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In Brief
Prescription Drug Monitoring Programs:
A Guide for Healthcare Providers
Winter 2017 • Volume 10 • Issue 1
Since the 1990s, a dramatic increase in prescriptions
for controlled medications—particularly for opioid pain
relievers such as oxycodone and hydrocodone—has
been paralleled by an increase in their misuse
1
and by
an escalation of overdose deaths related to opioid pain
relievers.
2
The number of state-run prescription drug
monitoring programs (PDMPs) has also increased during
this timeframe. Currently, 49 states, the District of
Columbia, and 1 U.S. territory (Guam) have
operational PDMPs.
The rst state PDMPs provided law enforcement and other
public agencies with surveillance data to identify providers
inappropriately prescribing controlled medications. The
objective was to minimize harmful and illegal use and
diversion of prescription medications, without interfering
with their appropriate medical use. Advances in technology
have enabled PDMPs to take on another important role—
that of an adjunct source of information that prescribers
and pharmacists can use to improve the care and safety of
individual patients. Helping healthcare providers make the
most informed prescribing and dispensing decisions, as
part of an initiative to address opioid-related overdoses and
deaths, is a federal government priority.
3
This In Brief is targeted to healthcare providers who
prescribe and/or dispense controlled medications, including
substance use treatment providers, primary care providers,
nurse practitioners, physician assistants, pain specialists,
psychiatrists, and pharmacists. The document explains the
emergence and purpose of PDMPs and describes how PDMP
use can enhance clinical decision making and improve
individual patient safety while also helping curb the public
health crises of prescription drug misuse and unintentional
overdose deaths. Additional sources of information are found
in the Resources section at the end of this document.
The Evolution of PDMPs
PDMPs are state-operated databases that collect
information on dispensed medications. The rst PDMP
was established in 1939 in California, and by 1990 another
eight state programs had been established.
4
PDMPs would
periodically send reports to law enforcement, regulatory,
or licensing agencies as part of eorts to control diversion
of medication by prescribers, pharmacies, and organized
criminals. Such diversion can occur through medication or
prescription theft or illicit selling, prescription forgery or
counterfeiting, nonmedical prescribing, and other means,
including diversion schemes associated with sleep clinics
(sedative-hypnotics and barbiturates), weight clinics
(stimulants), and pain clinics (opioid medications).
4
The rst PDMPs, which were paper based, did not provide
reports to healthcare providers for use during individual
patient care; however, today’s electronic databases have
a variety of features that make them practical for such
care. Depending on the particular state law, the types of
professionals who may register to access PDMP records
include prescribers (e.g., primary care doctors, nurse
practitioners, physician assistants), dispensers (e.g.,
pharmacists), medical examiners, practitioner licensure
board members, third-party payers, public health and
safety agency representatives, and law enforcement and
drug court personnel.
5
The majority of PDMPs permit
providers to delegate access to a mid-level practitioner,
such as a registered nurse or a pharmacy technician.
5
In
more than half of states, prescribers and pharmacists are
required to register with their respective PDMP; in some
of these states, registrants are also required to access
the PDMP for a patient’s prescription history before
prescribing or dispensing controlled substances.
5
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In Brief
The Nation’s Prescription Drug Problem
Misuse
■ A 2015 survey indicated that an estimated 3.8 million
people had used prescription pain relievers in the past
month for nonmedical purposes.
6
■ In 2010, there were 33,701 reported admissions
to substance use treatment facilities for combined
benzodiazepine and opioid pain reliever use, an
increase of 569.7 percent from the 5,032 admissions in
the year 2000.
7
■ The number of people who reported receiving treatment
for the nonmedical use of prescription pain relievers
has more than doubled since 2002, reaching 822,000 in
2015.
8
Emergency Department Visits
■ From 2004 to 2011, the rate of emergency department
visits involving misuse of all classes of pharmaceuticals
increased 114 percent. More than 1.4 million such visits
were made in 2011.
9
■ Over the same 2004–2011 period, the rate of
emergency department visits involving opioid pain
relievers increased 153 percent and involved more than
420,000 visits.
9
Deaths
■ From 1999 to 2014, the rate of drug poisoning deaths
involving opioid analgesics (powerful prescription
pain relievers) more than quadrupled, with 18,893 such
deaths in 2014.
10
■ Since 2000, the United States has experienced a
200 percent increase in the rate of overdose deaths
involving opioids (opioid pain relievers and heroin).
