Journal of the American Association of Nurse Practitioners
Background and purpose: Prescription drug monitoring programs (PDMPs) have begun to demonstrate themselves as useful tools in enhancing safe and responsible prescription of controlled substances. The purpose of this project was to describe current practice, beliefs, and barriers of Alaska nurse practitioners (NPs) regarding the Alaska PDMP.
Methods: A questionnaire was sent to 635 Alaskan NPs with a 33% return rate. The data depicted prescribing habits, barriers to use, barriers to registering, and opinions on how to make the PDMP more clinically useful.
Conclusions: More attention is needed to maximize PDMP exposure and incorporation into daily workflow if it is to achieve full potential. Registered users should be able to delegate PDMP authority to select staff members to reduce time commitments and increase usage. Many providers felt that assigning unique patient identifiers could prevent consumers from filling prescriptions under aliases. Finally, an overwhelming majority of users wanted faster data entry and proactive reports.
Implications for practice: This project explored the differences between PDMP users and nonusers and outlined NP suggestions for process improvement. A better understanding of PDMP use will aid providers in safe prescribing while curbing the prescription drug epidemic and ultimately reducing abuse, misuse, and death from overdose.
Prescription pain medication abuse is one of the fastest growing health problems in the United States (Shepherd, 2014). Before the mid-1990s, opioid pain relievers (OPRs) were reserved for the treatment of cancer pain (Reisman, Shenov, Atherly, & Flowers, 2009). By the late 1990s and early 2000s, a new movement began in which it was recognized that pain symptoms were being undertreated (Garcia, 2013). Pain became recognized as the fifth vital sign, and a method for routine screening and assessment of pain was established (Garcia, 2013).
Consequently, the Joint Commission implemented the use of pain scores as a measure of patient satisfaction (Perrone, DeRoos, & Nelson, 2012). The American Pain Society published guidelines that called for aggressive treatment of any reported pain and recommended an extension on the indication for OPRs to include treatment of chronic, noncancer pain (Keyes, Cerda, Brady, Havens, ´ & Galea, 2014; Perrone et al., 2012). The Department of Veterans Affairs also initiated a campaign that was aimed at improving pain management and treating chronic pain (Keyes et al., 2014). The threat of tort litigation for failure to treat or manage pain was used to encourage providers to comply and incentivize change (Garcia, 2013). The combination of these actions served to further fuel the movement to aggressively treat pain with OPRs (Keyes et al., 2014).
Over time, health care’s philosophy on the use of opioids for noncancer pain shifted, and practitioners increased their rate of opioid prescriptions in an attempt to meet these new recommendations (Paulozzi et al., 2012). In many cases, a patient’s subjective reports of pain took precedence over other considerations that could potentially compete with their need for pain relief, such as addiction (Garcia, 2013). Despite their benevolent intentions, this new model created a scenario where prescribers, including physicians, physician assistants, dentists, and nurse practitioners (NPs), joined drug cartels and street dealers as major players in the escalating drug use problem that America faces today (Perrone et al., 2012).
During this same time span—between 1997 and 2003—there was a drastic increase in the yearly shipments of pain medications to the United States (Reisman et al., 2009). Between 1999 and 2010, the sale of OPRs quadrupled, resulting in a prescription rate of OPRs high enough to medicate every adult in America with 5 mg of hydrocodone every 4 hours for a month (Paulozzi, Jones, Mack, & Rudd, 2011). By 2009, Americans were estimated to be just 4.6% of the world’s population, yet they consumed nearly 80% of the global supply of OPRs (Wang & Christo, 2009). The United States consumes OPRs at a greater rate than any other nation in the world (Paulozzi, Mack, & Hockenberry, 2014).
In addition, by 2012, 37% of opioid users consumed an opioid stronger than morphine (Frenk, Porter, & Paulozi, 2015). As a result, in the past few years alone, one of every 20 Americans reported that they had misused or abused prescription painkillers, and almost 17,000 Americans died of prescription painkiller overdoses (Shepherd, 2014). The problem has become so invasive in our culture that the Centers for Disease Control and Prevention (CDC) has classified prescription medication abuse as a health epidemic (Shepherd, 2014). This sentiment was recently echoed by Alaska Governor Bill Walker, who declared the opioid epidemic in that state a public health crisis (State of Alaska, 2017a).
