted a systematic literature review to better understand the PDMP impact on reducing opioid abuse, improving prescriber practices, and how EHR integration has impacted PDMP usability. Lessons learned can help guide federal and state-based efforts to better respond to the opioid crisis.

• Alogaili F, Abdul Ghani N, Ahmad Kharman Shah N. Prescription drug monitoring programs in the US: A systematic literature review on its strength and weakness [published online ahead of print, 2020 Jul 18]. J Infect Public Health. 2020;S1876-0341(20)30565-7. doi:10.1016/j.jiph.2020.06.035

 

https://www-sciencedirect-com.york.ezproxy.cuny.edu/science/article/pii/S1876034120305657

 

 Abstract

Prescription Drug Monitoring Program (PDMP) is an electronic database that tracks the prescriptions of controlled drugs with its aims to combat the incidence of drug abuse. Although the establishment of PDMP in the US was since 2003, evidence of the impact of PDMP’s strength and weakness towards its implementation is still scarce. A systematic literature review according to Preferred Reporting Items for Systematic Review (PRISMA) standard was conducted to investigate the influence of PDMP’s strength in combating the incidence of drug abuse and also to review the weaknesses of PDMP that prohibit its implementation. Results from this study reveal that the implementation of PDMP has mitigated the issue of drug abuse and has increased work efficiency among healthcare practitioners. However, the implementation rate of this system is low due to its weaknesses such as limited internet access and limited access to the PDMP system. Therefore, efforts to overcome the weaknesses of PDMP need to be instituted to ensure the healthcare system could fully optimize PDMP’s benefits.

• Rhodes E, Wilson M, Robinson A, Hayden JA, Asbridge M. The effectiveness of prescription drug monitoring programs at reducing opioid-related harms and consequences: a systematic review. BMC Health Serv Res. 2019;19(1):784. Published 2019 Nov 1. doi:10.1186/s12913-019-4642-8

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6825333/

Abstract

Background

In order to address the opioid crisis in North America, many regions have adopted preventative strategies, such as prescription drug monitoring programs (PDMPs). PDMPs aim to increase patient safety by certifying that opioids are prescribed in appropriate quantities. We aimed to synthesize the literature on changes in opioid-related harms and consequences, an important measure of PDMP effectiveness.

Methods

We completed a systematic review. We conducted a narrative synthesis of opioid-related harms and consequences from PDMP implementation. Outcomes were grouped into categories by theme: opioid dependence, opioid-related care outcomes, opioid-related adverse events, and opioid-related legal and crime outcomes.

Results

We included a total of 22 studies (49 PDMPs) in our review. Two studies reported on illicit and problematic use but found no significant associations with PDMP status. Eight studies examined the association between PDMP status and opioid-related care outcomes, of which two found that treatment admissions for prescriptions opioids were lower in states with PDMP programs (p < 0.05). Of the thirteen studies that reported on opioid-related adverse events, two found significant (p < 0.001 and p < 0.05) but conflicting results with one finding a decrease in opioid-related overdose deaths after PDMP implementation and the other an increase. Lastly, two studies found no statistically significant association between PDMP status and opioid-related legal and crime outcomes (crime rates, identification of potential dealers, and diversion).

Conclusion

Our study found limited evidence to support overall associations between PDMPs and reductions in opioid-related consequences. However, this should not detract from the value of PDMPs’ larger role of improving opioid prescribing.

 

• Haegerich TM, Jones CM, Cote PO, Robinson A, Ross L. Evidence for state, community and systems-level prevention strategies to address the opioid crisis. Drug Alcohol Depend. 2019 Nov 1;204:107563. doi: 10.1016/j.drugalcdep.2019.107563. Epub 2019 Sep 19. PMID: 31585357.

https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0376871619303400?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0376871619303400%3Fshowall%3Dtrue&referrer=https:%2F%2Fpubmed.ncbi.nlm.nih.gov%2F

Abstract

Background

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

Methods

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

Results

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

Conclusions

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

 

 

 

 

 

