Wednesday, May 30, 2018
Maybe Real Time Prescription Monitoring Is Not All It Is Cracked Up To Be.
This week we have had more calls for prescription monitoring:
A prescription monitoring system to prevent "doctor shopping" in Queensland is needed urgently within the next two years, rather than the state waiting for a national scheme to come online, an inquest into four opioid deaths has found.
Coroner James McDougall examined the deaths of William House, Jodie Anne Smith, Vanessa Joan White and Daniel Keith Milne between 2012 and 2014.
Medical bodies including the Australian Medical Association and the Pharmacy Guild have repeatedly called for a real-time monitoring system to be introduced in Queensland to prevent addicts from visiting different doctors to collect multiple opioid prescriptions.
There are already moves towards a national monitoring system, after Federal Health Minister Greg Hunt announced $16 million in funding for one last July.
But Mr McDougall said Queensland Health should look to implement its own real-time tracking system "urgently" — definitely within two years.
"The number of deaths that will occur in the interim whilst implementation is taking place is alarming," he said.
"Coronial statistics indicate an annual death toll from prescription opioids approaching 1,500 people each year and increasing.
"Given the growing epidemic associated with opioid misuse, the states and territories need to take responsibility for addressing the increasing issues associated with the prescribing, dispensing and monitoring of drugs of dependence."
The coroner also said more education was needed for doctors prescribing schedule 8 medicines.
A joint inquest into four recent deaths was recently held in the Coroners Court of Queensland with the aim to consider the issues associated with misuse of opioid prescription medication in Queensland and, more broadly, Australia.
Coroner James McDougall explored the circumstances surrounding the deaths of William House, 30 years old at the time of his death; Jodie Anne Smith, 41 years old at the time of her death; Vanessa Joan White, 38 years old at the time of her death; and Daniel Keith Milne, 40 years old at the time of his death.
Each of the patients had participated in doctor shopping in the lead up to their deaths, and in several instances had been able to gain access to large amounts of OxyContin and fentanyl from various doctors at different medical practices, sometimes on the same day or within days of the last prescription.
This was in addition to sometimes being supplied opioids after presenting at hospital emergency departments.
But then this appears:
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.
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.
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.
Observational studies (published in English) from U.S. states that examined an association between PDMP implementation and nonfatal or fatal overdoses.
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.
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.
Few studies, high ROB, and heterogeneous analytic methods and outcome measurement.
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.
National Institute on Drug Abuse and Bureau of Justice Assistance.
The summary review in Journal Watch said in a comment:
“Results of this systematic review are tempered by the observational design of the included studies, moderate-to-high risk for bias in nearly all the studies, and heterogeneity of PDMP features among states (e.g., some states require clinicians to review PDMP data when prescribing narcotics, whereas others do not; similarly, not all states share data). Editorialists emphasize that, although PDMPs probably will curb prescription opioid supplies in U.S. communities, these same communities also require efforts to address heroin and other illegal drug supplies and initiatives to engage patients in drug-treatment programs.”
So what is clear here is that not only do you need prescription monitoring but you have to do it right. The full paper provides some tips as to what ‘right’ may look like!
Clearly worth a read.
Posted by Dr David G More MB PhD at Wednesday, May 30, 2018