11
■ In 2014, drug overdose involving some type of opioid
took the lives of 28,647 people; prescription opioids
were involved in at least half of these deaths.
11,12
■ Methadone prescribed for pain puts users at particularly
high risk for overdose death. Methadone is involved
in about one-third of deaths related to opioid pain
relievers, even though only 2 percent of pain reliever
prescriptions are for this medication.
13
(Methadone
used in medication-assisted treatment is not considered
part of the escalating problem of prescription drug
misuse; nationwide, only a small percentage of opioid-
related deaths involve patients receiving treatment in
opioid treatment programs [OTPs]).
14
Overview of Current PDMPs
PDMP databases in most states are housed within a
licensing or public health agency; in a few states, they are
located within a law enforcement agency. Most states track
prescriptions for Schedule II–V controlled medications,
and some also track unscheduled medications with misuse
potential (e.g., ephedrine, which can be used in the
manufacture of methamphetamine). PDMP funding varies
by state but includes federal, state, or private sources
and revenue generated through licensing fees or other
mechanisms.
4
Most PDMPs update their data on a daily or weekly basis,
enabling prescribers and dispensers to assess a patient’s
recent patterns of use or misuse. Systems are evolving
toward even more frequent updating; in 2012, Oklahoma
became the rst state to institute real-time reporting,
with prescription data available within 5 minutes after
medication is dispensed.
15
Real-time reporting can oer
some advantages; in particular, emergency department
care providers can nd near real-time prescription histories
for patients presenting for acute care.
Some state PDMPs provide batch reporting; this is a utility
that enables prescribers to obtain summary histories for a
group of patients, such as those scheduled for upcoming
appointments. The practitioner can review the summaries
to determine whether a full report should be ordered for
any particular patient.
4
A majority of state PDMPs are authorized to send
unsolicited reports to providers, licensing boards, or law
enforcement agencies when a prescriber’s or prescription
recipient’s activity exceeds thresholds established by
the PDMP.
5,16
Unsolicited reports can alert healthcare
providers to intervene with patients whose prescription-
related behavior may suggest substance misuse, whereas
unsolicited reports to investigative agencies or licensure
boards can support investigations into potential drug
diversion or problematic prescribing.
16
More than half of the states
5
are building out systems to
allow for data sharing across systems, agencies, and states.
Benets of this system integration include the following:
providers can obtain patient prescription history within
the electronic health record system instead of logging
into two separate systems; state Medicaid agencies can
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Prescription Drug Monitoring Programs: A Guide for Healthcare Providers
Winter 2017, Volume 10, Issue 1
share information with federal health service providers
(e.g., U.S. Department of Veterans Aairs, Indian Health
Service); and adjacent states are able to share information
to address illicit cross-border prescription lling or to
provide for better coordination of the care that a patient is
receiving in dierent states.
How PDMP Data Are Collected
Pharmacies must submit required data to their state’s
PDMP for each prescription they dispense for specied
controlled substances. Pharmacies in the U.S. Department
of Veterans Aairs and in the Indian Health Service
are also authorized to submit data to PDMPs, and such
pharmacies in many states do so.
17,18
Depending on a
state’s legislative requirements, the following entities/
individuals may also be required to submit prescription
data when dispensing controlled substances: emergency
departments, wholesale distributors, licensed hospital
pharmacies, physicians, veterinarians, dentists, and
medical and behavioral health service providers.
Information collected typically includes date dispensed,
patient, prescriber, pharmacy, medication, and quantity.
This information is submitted to databases in electronic
form. The intervals at which pharmacies are required to
submit data vary by state.
Privacy and Security
Ensuring the privacy and security of health information
is critical for several reasons, including prevention
of identity theft and medical fraud. One example of
a safeguard is that many PDMPs are prohibited from
providing identifying information about individual
patients or practitioners in reports to law enforcement
agencies, except in specied situations such as in response
to a subpoena or for an active case investigation.
4,19
Such
prohibitions are also intended to protect condentiality
and avoid potential targeting of providers engaged in
legitimate prescribing and dispensing activities.
How Prescribers and Pharmacists Use
PDMP Data
PDMP reports can be used by a healthcare practitioner
with other support tools (e.g., documentation templates,
patient data reports and summaries, computerized
alerts and reminders) when screening a new patient or
monitoring a current patient. The practitioner can review
the patient’s prescription record from the PDMP to conrm
or augment information provided by the patient’s own
reports and the medical exam. Providers can promote
patients’ acceptance of this tool by proactively informing
them that PDMP data are routinely checked for all patients
to enhance care and that condentiality and privacy are
protected by law and regulation.