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Fink DS, Schleimer JP, Sarvet A, et al. (2018)	Systematic Review	-The following databases were searched for this study: MEDLINE, Current Contents Connect (Clarivate Analytics), Science Citation Index (Clarivate Analytics), Social Sciences Citation Index (Clarivate Analytics) and ProQuest Dissertations. -Out of 2,661 records 17 articles met the inclusion criteria (4 reported non-fatal drug overdose and 13 reported fatal drug overdoses). The articles analyzed PDMP implementation only, program features only, PDMP implementation and program features, PDMP implementation with mandates provider review combined with pain clinic laws, and PDMP robustness	-The primary purpose of this review was to examine whether implementation of PDMP is associated with changes in non-fatal and fatal overdoses. Additional interests included identifying features of programs that are differentially associated with these outcomes, and to investigate any potential unintended consequences of the programs.	-There is insufficient evidence to draw conclusion regarding PDMP implementation fatal and non-fatal overdoses   -There is low strength evidence indicating a reduction in fatal overdoses with PDMP implementation   -Program features that were associated with a decrease in overdose included the following: mandatory provider review, provider authorization to access PDMP data, frequency of reports, monitoring of non-scheduled drugs   -Implementation of PDMPs may have unintended negative outcomes (i.e. increase in heroin overdose)	-The authors recognized that their systematic review had several limitations: all studies were observational, many had serious or critical risk of bias, studies used different modeling strategies to account for confounding factors, and different years of data/different outcomes were often examined.
Ponnapalli A, Grando A, Murcko A, Wertheim P. (2018)	Systematic Literature Review	– Using PubMed database, the authors initiated a literature review to identify search terms as well as inclusion and exclusion criteria. Afterwards they modified their review methodology according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRSIMA) guidelines.   -Out of the 408 papers yielded from this search, 27 publications were included in the final review which tackled the effect of prescription drug monitoring programs on reducing opioid abuse, improvement in prescriber practices, and integration of electronic health record on PDMP usability.	-The main goal of this review was to address the following two research questions: 1) How have PDMPs impacted opioid-related clinical outcomes and other related metrics? 2) How has the integration of PDMPs into EHRs impacted utilization and usability?	– Most PDMPs have had a positive impact and have led to decreases in opioid prescriptions as well as decreases in opioid-related overdoses and deaths -Low utilization among providers is a prominent issue that results in lack of PDMPs being used to their full potential -A better understanding of the technology and usability behind PDMPs is recommended to improve its overall efficacy	-The authors recognized that there were some limitations of their study:  papers were only received from PubMed database, only papers from the US were included, and the included results are based solely on scientific papers.
Alogaili F, Abdul Ghani N, Ahmad Kharman Shah N (2020)	Systematic Literature Review	-This study conducted a systematic literature review adhering to the Preferred Reporting Items for Systematic Review’s (PRISMA) guidelines. Two main databases were used: Scopus and Web of Science (WoS).   -The search yielded a total of 35 papers, of which 19 were ultimately included in the final stage.	-The primary goal of this review was to assess the effectiveness of PDMP’s in its attempt to lower the incidence of drug abuse, and to also acknowledge the weaknesses of PDMP implementation.	-Implementation of PDMP effectively reduces the incidence of drug abuse in the US while simultaneously increasing work efficacy among healthcare providers   -PDMP has weaknesses that limit its capability to be fully effective and optimized (i.e. implementation gap, infrastructure challenges, data availability, limited internet access, limited access to the PDMP system itself)	-The authors do not note any sources of limitations or biases. There are no funding sources, nor competing interests declared.
Rhodes E, Wilson M, Robinson A, Hayden JA, Asbridge M.(2019)	Systematic Review	-The search strategy followed a predefined protocol according to the PRISMA guidelines. The following databases were searched: MEDLINE, Embase, CINAHL, PsycInfo, Web of Science.   -A total of 161 articles were assessed and ultimately 22 studies were included which addressed the association of PDMP status with opioid related consequences/harms.	-The outcomes of interest included in this review were solely related to opioids and were grouped into categories by theme: 1) Opioid related care outcomes (i.e. hospital visits, treatment program admissions) 2) Opioid related adverse effects (i.e. overdose, death) 3) Opioid related legal and criminal outcomes (i.e. arrests, diversion)	-States that feature PDMP programs are associated with lower treatment admissions for prescription opioids -There are conflicting results related to opioid adverse events (i.e. whether there is a decrease vs. an increase in opioid-related overdose deaths with PDMP implementation) -There is no statistically significant association between PDMP status and opioid-related legal/crime outcomes (i.e. crime rates, identification of potential dealers, diversion)	-The authors note that they were unable to perform meta-analyses (due to heterogeneity across studies/outcomes).   -Other limitations were that the included studies varied in how they measured associations and used different units of analysis (i.e. person years vs. state years), populations (i.e. insured/not)  and overarching analytic approach.
Haegerich TM, Jones CM, Cote PO, Robinson A, Ross L. (2019)	Systematic Review	-A systematic search of the following electronic databases was performed: CINAHI, Medline, PsychInfo, Scopus.   -Out of the 12,558 publications identified, ultimately 251 publications met the final inclusion criteria for this review.   -26 studies in particular evaluated state prescription drug monitoring programs as the primary intervention	-The main outcome of this study was to identify the various interventions implemented to address the ongoing opioid overdose epidemic. These interventions included: 1) state and legislation regulation 2) prescription drug monitoring programs (PDMPs) 3) insurance strategies 4) clinical guideline implementation 5) provider education 6) clinical health system interventions 7) naloxone education and distribution 8) safe storage/disposal 9) public education 10) community coalitions 11) interventions employing public safety and public health collaboration	-States with mandatory PDMP use demonstrated significant decreases in days’ supply of opioids prescribed and deaths involving prescription opioids. -Stronger PDMP states (i.e. those that require mandatory use, more monitoring, updated more frequently) demonstrated greater reductions in overdose deaths, including prescription opioids -Significantly lower opioid related deaths were found in states with PDMP compared to states without	-The authors recognize the limitations of their review. For example, they did not systematically rate individual study quality, rather the assessment synthesized the overall quality of evidence for each intervention category. Additionally, it is possible that relevant articles were not identified, and that the review is subject to publication bias if studies that found no significant effects were not published.

