Before admitting new patients to his practice, Dr. Miguel Diaz checks their prescription history. Diaz, a family medicine physician with Community Care Physicians, PC in Clifton Park, New York, logs onto the state’s prescription drug monitoring program, or PDMP. There, he sees everything the patient has been prescribed during the past year and who prescribed it.
“I have had patients who requested to come in and I checked the P[D]MP and they clearly were doctor-shopping and getting too many prescriptions,” he tells Filter. Diaz says that when he has come across doctor-shoppers asking for an appointment, “I just didn’t accept them into my practice.”
Last fall, President Trump signed the SUPPORT for Patients and Communities Act into law, a lengthy piece of legislation meant to address the opioid-involved overdose crisis. It outlines provisions for expanding PDMPs—electronic databases that physicians, other prescribers, pharmacists and law enforcement can check to track the prescribing of controlled substances, particularly opioids.
Once this piece of the law takes effect in October 2021, physicians in every state will be required to check their state’s PDMP before prescribing controlled substances.
“It makes me more comfortable in my prescribing habits, that I’m giving the right drug for the right reason to the right person.”
Right now, every state except Missouri already has an operational, state-wide PDMP. However, from state to state, “they’re really different in terms of how sophisticated they are, what drugs they cover, how fast they respond, and whether or not physicians are required to check them,” says Keith Humphreys, a professor of mental health policy at Stanford University who advised on the SUPPORT Act.
In Texas, for example, it’s not yet mandatory for prescribers and pharmacists to check the PDMP before dispensing or prescribing opioids (although it will become mandatory in September). In Alabama, pharmacies and prescribers only need to report if they dispense schedule II-V drugs; they are not required to check the PDMP before prescribing—although, as happens in some other states, Alabama’s state medical board has slightly more stringent requirements than the law demands. In Illinois, meanwhile, prescribers do need to check the PDMP before prescribing schedule II drugs. In New York state, prescribers must consult the PDMP before prescribing schedule II-IV drugs.
PDMP Pros and Cons
The expansion of PDMPs is meant to prevent physicians from over-prescribing opioids and encourage responsible prescribing habits. Diaz and Dr. Eric Schnakenberg, another family medicine physician with Community Care Physicians, see PDMPs as necessary medical tools.
“It makes me more comfortable in my prescribing habits, that I’m giving the right drug for the right reason to the right person,” says Schnakenberg.
PDMPs can also help physicians identify patients with an addiction, giving them the opportunity to talk to patients about treatment. “If they’re already in my practice, and they are clearly abusing opioids or need help, we can refer them to lots of things,” says Diaz.
“I think more than anything that the PDMP is generally used as a tool of refusal.”
Described like this, PDMPs sound useful and benign. But these systems are also used in ways that many advocates, researchers and patients find deeply troubling. For example, PDMP information can be used to turn away patients with opioid use disorder (OUD)—without offering them resources for addiction. It can also be used to snub chronic pain patients who have a medical need for opioids.
“I think more than anything that the PDMP is generally used as a tool of refusal,” says Liz Chiarello, a medical sociologist at St. Louis University who interviews pharmacists and physicians for her research on PDMPs.
In New York, for instance, before a new patient’s first appointment, the provider has to look up the patient in the PDMP. If the physician finds that the patient has opioid prescriptions from multiple doctors, “it’s almost certain that this person will never receive care from that provider,” says Leo Beletsky, a public health researcher at Northeastern University who is currently studying the effects of PDMPs nationwide.
For chronic pain patients, who often take opioids to manage their symptoms, PDMPs are often quite simply a source of anxiety. As Filter has reported, pain patients being cut off from medical care has led to widespread despair and a number of suicides.
“I get nervous every time before I go to the doctor,” says Shasta, a chronic pain patient from Sonoma County, California who asked me not to use her last name. “Because there’s so much liability around taking care of a patient with opioids, if you see something in there and know that you’d rather not deal with that person because, as a practitioner, you don’t want to be under scrutiny, you can just say, ‘I’m not going to prescribe to you.’”
“We don’t use it as a discriminatory thing,” he says. But at the same time, “I don’t want heroin addicts in my waiting room.”
