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What is a PDMP (Prescription Drug Monitoring Program)?

According to the Centers for Disease Control and Prevention (CMS), a Prescription Drug Monitoring Program (PDMP) is a statewide electronic database that tracks all prescriptions for controlled substances. The goal of PDMPs is to improve the way that opioids and other controlled substances are prescribed, reducing the number of people who misuse, abuse, or overdose while, at the same time, continuing to provide safe and effective pain management to patients who need it. Prescribing physicians and pharmacists are encouraged to check their state’s PDMP prior to prescribing or dispensing controlled substances to help them identify patients who are misusing opioids or other prescription medications. PDMPs can improve patient safety by allowing clinicians to:1-4

  • Identify patients who are obtaining opioids or other controlled substances from multiple providers
  • Identify patients who are obtaining opioids or other controlled substances from multiple pharmacies
  • Calculate the total number of opioids they are prescribing daily
  • Identify patients who are being prescribed other medications that may increase the risk of using opioids, such as benzodiazepines

To be fully effective in their goal of controlling prescription drug abuse and diversion, PDMPs must be fully utilized. This is one reason many states have implemented mandates requiring physicians and pharmacists to check PDMPs prior to prescribing or dispensing controlled substances. In states where PDMP use is not required, utilization rates are well below 50%.5 However, research shows that mandating PDMP usage quickly increases both PDMP registration and utilization. This results in decreases in prescriptions for some commonly abused controlled substances as well as decreases in common measures of “doctor shopping.”5 Currently, forty-six states have mandates for PDMP utilization.6

It is vital for providers to know their state’s requirements for PDMP usage when prescribing controlled substances. In this article, we will take a close look at PDMPs, including who operates them; who can access them; their requirements for use in several states; and how PDMPs relate to the Merit-based Incentive Payment System (MIPS) of the Quality Payment Program (QPP).

Who operates PDMPs?

PDMPs are operated at the state level, and individual state requirements for their usage differ from state to state.2 While the specific laws vary, though, most state PDMPs require prescribing physicians and dispensing pharmacists to review a patient’s prescribing information for the past twelve months prior to prescribing or dispensing any Schedule II-IV controlled substances. They are also required to enter information regarding controlled substance prescriptions into the database. Numerous states already have mandates in place requiring practitioners to query the PDMP prior to prescribing/dispensing controlled substances.6

Effective January 1, 2022, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act will require that all controlled substance prescriptions under Medicare’s Part D drug plan be transmitted electronically.7* Twenty-seven states currently require electronic prescription of controlled substances (EPCS), which will help to standardize prescribing practices across all providers. It will also facilitate entering prescriptions for controlled substances into the state’s PDMP.6, 8, 9 Several other states have set upcoming dates for establishing EPCS mandates, including:6, 10, 11

  • Michigan (October 1, 2021)
  • California (January 1, 2022)
  • Colorado (July 1, 2023 for practitioners and dentists in rural areas; EPCS is currently required for all others)

Many states that mandate PDMP use have enabled integration with individual practices’ electronic health record (EHR) systems.3, 12-15 Requirements for integration between EHR and PDMP also vary from state to state. Practice Fusion is currently able to integrate with six states:

  • Arizona
  • Idaho
  • Illinois
  • North Carolina
  • Texas
  • Ohio

The specific state requirements for PDMP and EPCS utilization for these states are listed below.

State PDMP Requirement

Arizona6, 16, 17

Prescriber review of the Prescription Monitoring Program (PMP) became mandatory effective October 1, 2017:

  • Prescriber must check PMP for all new patients and continue checking quarterly for patients being prescribed a schedule II, III, or IV opioid analgesic or benzodiazepine.

Mandatory EPCS was reinstated beginning July 9, 2021

Idaho6, 18

Prescriber review of PDMP became mandatory beginning July 1, 2020 (with limited exceptions, such as patients receiving treatment in inpatient settings, patients in hospice care, and others listed):

  • Prescriber or prescriber’s delegate must query the PDMP before giving patient a prescription for outpatient use of an opioid analgesic, benzodiazepine, or other schedule II, III, or IV medication.
  • He or she must review the patient’s prescription drug history for the previous twelve months and check for signs of prescription drug diversion or misuse.

EPCS is not mandatory.

Illinois3, 6, 19

Prescriber review of PMP is mandatory (with limited exceptions, such as patients receiving inpatient treatment, patients receiving palliative care, and others listed):

  • Prescriber or prescriber’s delegate must query the PMP before issuing a prescription for Schedule II narcotics such as opioids.