 

Conclusion(s):

 

Article #1:  Fink DS, Schleimer JP, Sarvet A, et al. concluded that overall, the evidence is not sufficient to determine whether or not PDMP increases or decreases non-fatal or fatal overdoses, and potential unintended negative outcomes (i.e. increased rate of heroin overdose). 

 

Article #2: Ponnapalli A, Grando A, Murcko A, Wertheim P concluded that PDMPs have a mixed but mostly positive impact on opioid use and its associated morbidity and mortality. Furthermore, with a better understanding of its technology and usability, the overall utility of PDMPs by providers will be improved. 

 

Article #3: Alogaili F, Abdul Ghani N, Ahmad Kharman Shah N concluded that PDMPs have been able to reduce the incidence of drug abuse in the US while simultaneously increasing work efficiency among healthcare providers. The authors recognize the weaknesses to the program and acknowledge that by overcoming such obstacles then PDMP can be implemented to its fullest potential.

 

Article #4: Rhodes E, Wilson M, Robinson A, Hayden JA, Asbridge M. concluded that there is limited evidence to support PDMPs capability to reduce opioid-related consequences. However, this should not take away from the capability and impact that PDMPs have on improving opioid prescribing.

 

Article #5: Haegerich TM, Jones CM, Cote PO, Robinson A, Ross L concluded that PDMP has one of the strongest quality evidences available when compared with the alternative interventions studied on preventing overdose

 

My overall conclusion for this CAT assignment is that in adult patients prescribed opioids, prescription drug monitoring programs (PDMPs) have the potential to be an effective means of preventing drug overdose. The research conducted does support the use of prescription drug monitoring programs as a means of combating drug overdose, despite instances of insufficient evidence. Each article recognizes the unique challenges that providers can face when using the PDMP system, and therefore with the proper education on its technological use, PDMPs have the capability to be optimized to their full potential.

 

 

Clinical Bottom Line:

 

I weigh my studies in the following order:

• Article #3: Alogaili F et al
• Article #5: Haegerich et al
• Article #2: Ponnapalli et al
• Article #4: Rhodes E et al
• Article #1: Fink DS et al

 

 

Alogaili F et al was the highest level of evidence since it was a systematic review and it was published in 2020. Its recent publication makes it extremely up to date and pertinent. Furthermore, the authors did not note any sources of limitations or biases, and there were no funding sources, nor competing interests declared.