This OPR abuse has been noted to be more concentrated in states that have a high number of individuals living in rural communities, such as Kentucky, West Virginia, Alaska, and Oklahoma (Keyes et al., 2014). Overall, many counties outside urban regions have been found to have higher rates of overdoses related to OPRs, higher injury rates related to OPRs, and higher ratios of nonmedical to medical users of OPRs (Keyes et al., 2014). There is clear evidence that many misused OPRs are obtained from family, friends, or acquaintances who originally obtained the medication through legitimate channels (Keyes et al., 2014). Because family structures in rural areas are larger and tend to develop wider networks, there is greater potential to secure illicit narcotics. In addition, research has found that adolescents in rural communities are more likely to abuse OPRs recreationally than their metropolitan counterparts (Keyes et al., 2014). Because most of Alaska is still considered rural, and Alaska’s annual drug reports indicate that overall prescription drug abuse is still on the rise, OPR abuse remains a significant public health threat facing Alaska (Alaska State Troopers, 2015).
Because of the national recognition of this OPR abuse epidemic, the focus has largely shifted from the undertreatment of pain to addressing prescription drug morbidity and mortality (Garcia, 2013). Various policies, prescriber guidelines, and regulatory approaches are being developed in an effort to combat this prescription drug abuse epidemic (Chakravarthy, Shah, & Lotfipour, 2012; Garcia, 2013; Dowell, Haegerich, & Chou, 2016). Many states, including Alaska, are now using statewide drug monitoring programs, and many are even making them mandatory (Haffajee, Jena, & Weiner, 2015; NAMSDL, 2017).
These prescription drug monitoring programs (PDMPs) were originally developed by the law enforcement community to identify patterns of drug misuse, diversion, or excessive prescribing (Hildebran et al., 2014). Now, PDMPs are increasingly gaining recognition in the health care community as a tool to aid providers in identifying patients who are at risk of harm from prescription drug abuse, as well as helping to identify potential sources of drug diversion (Hildebran et al., 2014). The White House Office of National Drug Control Policy, the CDC, and the Food and Drug Administration have realized the potential of these programs and are currently suggesting that state-based PDMPs be expanded (Perrone & Nelson, 2012), and many are advocating that these programs be mandated (Haffajee et al., 2015).
Although the potential benefit of PDMPs is beginning to be realized, they remain underused because of inadequate funding, variable levels of functionality, and inconsistent use (Haffajee et al., 2015; Perrone et al., 2012). Several recent studies have indicated that although the majority of primary care providers are aware of PDMPs, many still do not use them routinely (Rutkow et al., 2015). Specifically in Alaska, health care practitioners have been able to access the patient database since 2012, but in 2016, less than 1/3 of Alaska’s licensed NPs were registered to use the program (State of Alaska, 2017b).
Additional information about how health care providers integrate state PDMPs into their daily clinical workflow could help identify “best practices” regarding PDMPs and help guide their development in ways that best suit prescribers’ needs (Hildebran et al., 2014; Rutkow et al., 2015). Currently, there has been little research on how NPs are using PDMPs, how the information affects patient care and diversion, and whether NPs think PDMPs are easy to use and add value to their practice (LeMire, Martner, & Rising, 2012).
Purpose statement and research questions
The purpose of this project is to identify the barriers that may prevent NPs in Alaska from using PDMPs and barriers to enrollment for nonusers. These data will serve as a starting point for understanding the barriers Alaska NPs face in regard to PDMP enrollment and use. Ideally, this will allow Alaska PDMPs to implement targeted education, thus decreasing barriers and increasing the use of the program among Alaska NPs. The following research questions will be addressed:
Who are the primary users and nonusers of the PDMP?
What are the prescribing patterns of users and nonusers?
What are the perceived barriers to use in regard to the Alaska PDMP?
What are the perceived barriers to enrollment by nonusers?
What would make the PDMP easier to use?
What would make the PDMP more useful in daily practice?