EPCS is not mandatory; however, a statute entered June 25, 2021 proposes to amend the Illinois Controlled Substances Act by requiring that prescriptions for Schedule II, III, IV, or V controlled substances be sent electronically.

North Carolina6, 12, 14, 20, 21

Prescriber review of PDMP—known as the North Carolina Substances Reporting System (CSRS)—became mandatory effective July 7, 2021:

  • Prescribers must query the NC CSRS before writing a prescription for any Schedule II or III controlled substance to check the patient’s twelve-month prescription history.
  • Prescribers should also query the CSRS and review every three months that the prescription continues or any time the medication or dosage changes.

EPCS is mandatory.

Texas4, 6, 22

Review of the PMP—also known as PDMP, Rx AWARE, or PMP AWARxE—became mandatory for both prescribers and pharmacists effective March 1, 2020 (with limited exceptions, such as patients diagnosed with cancer, terminally ill patients, or patients in inpatient treatment):

  • Prescribers and pharmacists (or their delegates) must query the PMP to check patient’s history before prescribing or dispensing opioids, benzodiazepines, barbiturates, or carisoprodol, no matter the duration of the prescription.
  • Prescribers are not required to review the PMP at regular intervals after the initial prescription.

EPCS is mandatory.

Ohio6, 23-25

Prescriber review of the PDMP—also known as the Ohio Automated Rx Reporting System (OARRS)—is mandatory (with limited exceptions, such as patients receiving treatment in hospices, hospitals, nursing homes, or residential care facilities; patients diagnosed as terminally ill; and others listed):

  • Before initially prescribing or personally providing an opioid analgesic or benzodiazepine, prescriber or delegate must request and review patient information from OARRS from at least the past twelve months.
  • Prescriber or delegate must also make periodic requests to OARRS if treatment continues for more than ninety days; requests must be made of intervals of not greater than ninety days.

EPCS is not mandatory.

Note: If you do not see your state listed here, refer to your state’s Department of Health website for information about their specific PDMP and EPCS requirements.

Who has access to PDMPs?

PDMPs allow authorized users access to check patients’ prescription data, such as medications dispensed to individuals, dosages, and prescribing physicians.2 The definition of “authorized user” varies slightly from state to state. Most states allow access to prescribing physicians and their delegates, pharmacists, and law enforcement officers.3, 4, 18, 19, 26

Some states also allow access to other individuals whose work relates to the PDMP’s information.

Most states allow physicians to designate one or more delegates, also known as designees. The delegate can access the PDMP on the physician’s behalf when a patient’s prescription history needs to be checked. A delegate might be a nurse or non-clinical medical practice staff. However, some states do not permit clerical staff to access the PDMP, so it’s important to check your specific state’s regulations.3 In general, delegates must conform to the following guidelines:3, 4, 14, 16, 18, 22

  • They must have their own, unique PDMP registration and login information; they may not use the physician’s login.
  • They can obtain the report of the patient’s prescription drug usage; however, the report must be assessed by the ordering physician, not the delegate.
  • Some states allow physicians to appoint as many delegates as they can effectively supervise; others limit physicians to a certain number of delegates.

Often, the requirement to check the PDMP when prescribing controlled substances includes a requirement to document this check in the patient’s record. The specific documentation requirements vary from state to state, but generally do not require the practice to keep a physical or electronic copy of the report. In most cases, a note that the PDMP was accessed and assessed is sufficient—but again, it’s important to check your specific state requirements.3, 4, 14

In all states, authorized users are limited in when they are allowed to access the PDMP. The PDMP may only be used for an authorized purpose. For instance, a physician or physician’s delegate may only access the PDMP for a patient with whom they have an existing relationship, to perform a check when prescribing a controlled substance. A law enforcement officer may only access the PDMP for a report related to an ongoing investigation. Accessing the PDMP for personal reasons, or for someone not connected with your practice, is prohibited.3, 25

How do the PDMPs relate to the Merit-based Incentive Payment System (MIPS) of the Quality Payment Program (QPP)?

Promoting Interoperability is one of the performance categories for the Merit-based Incentive Payment System (MIPS). MIPS is a program designed to reward high-value, high-quality Medicare clinicians with payment increases while, at the same time, decreasing payments to clinicians who are not meeting performance standards.27, 28 Although PDMP usage is not required for the Promoting Interoperability Performance Category score, it is one eligible means for providers to earn a ten-point bonus score in this category.29

To qualify for the five-point bonus, MIPS eligible providers must query the PDMP for the prescription drug history related to at least one electronically prescribed Schedule II opioid that was prescribed using Certified Electronic Health Record Technology (CEHRT), except where prohibited and in accordance with applicable law. The PDMP query must take place prior to electronic transmission of the Schedule II opioid prescription.29

Why the interest in PDMPs?

