Clinical and Health Affairs
Minnesota’s Prescription Monitoring Program
How to Identify Patients Who May be Abusing Controlled Substances
By Barbara A. Carter and Cody Wiberg, Pharm.D., M.S., R.Ph.
■ The Minnesota Prescription Monitoring Program, which was launched by the Minnesota Board of Pharmacy last year, is collecting data on prescriptions of controlled substances. Reporting is required from in-state pharmacies and others including physicians who dispense medications as well as from out-of-state pharmacies that ship controlled substances to Minnesota residents. This article describes the program, how it works, and how it can benefit physicians.
The abuse and diversion of controlled substances is a significant and persistent problem in the United States. Current data from the Substance Abuse and Mental Health Services Administration show that approximately 7 million individuals ages 12 or older are nonmedical users of controlled prescription drugs (opioid pain relievers, tranquilizers, sedatives, or stimulants).1 Although the number of nonmedical users has remained relatively unchanged over the past seven years, the number of drug-treatment admissions and controlled-substance-related deaths has increased significantly.1
In a July 2010 brief, the U.S. Centers for Diseases Control and Prevention (CDC) cited trend data showing that the number of unintentional drug overdose deaths increased five-fold from 1990 to 2006.2 According to the report, in 2006, “overdose deaths were second only to motor vehicle crashes among leading causes of unintentional-injury death … in the United States,” with opioid analgesics “involved in more overdose deaths than heroin and cocaine combined.” In 2008, the number of emergency department visits involving the nonmedical use of prescription or over-the-counter drugs—about 1 million—was equal to those involving illicit substances.2
In 2007, in an effort to reduce the misuse of controlled substances and improve patient care, the Minnesota Legislature passed a law authorizing the Minnesota Board of Pharmacy to establish a program to help identify individuals who inappropriately obtain excessive amounts of controlled substances from multiple prescribers and pharmacies. Minnesota is now one of 34 states to monitor prescriptions of controlled substances.
The Minnesota Prescription Monitoring Program (PMP) collects data on prescriptions of all Schedule II to IV drugs and on certain prescriptions of federal Schedule V controlled substances that are designated as Schedule III substances in Minnesota (eg, codeine-containing cough syrups). Reporting is required from in-state pharmacies and other dispensers such as prescribers, hospitals, and clinics as well as from out-of-state pharmacies that ship controlled substances to Minnesota residents. The law allows prescribers, pharmacists, and other specified individuals to access the information in order to better treat patients and identify those who may be abusing prescription drugs.
As the legislation that established the PMP was being developed, some expressed concern about privacy, patients’ rights, and the “chilling effect” that a registry might have on physicians’ prescribing practices. In order to alleviate those concerns, the law placed limitations on the PMP and those who use it. For example:
- A PMP staff person who notices that an individual visited multiple prescribers and/or pharmacies in a 30-day period is not allowed to notify the prescribers and pharmacies. It is up to prescribers and pharmacists to identify patients whose behavior suggests prescription drug abuse and consult the PMP database to find out if that person is receiving controlled substances from multiple sources.
- Prescribers and pharmacists are not required to use the database to get information about a patient.
- Prescribers and pharmacists aren’t required to report patients they suspect of drug abuse or withhold prescriptions from them.
- Pharmacists and prescribers are immune from criminal, civil, or administrative liability if they make a medical decision based on information provided by the database.
- Law enforcement officials can obtain data from the registry only if they obtain a search warrant from a judge.
Pharmacies and others began reporting the dispensing of controlled substances on January 4, 2010. During the first year, data on more than 6.6 million prescriptions were entered into the database. During the first six months of 2011, PMP data were used to identify 86 individuals who had seen 10 or more prescribers; one had seen 45 prescribers. Of those 86 people, 64 had received prescriptions from more than 10 different pharmacies; one had been to 47 pharmacies. Although this information by itself does not establish that these individuals are “doctor shoppers”—people who see more doctors and receive more medicine than necessary for their therapeutic needs, it certainly reflects behaviors that may indicate prescription drug abuse.