Material and methods
This project was performed using a quantitative descriptive design. An 11-question survey was used for data collection: The first question was used to establish prior knowledge of the PDMP, followed by five multiple choice Likert scale questions with open-ended space for additional comments, and finally five questions regarding demographics. The final questionnaire used in this study required less than 10 minutes to complete (see Appendix A, Supplemental Digital Content 1, http://links.lww.com/JAANP/A0).
Survey respondents and techniques
The surveys were adapted with permission from those developed by Irvine et al. (2014). The authors of the survey developed the questionnaire based on current gaps in the literature, input from state program experts, clinical experts, an earlier and smaller state survey, and focus groups with clinicians from nine other states who were active users of their states’ PDMPs (Irvine et al., 2014). Content validation was performed by the authors; however, further psychometric testing has not been completed. Minor changes were made to the survey to adapt the survey to NPs practicing in Alaska. Additional questions were added asking NPs to score their thoughts regarding loss of business and poor satisfaction scores being seen as barriers to PDMP use following the literature review. An additional demographic question was added asking providers whether they practiced in urban, rural road, or rural offroad environments, which are specifics related to living and practicing in Alaska. Additional minor modifications to the questionnaire were made following recommendations from faculty of the University of Alaska School of Nursing.
The intended sampling frame included exclusively NPs practicing in Alaska. First, the professional license database was downloaded from the State of Alaska Department of Commerce, Community, and Economic Development website. There were 878 NPs licensed to practice in the state of Alaska. Because the aim of this study was to look at NPs who work in Alaska, and therefore may use the Alaska PDMP, all out-of-state addresses were eliminated from the mailing list. Ultimately, 635 NPs (72%) were eligible to participate in this study.
A preliminary postcard to announce the study was mailed 2 weeks before the questionnaire in an attempt to raise awareness and improve the response rate. The author then prepared hand-addressed envelopes also in an attempt to increase return rates. Included in the mailing was an introduction letter that explained the survey and the implied consent, as well as a self-addressed, stamped envelope for the return of the survey. Data were collected over a 3-week period and resulted in 204 questionnaires being included in the analysis.
The Institutional Review Board at the University of Alaska Anchorage approved the project. A cover letter explaining the project to potential respondents was included with every mailing (see Appendix B, Supplemental Digital Content 2, http://links.lww.com/JAANP/A1). Nurse practitioners provided their consent to participate in the study by completing and returning the survey. There was no identifying information on the surveys other than basic demographic information.
Analysis of the data was performed using SPSS version 23 to complete demographic statistics. All responses were converted to a numeric score for data entry. Answers to the open-ended questions were entered into SPSS as they were written by the respondent and were analyzed to identify any recurring themes within the responses using inductive content analysis as described by Elo and Kyngas (2007). Respondents were asked demographic questions in regard to age, gender, years practicing as an NP, specialty of practice, and practice setting. Demographic information regarding years of practice was collected through an open-ended question and was later grouped into five-year categories, which resulted in eight groups. The respondents’ areas of practice were also combined into categories to facilitate comparisons and resulted in the following: Family Practice, Women’s Health, Midwifery/OBGYN, Mental Health/Psychiatry, Pediatrics, Specialty Clinic, and Other groupings. Where appropriate, chi-square tests were used to determine statistical differences between groups.
A total of 635 questionnaires were mailed. After removing 32 questionnaires that were returned as undeliverable, the total number of potential respondents was 603. A total of 217 surveys were returned. Six of these surveys were excluded because the NPs stated they were retired and therefore did not complete the survey in its entirety. An additional seven surveys were excluded because the majority of the survey was incomplete, and there was no demographic information. This left 204 valid surveys for a 33.8% response rate. The demographic characteristics of these respondents according to the PDMP user status are summarized in Table 1.
Comparison of registered users versus nonusers
There was no significant statistical difference between registered users versus nonusers when comparing the groups based on age, gender, or years of experience. There was no significant statistical difference when comparing groups based on areas of practice, rural, rural off-road, or urban. There was a significant difference when comparing groups based on the specialty of practice (Figure 1).
Nurse practitioners who were registered users reported prescribing all classes of controlled substances more often than nonusers (Table 2). However, many of the nonregistered NPs also reported frequently prescribing controlled substances.