Opioids are extremely effective for pain relief. Unfortunately, they also bring a high risk of addiction and overdose. State-implemented PDMPs are the principal strategy currently used in the United States to combat prescription drug abuse, by collecting data that make it easier to detect suspicious prescribing and utilization practices.2, 30, 31

Research has shown that PDMPs are effective tools to help identify possible misuse and diversion of controlled substances.2, 5 However, research also shows that PDMPs must be fully utilized to truly be effective.

States programs have evolved over time and continue to differ in several ways, most significantly in whether they require providers to use the PDMP before prescribing a controlled substance. PDMP administrative data shows that when provider usage is not required, only a small number of providers actually create logins and request prescription histories for their patients. PDMPs in states without “must access” mandates have been found to be largely ineffective.31

On the other hand, in states that do have “must access” mandates, PDMPs have been found to both improve provider participation and reduce opioid-related negative events.31, 32 For instance, putting a comprehensive PDMP mandate in place was associated with:32

  • A significant decrease in the number of opioids prescribed
  • A significant decrease in the number of inpatient stays related to opioid use
  • A significant decrease in the number of opioid-related visits to emergency departments

In one study, researchers estimated annual reductions of approximately 12,000 inpatient stays and approximately 39,000 emergency department visits. Together, these could save over $155 million in Medicaid spending.32

This study additionally found that implementing a “must access” PDMP policy reduced behaviors suggestive of medication hoarding, such as patients obtaining more than a seven-month medication supply within six months and patients filling prescriptions before the previous supply has been used. “Doctor shopping” behaviors were also reduced, such as patients obtaining prescriptions from five or more prescribers or obtaining prescriptions from five or more pharmacies.31

The overall goal of increased PDMP use is to improve the way opioids are prescribed, ultimately reducing the numbers of people who misuse, abuse, or overdose using opioids while still allowing clinicians to provide safe and effective pain management to those patients who need it.1, 2 Understanding your state’s PDMP requirements is essential to be a part of this process.

*Note: CMS is considering a delay to this mandate.

References:

  1. Prescription Drug Monitoring Programs (PDMPs): What Healthcare Providers Need to Know. Centers for Disease Control and Prevention (CDC). Updated February 12, 2021. Accessed August 6, 2021, https://www.cdc.gov/opioids/providers/pdmps.html.
  2. Prescription Drug Monitoring Programs (PDMPs). https://www.cdc.gov/drugoverdose/pdf/PDMP_Factsheet-a.pdf.
  3. Illinois Prescription Monitoring Program Frequently Asked Questions. Illinois PMP. Accessed August 6, 2021, https://www.ilpmp.org/CDC/faqs.php.
  4. About the Texas PMP. Texas Prescription Monitoring Program. Accessed August 10, 2021, https://txpmp.org/about.
  5. COE Briefing: Mandating PDMP participation by medical providers: current status and experience in selected states, Revision 1. February 2014. Accessed August 6, 2021. https://www.ojp.gov/pdffiles1/bja/247134.pdf.
  6. State PDMP Profiles and Contacts. Prescription Drug Monitoring Pragram Training and Technical Assistance. Updated July 1, 2021. Accessed August 19, 2021, https://www.pdmpassist.org/State.
  7. CMS formally delays EPCS enforcement. National Community Pharmacists Association. Updated December 4, 2020. Accessed August 22, 2021, https://ncpa.org/newsroom/qam/2020/12/04/qam-ad-cms-formally-delays-epcs-enforcement.
  8. Get started with EPCS. Practice Fusion. Accessed August 12, 2021, https://www.practicefusion.com/epcs/.
  9. The SUPPORT for Patients and Communities Act (H.R. 6). American Society of Addiction Medicine.
  10. California: e-Prescribing of Controlled Substances. Practice Fusion. Accessed August 22, 2021, https://www.practicefusion.com/epcs/california-eprescribing-controlled-substances/.
  11. Colorado: e-Prescribing of Controlled Substances. Practice Fusion. Accessed August 22, 2021, https://www.practicefusion.com/epcs/colorado-eprescribing-controlled-substances/.
  12. NC Controlled Substances Reporting System. North Carolina Department of Health and Human Services (NCDHHS). Accessed August 6, 2021, https://www.ncdhhs.gov/divisions/mental-health-developmental-disabilities-and-substance-abuse/north-carolina-drug-control-unit/nc-controlled-substances-reporting-system.
  13. NC Controlled Substances Reporting System Integration Resources. North Carolina Department of Health and Human Services (NCDHHS). Accessed August 6, 2021, https://www.ncdhhs.gov/divisions/mhddsas/ncdcu/csrs/integration.
  14. Resources & Information. North Carolina Medical Board. Accessed August 6, 2021, https://www.ncmedboard.org/resources-information/faqs/nc-controlled-substances-reporting-system.
  15. Texas Prescription Monitoring Program Statewide Integration. Texas State Board of Pharmacy. Accessed August 6, 2021, https://www.pharmacy.texas.gov/pmp/PMPIntegration.asp.
  16. Prevent Opioid Misuse and Abuse in Arizona: Prescriber Requirements for Compliance with Arizona’s Controlled Substance Prescription Monitoring Program (PMP) (Arizona Medical Association (ARMA)) (2017).
  17. Frequently Asked Questions (FAQs). Arizona State Board of Pharmacy Controlled Substances Prescription Monitoring Program. Updated July 9, 2021. Accessed August 6, 2021, https://pharmacypmp.az.gov/faqs.
  18. FAQ for PDMP Mandatory Checking. 2021. January 7, 2021.
  19. Legislative Updates. Prescription Drug Monitoring Program Training and Technical Assistance Center (PDMP TTAC). Accessed August 6, 2021, https://www.pdmpassist.org/Policies/Legislative.
  20. CSRS Mandatory Use and Technical Assistance. North Carolina Department of Health and Human Services (NCDHHS). Accessed August 6, 2021, https://www.ncdhhs.gov/divisions/mental-health-developmental-disabilities-and-substance-abuse/north-carolina-drug-control-unit/nc-controlled-substances-reporting-system/csrs-mandatory-use-and-technical-assistance.
  21. Important Notice for North Carolina Prescribers: STOP Act is fully enacted. Accessed August 6, 2021. https://www.ncdentalboard.org/PDF/Prescribers%20Editorial.pdf.
  22. Texas Prescription Monitoring Program. Texas State Board of Pharmacy. Accessed August 6, 2021, https://www.pharmacy.texas.gov/pmp/.
  23. Ohio Automated Rx Reporting System. Ohio Automated Rx Reporting System (OARRS). Accessed August 6, 2021, https://www.ohiopmp.gov/.
  24. State of Ohio. When to Check OARRS - Pocket Card - Prescribers and Pharmacists. https://www.pharmacy.ohio.gov/Documents/LawsRules/RuleChanges/OARRSRules/When%20to%20Check%20OARRS%20-%20Pocket%20Card%20-%20Prescribers%20and%20Pharmacists.pdf.
  25. State of Ohio Board of Pharmacy. Mandatory OARRS Registration and Requests April 18, 2019. https://www.pharmacy.ohio.gov/Documents/Pubs/Special/OARRS/Mandatory%20OARRS%20Registration%20and%20Requests.pdf.
  26. Idaho PDMP. Idaho State Board of Pharmacy. Updated December 16, 2020. Accessed August 6, 2021.
  27. CMS. Quality Payment Program Overview. CMS. Accessed April 10, 2021, https://qpp.cms.gov/about/qpp-overview.
  28. Merit-based Incentive Payment System (MIPS) 2021 MIPS Quick Start Guide (CMS) (2021).
  29. Merit-Based Incentive Payment System (MIPS) Promoting Interoperability Performance Category Measure 2020 Performance Period (Centers for Medicare & Medicaid Services)
  30. Moyo P, Simoni-Wastila L, Griffin BA, et al. Impact of prescription drug monitoring programs (PDMPs) on opioid utilization among Medicare beneficiaries in 10 US States. Addiction. May 12, 2017;112(10)doi: https://doi.org/10.1111/add.13860.
  31. Buchmueller TC, Carey C. The Effect of Prescription Drug Monitoring Programs on Opioid Utilization in Medicare. NBER Working Paper Series. February 2017. Accessed August 13, 2021. https://www.nber.org/system/files/working_papers/w23148/w23148.pdf.
  32. Wen H, M. H, Jeng PJ, Bao Y. Prescription Drug Monitoring Program Mandates: Impact On Opioid Prescribing And Related Hospital Use. Health Affairs. September 2019;38(9)doi:https://doi.org/10.1377/hlthaff.2019.00103.
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