 

 

Haegerich et al was also at the highest level of evidence since it was a systematic review, and it was published in 2019. It included 26 studies that particularly evaluated state prescription drug monitoring programs as the primary intervention.

 

Ponnapalli et al was also at the highest level of evidence since it was a systematic review that was published in 2018. Out of the 408 papers yielded from the search, 27 publications were ultimately included in the final review that discussed the effect of prescription drug monitoring programs on reducing opioid abuse, improvement in prescriber practices, and integration of electronic health record on PDMP usability.

 

 

Rhodes et al was also at the highest level of evidence since it was a systematic review that was published in 2019. Out of the 161 articles that were assessed, ultimately 22 studies were included which addressed the association of PDMP status with opioid related consequences/harms.

 

Fink DS et al was also at the highest level of evidence since it was a systematic review that was published in 2018. However, it was ranked last because only 17 articles met the inclusion criteria and the evidence was deemed low strength and insufficient. It was still included in my CAT because of it is a systematic review that directly relates to my clinical scenario and search question.

 

 

 

 

Magnitude of any effects:

 

Article #1:  Evidence from 3 studies was insufficient to draw conclusions regarding an association between PDMP implementation and non-fatal overdoses. Low-strength evidence from 10 studies suggested a reduction in fatal overdoses with PDMP implementation. Three out of six studies did find an increase in heroin overdoses after implementation of PDMP.

 

Article #2: Five studies depicted a decline in opioid-related overdoses and deaths with use of PDMP. Specifically, states with “stronger” PDMPs demonstrated a larger decrease in opioid related deaths when compared to states with “weaker” PDMPs (strength criteria included 11 factors that were each assigned a point value, thereby assigning a state with a higher total point value as a “stronger” PDMP).

 

Article #3: One study depicted how PDMP implementation will help reduce the number of cases of prescription opioid overdose which relates to approximately 20% reduction in deaths resulting from opioid pain reliever overdose. Another study demonstrated that with implementation of this program, the trend of heroin overdose decreased considerably.

 

Article #4: Of the 13 studies that reported on opioid-related adverse events, two found significant (p< 0.001 and p< 0.05) but conflicting results; one study showed a decrease in opioid related overdose deaths after PDMP implementation while the second study showed an increase.

 

Article #5: States with mandatory PDMP use demonstrated significant decreases in the number of deaths involving prescription opioids. Additionally, “stronger” PDMP states (i.e. those requiring mandatory use, monitored/updated more frequently) had greater reduction in prescription opioid overdose deaths.

 

Using the evidence from this assignment, prescription drug monitoring programs do have a significant effect at preventing drug overdose, with the potential to have an even greater effect in the future.

 

Clinical Significance:

 

Unfortunately, opioid abuse has been an ongoing problem here in the United States. The number of overdose deaths has continued to rise, prompting the institution of both national as well as state guidelines to help combat this issue. Prescription drug monitoring programs continue to serve as decision support for prescribers, pharmacists, and state/federal regulators. These electronic databases are used as means of informing prescribers of concurrent prescriptions and to expose any drug misuse prior to prescribing. The effectiveness of this tool is highlighted by the fact that as of 2017, all 50 states have some form of PDMP in place.

 

Overall the research does support the use of prescription drug monitoring programs as a means of combating drug overdose. Each source recognizes the unique challenges that providers might face when using the PDMP system. With the proper education on its technological use, PDMP systems have the capability to be optimized to their full potential. The overall clinical conclusion from this research is significant as it provides support for a technologically innovative means of combating the ongoing public health issue of drug overdose.

 

Any other considerations important in weighing this evidence to guide practice:

 

Future studies are certainly warranted and should be conducted. One aspect that should be acknowledged is if having a standard set of universal PDMP features can prevent unintended consequences. Furthermore, it would be interesting to see how creating a user-friendly system could impact the reduction in drug overdose overall. In the meantime, PDMPs remain an important tool for minimizing potential harm of opioid abuse and should be recognized as a key instrument in combating the ongoing opioid crisis.