Barriers to use by registered users
Registered users were provided with a list of concerns and asked to check which and to what extent each was a barrier to using the PDMP. The NPs who were enrolled in the PDMP identified time constraints as the largest barrier to use with 66% (n = 64) finding it to be a somewhat or a significant barrier. Being unable to designate someone to access the system on the registrants’ behalf had a mixed response, with 49.5% (n = 48) finding it to be a somewhat or a significant barrier. Enrolling in the program was also seen as a barrier by many, as the cumbersome registration process was cited as a somewhat or a significant barrier by 42.3% (n = 41). Areas that were not identified as a barrier to use or only rarely a barrier included concerns related to loss of business (99%, n = 96), concerns related to poor patient satisfaction scores (99%, n = 96), comfort using a computer or internet (96.9%, n = 94), concerns related to scrutiny by professional licensing board (95.9%, n = 93), concerns related to scrutiny by law enforcement (93.8%, n = 91), and lack of training (71.1%, n = 69).
In the free text area provided for respondents to enter other barriers, seven cited concerns with passwords, the password reset process, and password retrieval. Four individuals took the time to praise the system or state that there were no barriers. Finally, two other individuals remarked that it was not connected to their electronic health record, and this causes them lost time and difficulty researching a client, as they are forced to navigate between two different programs.
Reasons nonusers have yet to register
There were a total of 106 nonregistered individuals, and 38 (35.8%) of this subgroup had never heard of the PDMP before receiving the questionnaire. In addition, a full 55.7% (n = 59) of unregistered users were not aware that they could register. A similarly large percentage, 44.3% (n = 47), cited that the reason for not registering was that they rarely prescribed controlled substances. By contrast, areas that were less cited as barriers to registering were as follows: no internet at work (3.8%, n = 4), objection to surveillance (3.8%, n = 4), limited resources to do anything with the information (3.8%, n = 4), not allowed to share with staff (4.7%, n = 5), do not think that there would be any benefit (11.3%, n = 12), and too busy (24.5%, n = 26).
In the free text area provided for respondents to enter other barriers, nine federal employees (Military and Indian Health Services) stated that they did not believe that their computer systems would allow them to access an outside vendor or assumed that the pharmacist would provide surveillance. Five respondents were inpatient providers or serviced long-term care or incarcerated clients and did not feel that the PDMP would influence their prescribing patterns. Only one provider stated that she prescribed exclusively to their long-term clients and that they knew them well enough to not be concerned.
Making the prescription drug monitoring program easier to use and more useful in clinical practice
All participants were asked what would make the Alaska PDMP easier to use (Table 3) and what would make the PDMP more useful in clinical practice (Table 4). The most common response by all users was that they wanted to have generated reports sent to them when someone they prescribe for is suspected of misuse or diversion and the majority felt that authorizing someone else to access the system on their behalf would make the system easier to use. User groups differed in their desire to receive training on how to use the system. The majority of NPs thought that faster entry and display of prescriptions in a database would be somewhat or very useful.
The PDMP seemed to be widely used by NPs from many disciplines, especially those from Family Practice, Mental Health/Psychiatry, and Pain Management. Pediatric and Women’s Health NPs were predominately nonusers of the program. No Pediatrics NPs in this survey were registered users, but they all also reported never prescribing opioids, benzodiazepines, or sleep aids, and only occasionally prescribing amphetamine-like medications. However, research has found that adolescents in rural communities such as Alaska are more likely to recreationally abuse OPRs (Keyes et al., 2014). This pattern was seen in other specialties, as respondents who were not registered users of the PDMP were infrequent prescribers of controlled substances compared with their counterparts. However, nearly half of all nonusers reported prescribing at least one class of controlled substance weekly, raising concerns that providers may underestimate the amount of controlled substances they prescribe.
As noted in the data analysis, time constraints and not being able to designate someone to access the system on the provider’s behalf were the two most commonly cited barriers to using the PDMP by those who are currently registered users. Additional consideration should be given to allowing a licensed staff member to access the PDMP, thereby decreasing the NP’s time burden and increasing the use of the program, as Alaska is one of the rural states that have been identified as having an increase in OPR abuse (Keyes et al., 2014). Although not listed as a choice, many providers wrote in that they had difficulty with the password portion of the PDMP. Future program upgrades should focus on streamlining the password retrieval system.
