Time series analysis of California's prescription monitoring program: impact on prescribing and multiple provider episodes.

UNLABELLED: Prescription monitoring programs (PMPs) are designed to reduce medication diversion by identifying individuals obtaining the same medication from multiple providers (termed multiple provider episodes [MPEs]). This study determined whether recent changes to California's PMP influenced: 1) the extent that practitioners issue prescriptions for a variety of Schedule II opioids; and 2) the incidence of MPEs involving these opioids. Intervention time series of California's PMP data was used to determine the effect of requiring practitioners to transition from using triplicate prescription forms for Schedule II medications to security forms for all controlled substances. Outcome measures included changes in number of prescriptions issued for Schedule II long-acting or short-acting (SA) opioids and the MPEs involving these medications. Requiring a security form was associated with a sustained prescribing increase for SA hydromorphone, meperidine, and SA oxycodone; no prescribing changes were found for SA fentanyl, methadone, and SA morphine, or for any long-acting opioids. The same policy change, however, increased MPEs involving all opioids. Further effort is required to determine how California's PMP can continue to ensure availability of prescription opioids for medical use while better mitigating their diversion. PERSPECTIVE: Statistical model-building was used to evaluate the influence of changes to California's prescription monitoring program. The extent that practitioners prescribe Schedule II opioids and the incidence of people receiving prescriptions from multiple providers were measured. Such research illustrates the viability of evaluating drug control program impact on prescribing practice and potential diversion behaviors.

An analysis of the number of multiple prescribers for opioids utilizing data from the California Prescription Monitoring Program.

BACKGROUND: Prescription monitoring programs scrutinize the prescribing of controlled substances to diminish the utilization of multiple prescribers (aka. "doctor shopping"). The use of multiple prescribers is not a problem per se and can be legitimate, as when the patient's regular physician is not available or a concurrent painful condition is being cared for by a different practitioner. PURPOSE: The primary objective of this study was to determine if those patients who used a few prescribers (two to five) in a 1-year period were distinguishable from those who used only one prescriber. METHODS: We performed a secondary data analysis of the California Prescription Monitoring Program, the Controlled Substance Utilization Review and Evaluation System, by using data collected during 1999-2007. RESULTS: The group who used a few providers (two to five) differed substantially from those who visited one provider over a 1-year period. However, the dissimilarity did not suggest that these patients were more prone to the abuse of opioids. CONCLUSIONS: The decision not to investigate patients who visit a low number of multiple prescribers (two to five) appears to be justifiable. If the number of providers in a given period of time is used to determine if a patient should be challenged as being a "doctor shopper," cutoffs with high specificity (low false-positive rates) should be chosen. Further epidemiologic research is needed to determine the association of the number of prescribers and misuse and/or abuse of opioids.

Computerized progress notes for chronic pain patients receiving opioids; the Prescription Opioid Documentation System (PODS).

OBJECTIVE: We herein provide a description of a health information technology tool using computer-assisted survey instruments as a methodology for documentation during long-term opioid therapy. DESIGN: We report our experience using the Prescription Opioid Documentation and Surveillance (PODS) System, a medical informatics tool that utilizes validated questionnaires to automate the assessment of opioid prescribing for chronic nonmalignant pain. SETTING AND PATIENTS: Chronic pain patients answered questions that were presented on a computer terminal prior to each appointment in a Department of Veterans Affairs Pain Clinic. MEASURES: Pain levels, activities of daily living, and screening for common psychological disorders were sought at each visit. Results were tabulated with some information gathered sequentially permitting evaluation of progress. Following a face-to-face interview, the clinician added additional comments to the medical record. RESULTS: By deploying a systematic series of questions that are recalled by the computer, PODS assures a comprehensive assessment. CONCLUSIONS: The PODS fulfills medicolegal requirements for documentation and provides a systematic means of determining outcomes. This process facilitates the determination of the appropriate intervals between clinic visits by stratifying patients into high, moderate, and low risk.

Documenting and improving opioid treatment: the Prescription Opioid Documentation and Surveillance (PODS) System.

OBJECTIVE: To demonstrate that a computer-assisted survey instrument offers an efficient means of patient evaluation when initiating opioid therapy. Design. We report on our experience with the Prescription Opioid Documentation and Surveillance (PODS) System, a medical informatics tool that uses validated questionnaires to collect comprehensive clinical and behavioral information from patients with chronic pain. SETTING AND PATIENTS: Over a 39-month period, 1,400 patients entered data into PODS using a computer touch screen in a Veterans Administration Pain Clinic. MEASURES: Indices of pain intensity, function, mental health status, addiction history, and the potential for prescription opioid abuse were formatted for immediate inclusion into the medical record. RESULTS: The PODS system offers physicians a tool for systematic evaluation prior to prescribing opioids The system generates an opioid agreement between the patient and physician, and provides medicolegal documentation of the patient's condition. CONCLUSIONS: PODS should improve patient care, refine pain control, and reduce the incidence of opioid abuse. Research to determine how PODS affects clinical care is underway. Specially, the effectiveness and efficiency of providing care utilizing PODS will be evaluated in future studies.

A qualitative study of the barriers to chronic pain management in the ED.

PURPOSE: This qualitative study sought to identify perceived barriers to diagnosing and treating patients with chronic pain in the emergency department (ED). BASIC PROCEDURE: Semistructured interviews were conducted with 24 ED physicians from 4 hospitals to elucidate their experiences of managing chronic pain in the ED. MAIN FINDINGS: Time limitations and a low triage priority were major barriers to caring for patients with chronic pain. But despite the inherent problems of treating a nonurgent condition in a time-limited setting, physicians were strong proponents for treating chronic pain in the ED. PRINCIPAL CONCLUSION: Acknowledging that pain can neither be verified nor disproved, physicians tend to err on the side of the patient, often providing an allotment of opioid medications. They also believe that the ED is not an optimal setting for treating patients in chronic pain but that it is often the last resort for many of these patients, thus, providing the rationale for serving them to the best of their ability.