For example, when treating for chronic pain, a practitioner
can check the state PDMP for data on the patient’s history
of prescriptions for controlled substances. This information
can be used to determine whether the patient is already
receiving opioid medications or other medications that,
when combined with an opioid prescription, might put him
or her at risk for overdose. The Centers for Disease Control
and Prevention (CDC) advises: “Clinicians should review
PDMP data when starting opioid therapy for chronic pain
and periodically during opioid therapy for chronic pain,
ranging from every prescription to every 3 months.”
20
Whether updated in real time or at some other regular
interval, a PDMP provides longitudinal information from
which a healthcare practitioner can identify patterns of
inappropriate prescription medication use or risky substance
use behavior. PDMP data may suggest that a patient has an
uneventful prescription history, giving condence to the
practitioner that the patient has a legitimate need for any
scheduled prescription medications under consideration. The
data can also reveal whether the patient has been prescribed
medication that may create a risk for interaction with
medication the practitioner is considering prescribing. For
example, the data can suggest the total level of morphine
equivalent to which a patient already has access and whether
the patient has access to other medication(s) that may, in
combination, put the patient at risk for overdose. Another
potential use of the data is to determine whether a patient
has failed to ll a prescription for medication previously
prescribed by that practitioner; in such situations, the
practitioner can initiate a conversation about why the patient
is not taking the medication as indicated.
A practitioner can also use PDMP data to monitor patients
with suspected or known substance use disorders by
checking patient records for medically unwarranted
concurrent use of prescription medication (e.g., high doses
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In Brief
Exceptions to PDMP Data Reporting
Requirements
Typically, prescriptions for intravenous medications and
those lled by hospice palliative care are not submitted
to PDMPs. In addition, federal condentiality rules
(42 CFR Part 2, Condentiality of Alcohol and Drug
Abuse Patient Records) exempt medications dispensed at
OTPs—that is, when a medication for the treatment of a
substance use disorder (e.g., methadone, buprenorphine)
is dispensed at an OTP, patient-identifying information is
not submitted to the PDMP. There are some exceptions
specied in the federal regulations. OTP-based prescribers
may access PDMP information to help manage the care
of their patients, and the Substance Abuse and Mental
Health Services Administration (SAMHSA) encourages
them to do so.
21
It is especially important that OTP-based
physicians and physicians who are qualied to prescribe
buprenorphine for opioid use disorder (i.e., physicians who
have received a waiver under the Drug Addiction Treatment
Act of 2000) access the PDMP, because these physicians
are the only practitioners who have full knowledge of their
patients’ controlled medication histories.
of several prescriptions, including long- and short-acting
opioids as well as benzodiazepines) and use of multiple
prescribers or pharmacies. Other indicators of potentially
problematic prescription use that a practitioner can look
for when reviewing PDMP data include early rells and
dose escalation.
Behavior that suggests substance misuse, a substance use
disorder, or diversion is known as aberrant drug-related
behavior.* PDMP data can alert a practitioner to aberrant
behavior such as doctor shopping (obtaining overlapping
prescriptions from dierent doctors for intended
nonmedical use) or pharmacy shopping (visiting multiple
pharmacies to ll prescriptions); these are called “multiple
provider episodes.”
PDMP data are best used in conjunction with other sources
of information, including clinical assessment, before
making any determinations about aberrant behavior,
22
because no validated and standardized criteria for the
threshold of questionable activity have been established.
4
A patient who has obtained prescriptions from multiple
providers is not necessarily a “doctor shopper”; the
patient could have legitimately received prescriptions
from dierent specialists for diverse conditions (e.g., a
terminal disease or disorder, chronic pain, postsurgical
pain). There are also plausible reasons why a patient
might ll prescriptions at multiple pharmacies (e.g.,
because dierent pharmacies may be closer to work or
home, because a particular pharmacy oered a coupon).
For these reasons, a proposed operational denition
of shopping behavior for medications at high risk for
misuse or diversion is having “overlapping prescriptions
written by dierent prescribers and lled at three or more
pharmacies” (emphasis added).
23
When PDMP data, combined with other information,
indicate that a patient may be engaging in aberrant
behavior, the practitioner can use this information in the
medical setting with the patient as a basis for an immediate
conversation or intervention. To ensure that the patient
does not misuse prescribed medication, the practitioner can
monitor PDMP data in conjunction with urine drug testing
and use of a treatment agreement (a contract between
patient and practitioner on what each of them will do).