Over half of all nonusers reported that they were not aware they could register for the PDMP, indicating a need to increase education on the existence of the program. In addition, registered users found the registration process cumbersome, and future versions of the program could simplify the process before attempting to recruit nonusers. However, increased recruitment efforts may not be hugely successful, given that nearly half of unregistered providers state that they rarely prescribe controlled substances. Among those who have yet to enroll in the PDMP, over half felt that training on the use of the system would improve the process, indicating that education on program usage is warranted for new users. These educational opportunities are important, as many programs are currently underused because of concerns regarding functionality (Haffajee et al., 2015; Perrone et al., 2012). A particular subgroup that could be targeted is NPs in the federal government systems, as they erroneously believe that the government computer systems will not allow them to access an outside vendor’s program or that the pharmacist will provide oversight on their behalf.
Providers from both groups indicated a desire to have proactive reports sent to them whenever they prescribed medications to a patient with a pattern that indicates misuse or diversion. This suggests that providers wish to have the information, but that time constraints may prevent them from investigating every patient. However, proactive reports increase the financial burden on the state. Nurse practitioners also felt that faster entry and display of prescriptions would make the PDMP more useful in clinical practice.
Several limitations of the study were identified. The survey used was not tested for reliability and was tested only for content validity. The survey response rate was suboptimal, and a low response rate has the potential of introducing a bias, as respondents may systematically differ from nonrespondents in their demographics, clinical characteristics, or perceived barriers. As always, results from one state’s population may not be generalizable to NP populations in other states. Several specialty groups contained small sample sizes, thereby making specialty comparisons difficult. As in any survey, social influences may create a bias, although this bias was potentially reduced by providing anonymity to the respondents.
Conclusions and recommendations
Prescription drug monitoring programs are relatively new developments that can aid providers in delivering high quality care while helping to maintain safety and oversight. With the White House Office of National Drug Control Policy, CDC, and the Food and Drug Administration all calling for an expansion of state-based PDMPs, it seems that these programs are here to stay. However, underutilization of these programs will continue to negate their potential benefits, rendering them ineffective in the fight to reduce prescription drug misuse (Rutkow et al., 2015). Some states have recognized this as a problem, and by the close of 2016, 35 states had passed legislation requiring prescribers to review the PDMP in certain scenarios (NAMSDL, 2017). Although PDMPs are not a panacea for OPR misuse, they are a valuable tool available to practitioners as an attempt to curb the overprescription of these drugs. Improving barriers to use of PDMPs also remains an important focus.
Now that the Alaska PDMP is well established, more attention is needed to maximize its exposure and incorporation into daily workflow if it is to achieve its full potential for reducing drug misuse and abuse while increasing patient safety. Despite the national focus on OPR abuse and the recent legislation in the state of Alaska mandating all advanced practice registered nurses with a Drug Enforcement Administration number to register with the Alaska PDMP, effective July 17, 2017, as of December 2016, just 27% (287/1,060) of NPs licensed in the state of Alaska were registered with the PDMP (State of Alaska, 2017b). Thus, future research should focus on identifying optimal strategies for reaching NPs who are either unaware of the existence and/or the potential clinical use of the Alaska PDMP.
Additional consideration should be given to authorizing registered users to access the PDMP, as delegation to a licensed person on their staff may reduce the time commitments required by NPs, and therefore could increase usage. Steps should also be taken to brief federal government employees on the program, and providers should be encouraged to take back responsibility for investigating their patients scheduled medication consumption patterns. In an attempt to provide new users with desired training, a brief video tutorial could be made available on the PDMP website detailing the basic usage of the program. Many providers felt that assigning each individual a unique patient identifier could prevent consumers from filling prescriptions under aliases or using multiple addresses, which undermines the effectiveness of the PDMP. Although an overwhelming majority of users want faster data entry and proactive reports, this could substantially raise the cost of the program and further study would be needed to evaluate the cost– benefit ratio.
Authors' contributions: All authors have contributed to the manuscript. H. Christianson developed the research proposal. H. Christianson and E. Driscoll developed the modified survey instrument and finalized the research project. H. Christianson and A. Hull acquired data. H. Christianson performed all the data analyses and wrote an initial draft of the manuscript. A. Hull revised the manuscript for final submission.
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