Like Diaz, Schnakenberg acknowledges that this can happen at Community Care Physicians. “We make decisions whether or not we’re going to accept patients based on what the P[D]MP is showing us,” he says. “You can weed out patients if you need to or want to.”
“We don’t use it as a discriminatory thing,” he says. But at the same time, “I don’t want heroin addicts in my waiting room.”
For patients who are flagged by PDMP screenings, finding primary care may prove nearly impossible. “That person is essentially blacklisted from receiving healthcare,” Beletsky says.
When a physician identifies a doctor-shopper, they’re not required to talk to that patient about treatment options, even if that patient is a member of the practice. “But,” says Schnakenberg, physicians “can cut off the prescription of the opiates. Is that a good thing or bad thing? Well, I think it’s a responsible thing. We can also offer them the antidote for overdose [naloxone].”
An Acute Lack of Services for Rejected Patients
While current PDMP requirements differ by state, no state trains physicians on what to do when they check the PDMP and find out that a patient has OUD. Doctors are free to reject patients without counseling them on addiction, prescribing naloxone, or sharing behavioral health resources.
Only 13 states and Guam mandate training on PDMP use for physicians, but those trainings don’t cover how to address addiction with patients. According to training materials on state websites, most of the instruction only involves how to use the technology. Nebraska’s and Maryland’s training videos do provide a couple minutes of instruction on what physicians should do if they encounter a doctor-shopping patient, encouraging doctors to discuss the issue with patients when appropriate or refer them to services. But if physicians are not already embedded within a healthcare system that provides widespread addiction services, referring a patient may be difficult.
According to Chiarello, this is the problem with PDMPs: the lack of services for those people physicians identify as doctor-shoppers. “What we haven’t done is created a strong therapeutic environment so that when people look in the PDMP, they have all kinds of resources to refer patients to,” she says. “Most physicians aren’t trained to provide medication-assisted treatment, and they don’t necessarily know who is.”
Schnakenberg says that few private practices have doctors trained to provide medication-assisted treatment or the resources to employ social workers or behavioral health professionals trained in addiction counseling. He is licensed to prescribe Suboxone (buprenorphine), a medication for people with OUD that greatly reduces mortality for this population. However, he is one of just three physicians in his practice—a practice that serves six counties in New York’s Capital Region of Albany and surrounding areas—licensed to do so.
Schnakenberg has also blocked his name from appearing on a registry of Suboxone prescribers in the region so that he doesn’t attract “potentially difficult” patients—something he suspects other physicians do as well.
“They [patients with OUD] come with a lot of social and emotional needs that most physician offices are probably under-prepared to handle,” he says. As a result, other physicians without a license to prescribe Suboxone may find themselves unable to refer an opioid-addicted patient to an appropriate provider.
In New York’s Capital Region, there are only six clinics available to serve over 4,000 clients.
Medication-assisted treatment clinics are even harder to come by—particularly in rural areas. “It’s difficult to send people for substance abuse treatment plan programs, they’re hard to get into. And then there’s not that many of them,” says Schnakenberg. In New York’s Capital Region, there are only six clinics available to serve over 4,000 clients, according to state data from 2016.
But even with scant resources, physicians can use the PDMP to help addiction patients. When Diaz comes across patients who are addicted to opioids within his practice, he can refer them to Schnakenberg for Suboxone treatment. And when treating a Suboxone patient, Schnakenberg can check the PDMP for an accurate record of their prescription history to protect them from harmful drug interactions.
Schnakenberg also believes that when the PDMP alerts physicians to doctor-shoppers, the information gives physicians the opportunity to talk with patients about addiction or prescribe lifesaving naloxone. “It gives you the option at least to have that dialogue with the patient.”
But for Diaz and Schnakenberg, this largely occurs only with patients already in their practice—not those who have been screened or rejected. “The private world cannot solve all these problems, says Schnakenberg. “You can’t expect the private world to accept patients who have substance use problems [because of a lack of in-house behavioral health resources], but they ought to have access to healthcare and that’s where the federal health clinics should be filling that gap.”
PDMPs have plenty of shortcomings, and will become increasingly controversial as the requirement to check them is rolled out nationwide. But “the biggest problem,” says Chiarello, “is that we don’t have a strong therapeutic infrastructure for dealing with addiction.”
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