Before prescribing an opioid for pain, the practitioner can
assess PDMP data to ensure that a patient is not obtaining,
through other prescribers, medication with sedative
eects (e.g., other opioids, benzodiazepines), which could
heighten risk of overdose when used simultaneously with
the opioid. PDMPs provide another valuable function
in that providers can use them to periodically review
their own prescribing record, to conrm that their Drug
Enforcement Administration (DEA)-controlled substance
number has not been used illegally by another person.
4,24
Not only prescribers but also pharmacists are enhancing
patient care through their use of PDMPs. For example,
pharmacists can identify interaction risks from multiple
prescriptions. Pharmacists can also initiate conversations
with patients whose prescription use patterns indicate
possible substance misuse, and they can refer such
patients for screening and counseling and link them with
informational resources on substance use disorders and
*Treatment Improvement Protocol (TIP) 54, Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders, provides a
description of aberrant drug-related behaviors on pages 54 and 56.
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Prescription Drug Monitoring Programs: A Guide for Healthcare Providers
Winter 2017, Volume 10, Issue 1
substance use disorder treatment. Alternatively, they
can contact the patient’s prescriber, who may be best
positioned to provide resources or referrals. Pharmacists
can also use PDMP data to ag suspicious prescribing
patterns that may indicate aberrant, illicit, or unsafe
prescribing by medical professionals.
PDMP Effectiveness
Provider surveys, case studies, state evaluations, and
other reports oer growing evidence that individual state
databases are reducing diversion while also improving
individual clinical decision making and prescribing
practices and lowering rates of admissions for substance
use treatment.
25
For example, after New York and Tennessee
required prescribers to consult their state’s database before
prescribing pain medications, the percentage of patients with
multiple provider episodes (receiving prescriptions from ve
or more prescribers or lling prescriptions at ve or more
pharmacies in a 3-month period) dropped 75 percent and
36 percent, respectively.
26
Evidence from states with mandates also suggests that
PDMP utilization supports appropriate prescribing and
dispensing. In the 1-year period beginning 2 months after
Kentucky’s mandate on enrollment and use of its PDMP
went into eect (in July 2012), overall dispensing of
controlled substances in the state declined 8.5 percent.
In approximately the same period, prescriptions for
buprenorphine (a medication used in treatment of opioid
use disorder) increased nearly 90 percent. According to
the PDMP Center for Excellence, these two data points
indicate that the PDMP mandate suppresses inappropriate
prescribing but does not impinge on legitimate prescribing.
26
PDMP utilization may also be a factor in reducing
mortality associated with opioid use. A 2016 study of
34 states (32 with PDMPs) found that the rate of opioid-
related deaths declined in states in the year after PDMP
implementation. States whose PDMPs had more robust
features (e.g., more frequently updated data) experienced
greater reductions in deaths compared with states whose
PDMPs did not have those features.
27
Ohio’s experience indicates that PDMPs can be a
signicant tool in a broader program to encourage and
enforce safe prescribing practices. In 2011, the state
adopted rules that mandate prescriber and dispenser
use of the PDMP under certain conditions. At the same
time, the state instituted other measures designed to curb
misuse of prescription drugs, including crackdowns on
pill mills (physicians, clinics, or pharmacies that prescribe
or dispense controlled medications inappropriately or
for nonmedical reasons), licensing restrictions on pain
management clinics to prevent overprescription of opioid
pain medications, and the institution of a drug take-back
program. In the rst quarter of 2014 alone, the PDMP
received requests for 2 million reports.
26
A concern that has been raised about PDMPs is that they
could suppress the availability of opioid medication for
legitimate cases of pain. A 2016 study found that across
24 states implementing PDMPs, a sustained 30 percent
reduction in the rate of prescribing Schedule II opioids
occurred; however, there was no signicant impact on the
overall prescribing of pain medication (the study did not
evaluate whether patients’ pain was eectively managed).
28
One small study (N=179) of patients presenting with
nonacute pain conditions in an emergency department
found that in 41 percent of the cases, clinicians altered
their prescribing plan after consulting the state’s PDMP;
changes went in both directions, with the planned opioid
prescribing reduced in 61 percent of the cases and
increased in 39 percent.