Reporting to the PMP
Any physician who dispenses the substances described in the law (eg, a pain management specialist) will need to report to the PMP. Generally, dispensers are required to report daily. They are required to submit a “zero report” at least every seven days even if they have not dispensed a controlled substance in a given week.
Physicians who will be reporting to the PMP will need to register to do so. (This is a separate process from registering to access the database.) This can be done online. The steps are outlined in the Dispenser’s Implementation Guide, which is available by selecting “Other Forms and Documents” on the PMP website (www.pmp.pharmacy.state.mn.us). The steps for reporting are also detailed in this guide. Reporting is done by uploading information (select “Uploader Website” from the options on the PMP site). The table lists the information that must be included.
Requesting a Patient Profile
Direct and secure access to the PMP database is available to any of the more than 25,000 Minnesota prescribers and pharmacists who are permitted by law to view controlled-substance prescription profiles of patients. Prescribers and pharmacists must apply for access to the database. (This is a separate process from registering to report dispensing of a controlled substance.) Access request forms can be downloaded from the PMP website (go to www.pmp.pharmacy.state.mn.us and select “Access Request Forms”) or obtained by contacting the PMP office. The provider must not only fill out the form but also have it notarized and return it to the PMP office. Users can enter information directly into the online version of the form. However, information cannot be saved in the forms, and the forms must be printed out in order to be notarized. Once the PMP staff receive the form, they will verify the practitioner’s credentials and employment and then email notification of approval and provide login instructions.
To request a profile of a patient, the prescriber will go to the PMP website and select “Login to the RxSentry PMP Database.” There, he or she must submit, at minimum, the patient’s name (full or partial) and date of birth. A report will be returned electronically. (A paper copy of the report is available upon request.) Users should be aware that the PMP does not warrant any patient profile to be accurate or complete, as it cannot guarantee that dispensers have accurately reported all of the controlled-substance prescriptions they have filled. First-time users are encouraged to go through the RxSentry Query and Reports Tutorial before submitting a query.
Prescribers may access the PMP database 24 hours a day, seven days a week. Prescribers or their employers may decide how often and when they will request patient profiles. Some may decide to do so for all patients. Others may do so only when they suspect potential abuse. The reports can be used to determine appropriate medical treatment such as referral to a pain-management specialist and to identify possible doctor-shopping. If a prescriber or pharmacist suspects a patient may be abusing a controlled substance, he or she can assist that person in finding help.
The patient profiles are private and, whether they are stored electronically or in print, must be given the same security considerations as other protected health information. Information about an individual cannot be used unless the prescriber or pharmacist is currently treating that person and is considering prescribing or dispensing a controlled substance for him or her. As of July 2011, more than 5,000 prescribers and pharmacists conducted more than 160,000 queries of the more than 7 million records stored in the secure database.
What’s Ahead
In the coming months, the PMP staff will be working to increase awareness of the PMP and encourage prescribers and pharmacists to apply for PMP access and to provide guidance in the use of the database. Staff will continue to gather data to demonstrate the effect the PMP is having on reducing diversion, abuse, or inappropriate use of controlled substances in Minnesota. Also, the PMP staff will be working with others to develop a process for exchanging PMP information with other states in order to prevent cross-border diversion. Finally, the PMP office will continue to work with legislators to modify the law in order to make the program more useful. The PMP is one way of addressing the problem of prescription drug abuse. Although the program will not change the circumstances that lead people to abuse prescription drugs, it can help clinicians and pharmacists distinguish between patients who may have unmet needs and those who are taking advantage of the health care system. MM
Barbara Carter is the manager of the Minnesota Prescription Monitoring Program. Cody Wiberg is executive director of the Minnesota Board of Pharmacy.
References
1. Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings. Rockville, MD: U.S. Department of Health and Human Services. Office of Applied Studies, September 2010. Available at: www.oas.samhsa.gov/NSDUH/2k9NSDUH/2k9Results.htm. Accessed September 12, 2011.
2. CDC’s Issue Brief: Unintentional Drug Poisoning in the United States. Washington, D.C.: Centers for Disease Control and Prevention, July 2010. Available at: www.cdc.gov/homeandrecreationalsafety/poisoning/brief.htm. Accessed August 25, 2011.