29
Other initial studies indicate that PDMPs do not have a
suppressive eect, although they may aect the types
of opioids that are prescribed. A 2009 study found that,
between 1997 and 2003, compared with states without
PDMPs, states with PDMPs had a smaller number of
shipments per capita (from suppliers to distributors such
as pharmacies) for oxycodone (a medication highly
associated with drug diversion) and reduced admissions
for the treatment of prescription opioid misuse. At the
same time, overall opioid shipments increased, indicating
no chilling eect on the prescribing of opioids overall.
30
According to a study on Project Lazarus—a program in
Wilkes County, NC, that combines PDMP surveillance
data with public health education, prevention, and
treatment eorts—overdose deaths in the county declined
69 percent from 2009 to 2011, even though the number of
opioid prescriptions remained nearly level and was higher
than the state average.
31
In a pilot study of the Indiana
PDMP in 2012, physicians reported that the clinical care
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6
In Brief
they provided was enhanced by use of PDMPs; depending
on their patients’
clinical needs, physicians both reduced
(by 58 percent) and increased (by 7 percent) the number of
prescriptions written or number of pills dispensed.
32
Another concern is the perception that increased
prescription monitoring through PDMPs may be a factor
that causes people who are dependent on prescription
opioids to switch to heroin use, contributing to heroin-
related overdose deaths (the rate of heroin-related deaths
almost tripled from 2010 through 2013
33
). However,
according to an analysis of 2002–2011 data from the
National Survey on Drug Use and Health, of people who
initiate nonmedical use of pain relievers, only 3.6 percent
transition to heroin use within 5 years of initiation.
34
According to the report Trends in Heroin Use in the United
States: 2002 to 2013, “The concern that eorts to prevent
the illegal use of prescription opioids are causing people
to turn to heroin is not supported by the trend data. . . .
Although research indicates that people who previously
misused prescription pain relievers were more likely
to initiate heroin use than people who had not misused
prescription pain relievers, most people who misuse
prescription pain relievers do not progress to heroin use.”
35
Furthermore, according to a 2016 review article,
36
implementation of most policy decisions aimed at reducing
rates of nonmedical use of opioid medications occurred
after heroin use rates had begun trending upward. The
authors point to heroin’s increased accessibility, reduced
price, and high purity as factors that may have contributed
to increases in the drug’s use. In addition, the review
highlighted studies of Florida and Staten Island, NY, that
found that policy-induced reductions in the rates of opioid
prescribing were associated with reductions in overall
opioid-related deaths (that is, deaths related to either
heroin or opioid medication use). Based on the overall
ndings of the review, the authors recommended enhanced
use of PDMPs as part of a comprehensive strategy to
reduce initiation of nonmedical opioid use.
PDMPs as a Public Health
Surveillance Tool
Projects are in development to enhance use of state
PDMPs for public health surveillance. Several states
have provided PDMP information (typically with patient-
and prescriber-specic identication details hidden or
removed) to researchers for the purpose of identifying
trends in prescribing patterns.
4
This type of aggregate
information can be combined with health outcomes
data—such as those compiled by emergency departments,
medical examiners, poison control centers, and substance
use treatment centers—to provide community-level risk
data for use in planning community-level interventions.
22
Several federal agencies have coordinated with the
PDMP Center of Excellence to establish the Prescription
Behavior Surveillance System (PBSS). This is an early
warning surveillance and evaluation tool that can analyze
de-identied, population-based, longitudinal data from
multiple states.
37
PBSS data are being used to measure
trends in controlled substance prescribing and to support
educational initiatives for safe and appropriate prescribing.
For example, one PBSS-based report, published in 2015,
analyzed data from eight states representing one-fourth
of the U.S. population.
38
Among other trends, the analysis
revealed the common practice of coprescribing opioids
and benzodiazepines. This happens despite the fact that
patients who concurrently use both types of medication
face increased risk for potentially fatal overdose.
2
How Prescribers and Pharmacists
Can Access PDMPs
A healthcare provider must enroll in a PDMP to become
an authorized user before obtaining access to its data.
Typically, the enrollment procedure involves certifying
credentials, authenticating providers through proper
identication, and establishing secure system access
through passwords and/or biomarkers. These procedures
are intended to restrict entry to users with legitimate
purposes for accessing the data. Several states have
developed streamlined registration systems that make
enrollment easier, while still maintaining condentiality
and security.
4
Related Recommendations for
Healthcare Providers
PDMP use complements other measures that providers
can take to prevent misuse and diversion of prescription
medications and to help ensure the safety of patients using
them. Some of these measures are described below.
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Prescription Drug Monitoring Programs: A Guide for Healthcare Providers
Winter 2017, Volume 10, Issue 1
Increase knowledge about substance use disorders
and their prevention and treatment. Many prescribers
have had little or no education on substance use disorder
issues, either in professional school or through recurrent
training.
39,40
Furthermore, many prescribers are not
educated or trained in prescribing practices that minimize
risk with commonly misused medications.
39,41
Less than
half of the states have statutes or regulations that require or
recommend education for prescribers of prescription pain
medication.
42
SAMHSA and other sources oer online
learning opportunities on substance use disorders and
related topics (see “Continuing education opportunities” in
the Resources section of this document).
Increase knowledge about safe opioid prescribing.
According to the Food and Drug Administration (FDA),
43
obtaining training on opioid pharmacotherapy is one
of three key actions prescribers can take to help curb
the opioid public health crisis in the United States. The
other two are reviewing and knowing the most current
opioid drug labels and helping educate patients on using
prescription opioids safely and eectively. Valuable
information on this topic is available from CDC and
other sources (see “Opioid prescribing resources” and
“Continuing education opportunities”).
Write prescriptions for controlled substances
electronically. Electronic Prescriptions for Controlled
Substances, a DEA initiative, permits electronic
prescribing so long as both the prescriber and the dispenser
use secure electronic health IT that meets DEA criteria.
44
Objectives of all electronic prescribing are to reduce
opportunities for fraudulent prescriptions and better
identify cases of misuse, improve eciency and streamline
prescriber workow, inform clinical decision making, and
improve patient safety by reducing adverse events. (See
“Opioid prescribing resources.”)
Become informed about risk-reduction strategies for
opioid overdose. Providers can incorporate overdose
prevention messages in their communications with patients
who have prescriptions for controlled medication and
with these patients’ caregivers. These messages can cover
opioid risk and safety, potential side eects, signs of
overdose, rescue breathing techniques, administration of
naloxone (see next paragraph), and guidance on when to
call 911. Providers can also consider developing a program
policy for responding to onsite overdose.
Become informed about the use of naloxone for
treatment of opioid overdose. Available by prescription,
naloxone is an opioid antagonist that is used to counter the
eects of opioid overdose. The medication successfully
reversed more than 26,000 overdoses between 1996 and
2014.
45
Wider distribution of naloxone, and more training in
its use, could save many lives.
46
The product is available in
auto-injector and nasal spray formulations, which facilitate
immediate administration by laypeople on the scene of
an overdose, before emergency response professionals
arrive.
47
U.S. Department of Health and Human Services
agencies, including SAMHSA, are working to expand
distribution of naloxone to law enforcement agencies,
emergency responders, prescribers, patients with opioid
prescriptions, and individuals who have experienced an
opioid overdose and their family members.
48
Providers can
consider having naloxone available in the oce setting
and prescribing naloxone to patients at risk for opioid
overdose, including those being treated for pain. Through
standing orders, collaborative practice agreements, and
pharmacists’ prescriptive authority, states are making it
substantially easier to gain access to naloxone.
49
The local department of public health can provide
information about programs in the community that
oer training on naloxone use. SAMHSA’s Opioid
Overdose Prevention Toolkit provides information for rst
responders, treatment and service providers, and people
recovering from opioid overdose.
Recognize signals that a patient may be misusing
prescription medications. Signs of prescription opioid
misuse, for example, include presenting with vague
complaints of pain, physical signs of acute intoxication,
symptoms of withdrawal, low blood pressure, slowed
heart rate, and respiratory depression.
50
Patterns of
behavior that may indicate prescription medication
misuse include escalated use (e.g., running out of
medication early, claiming to have lost a prescription and
needing a rell), frequent emergency department visits
in pursuit of prescriptions, or visits to clinics after hours
or at busy times.
51
Other warning signs are if the patient
charms or pressures the practitioner into prescribing an
opioid medication, particularly for a specic controlled
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Eective • People Recover
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In Brief
substance (that may have higher street value than generic
equivalents); feigns illness but avoids a physical exam
or diagnostic tests; uses other techniques to procure a
prescription;
51
or has a history of medication overdose.
Identify patients with risky substance use behaviors
and refer them to treatment. Before prescribing,
providers should determine whether a patient has a history
of substance misuse or whether he or she has risk factors
associated with substance misuse. Providers should also
try to provide support for people with suspicious patterns
of prescription medication use, rather than terminating
them as patients; these individuals may have substance
use disorders requiring treatment. In addition, PDMP
information that suggests a suspicious pattern of substance
use should be cross-checked to ensure that it does not
contain errors. Ways to encourage patients to adhere to
safe prescription use include the following:
■ Employ treatment agreements.
■ Regulate visit intervals.
■ Control the medication supply.
■ Conduct urine drug testing.
■ To the degree possible, include the patient’s support
network in monitoring eorts and coordinate care with
other providers.
Using a universal precautions approach, providers are
encouraged to employ the safe prescribing practices listed
above with all patients for whom they have prescribed
controlled medication, not just those at obvious risk.
52
When treating patients with suspicious patterns of
prescription medication use, providers can make clear
that they will continue to provide care but will not enable
medication misuse. SAMHSA’s TIP 54 provides guidance
on managing opioid use disorder risk in patients treated
with opioids.
52
Educate patients not to share medication prescribed to
them. In the majority of instances in which people ages
12 or older obtain prescription pain relievers for misuse
(dened as “use in any way not directed by a doctor,
including use without a prescription of one’s own; use in
greater amounts, more often, or longer than told to take a
drug; or use in any other way not directed by a doctor”
53
),
they obtain it for free, buy it, or take it without asking from
a friend or family member.
6
Usually, that friend or family
member obtained the medication by prescription from
one doctor (that is, through legitimate means). Patients
receiving prescriptions should be counseled not to share
their medications, because a medication appropriate for
one individual may be inappropriate for another. Also,
illicit use of prescription drugs can be as dangerous as use
of illegal drugs, potentially leading to opioid use disorder,
overdose, and/or death.
Promote proper storage and disposal of prescription
medications. Providers can advise patients to secure
prescriptions with addiction potential in a locked box
or cabinet. Providers can also encourage patients to
follow disposal instructions on the drug label or patient
information that accompanies a particular medication.
FDA, in cooperation with the Oce of National Drug
Control Policy, has developed guidelines for medication
disposal, which dier based on medication type. Many
communities oer “take-back days” that allow the public
to bring unused medication to a central location for proper
disposal. On an ongoing basis, consumers may also bring
or mail back unused prescription medication to locations
authorized by DEA. Consumers can contact their local
household trash and recycling service for information on
their community’s take-back programs. (See “Medication
disposal resources” for links to the FDA guidelines and
DEA’s disposal information.)
Conclusion
PDMPs are an increasingly valuable and easy-to-use
resource for healthcare providers who prescribe and
dispense controlled medication. Regulation and oversight
of these databases ensure that the benets for clinical care
do not jeopardize patient privacy and security. Providers
are encouraged to register to use their state’s PDMP and
to routinely query the database in regard to their patients’
prescription histories. This practice can help curtail
prescription medication misuse and diversion, reduce risk
of substance use disorders, and prevent opioid overdoses
and deaths.
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Eective • People Recover
9
Prescription Drug Monitoring Programs: A Guide for Healthcare Providers
Winter 2017, Volume 10, Issue 1
Resources
PDMP resources
National Alliance for Model State Drug Laws
www.namsdl.org/prescription-monitoring-programs.cfm
National Association of State Controlled Substances
Authorities
www.nascsa.org/rxMonitoring.htm
Prescription Drug Monitoring Program Training and
Technical Assistance Center (the PDMP TTAC and the
PDMP Center of Excellence have merged into a single
program)
www.pdmpassist.org
Opioid prescribing resources
Attention Prescribers: FDA Seeks Your Help in Curtailing
the U.S. Opioid Epidemic
www.fda.gov/downloads/Drugs/DrugSafety
/InformationbyDrugClass/UCM330618.pdf
CDC Guideline for Prescribing Opioids for Chronic Pain
www.cdc.gov/drugoverdose/prescribing/guideline.html
National Pain Strategy
https://iprcc.nih.gov/docs/HHSNational_Pain_Strategy.pdf
Electronic Prescriptions for Controlled Substances (EPCS)
www.deadiversion.usdoj.gov/ecomm/e_rx
The Extended-Release and Long-Acting Opioid Analgesics
Risk Evaluation and Mitigation Strategy (provided by
pharmaceutical companies as required by FDA, this
website links to resources and accredited continuing
education for healthcare providers)
www.er-la-opioidrems.com
Keeping Patients Safe: A Case Study on Using
Prescription Monitoring Program Data in an Outpatient
Addictions Treatment Setting
www.pdmpassist.org/pdf/COE_documents/Add_to_TTAC
/methadone_treatment_n_%203_2_11.pdf
VA/DoD Clinical Practice Guidelines, Management of
Substance Use Disorders
www.healthquality.va.gov/guidelines/MH/sud
Medication disposal resources
Drug Disposal Information
www.deadiversion.usdoj.gov/drug_disposal
How To Dispose of Unused Medicines
www.fda.gov/ForConsumers/ConsumerUpdates
/ucm101653.htm
Continuing education opportunities
HealtheKnowledge
www.healtheknowledge.org
Opioid and Pain Management Continuing Education
www.drugabuse.gov/opioid-pain-management-cmesces
OpioidPrescribing.org: Safe and Eective Opioid
Prescribing for Chronic Pain
www.opioidprescribing.com
Providers’ Clinical Support System for Medication
Assisted Treatment
http://pcssmat.org
Providers’ Clinical Support System for Opioid
Therapies
http://pcss-o.org
SAMHSA’s Knowledge Application Program
E-Learning Website (includes courses on prescription
medication misuse, abuse, dependence, and addiction)
https://kap-elearning.samhsa.gov
Relevant publications from SAMHSA
(available through http://store.samhsa.gov)
Opioid Overdose Prevention Toolkit
Substance Abuse Treatment Advisory: OxyContin
®
:
Prescription Drug Abuse—2008 Revision
Substance Abuse Treatment Advisory: Prescription
Medications: Misuse, Abuse, Dependence, and Addiction
Treatment Improvement Protocol (TIP) 54: Managing
Chronic Pain in Adults With or in Recovery From
Substance Use Disorders
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Eective • People Recover
10
In Brief
Treatment referral resources
SAMHSA’s National Helpline
(24 hours a day, 365 days a year; English and Español)
1-800-662-HELP (1-800-662-4357)
SAMHSA’s Behavioral Health Treatment
Services Locator
https://ndtreatment.samhsa.gov
American Society of Addiction Medicine,
Membership Directory
https://asam.ps.membersuite.com/directory
/SearchDirectory_Criteria.aspx
Notes
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3
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Opioid abuse in the U.S. and HHS actions to address opioid-drug
related overdoses and deaths [Issue brief]. Retrieved December 2,
2016, from https://aspe.hhs.gov/basic-report/opioid-abuse-us-and
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4
Clark, T., Eadie, J., Kreiner, P., & Strickler, G. (2012). Prescription
drug monitoring programs: An assessment of the evidence for best
practices. Waltham, MA: Brandeis University, Heller School for
Social Policy and Management, Prescription Drug Monitoring
Program Center of Excellence.
5
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data 2012 and 2014. Retrieved December 2, 2016, from
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6
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7
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8
Hughes, A., Williams, M. R., Lipari, R. N., Bose, J., Copello,
E. A. P., & Kroutil, L. A. (2016, September). Prescription drug use
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Survey on Drug Use and Health. NSDUH Data Review. Retrieved
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9
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17
Gunderson, C. (2014, September). Prescription drug monitoring
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18
Prescription Drug Monitoring Program Training and Technical
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Aairs pharmacies reporting to PDMP. Retrieved December 2,
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19
Prescription Drug Monitoring Program Training and Technical
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_PDMP_CURRICULUM_Final.pdf
20
Centers for Disease Control and Prevention. (2016). CDC guideline
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MMWR Recommendations and Reports, 65(1), 16.
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Eective • People Recover
11
Prescription Drug Monitoring Programs: A Guide for Healthcare Providers
21
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22
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25
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26
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In Brief
This In Brief was written and produced under contract numbers 270-09-0307 and 270-14-0445 by the Knowledge Application
Program (KAP), a Joint Venture of JBS International, Inc., and The CDM Group, Inc., for the Substance Abuse and Mental
Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Christina Currier and
Suzanne Wise served as the Contracting Offic ’s Representatives, and Candi Byrne served as KAP Project Coordinator.
Disclaimer: The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the
views, opinions, or policies of SAMHSA or HHS.
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Recommended Citation: Substance Abuse and Mental Health Services Administration. (2017). Prescription Drug
Monitoring Programs: A Guide for Healthcare Providers. In Brief, Volume 10, Issue 1.
Originating Offic Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center
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Published 2017
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