Association of Mandatory-Access Prescription Drug Monitoring Programs With Opioid Prescriptions Among Medicare Patients Treated by a Medical or Hematologic Oncologist | Clinical Pharmacy and Pharmacology | JAMA Oncology | JAMA Network
[Skip to Navigation]
Sign In
Figure 1.  Timeline of Number of States That Implemented Mandatory-Access Prescription Drug Monitoring Programs (PDMP)
Timeline of Number of States That Implemented Mandatory-Access Prescription Drug Monitoring Programs (PDMP)
Figure 2.  Adjusted Percent of 40 739 Patients Treated by a Medical or Hematologic Oncologist With Any Opioid Prescription
Adjusted Percent of 40 739 Patients Treated by a Medical or Hematologic Oncologist With Any Opioid Prescription
1.
Gellad  WF, Good  CB, Shulkin  DJ.  Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs.   JAMA Intern Med. 2017;177(5):611-612. doi:10.1001/jamainternmed.2017.0147 PubMedGoogle ScholarCrossref
2.
Nelson  LS, Perrone  J.  Curbing the opioid epidemic in the United States: the risk evaluation and mitigation strategy (REMS).   JAMA. 2012;308(5):457-458. doi:10.1001/jama.2012.8165 PubMedGoogle ScholarCrossref
3.
Dowell  D, Zhang  K, Noonan  RK, Hockenberry  JM.  Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.   Health Aff (Millwood). 2016;35(10):1876-1883. doi:10.1377/hlthaff.2016.0448 PubMedGoogle ScholarCrossref
4.
Wen  H, Schackman  BR, Aden  B, Bao  Y.  States with prescription drug monitoring mandates saw a reduction in opioids prescribed to Medicaid enrollees.   Health Aff (Millwood). 2017;36(4):733-741. doi:10.1377/hlthaff.2016.1141 PubMedGoogle ScholarCrossref
5.
Bernabei  R, Gambassi  G, Lapane  K,  et al.  Management of pain in elderly patients with cancer. SAGE Study Group: systematic assessment of geriatric drug use via epidemiology.   JAMA. 1998;279(23):1877-1882. doi:10.1001/jama.279.23.1877 PubMedGoogle ScholarCrossref
6.
Dowell  D, Haegerich  T, Chou  R.  No shortcuts to safer opioid prescribing.   N Engl J Med. 2019;380(24):2285-2287. doi:10.1056/NEJMp1904190 PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Research Letter
    May 7, 2020

    Association of Mandatory-Access Prescription Drug Monitoring Programs With Opioid Prescriptions Among Medicare Patients Treated by a Medical or Hematologic Oncologist

    Author Affiliations
    • 1Winship Cancer Center, School of Public Health, Department of Health Policy and Management, Rollins Emory University, Atlanta, Georgia
    JAMA Oncol. 2020;6(7):1102-1103. doi:10.1001/jamaoncol.2020.0804

    More than 30 states have enacted laws mandating use of prescription drug monitoring programs (PDMP) to reduce inappropriate opioid prescribing. Clinicians in those states must check the PDMP database before writing opioid prescriptions. These mandates vary substantially across states in their timing and scope; for example, some exempt patients with cancer.1,2 We examine the association between state mandatory-access PDMPs and changes in the percent of oncologists’ Medicare patients with any opioid prescription fills.

    Methods

    We used the physican-level Medicare Part D Prescriber files for 2013 to 2017 and restricted the sample to physicians specialized in medical or hematologic oncology. For each year, we classified states as having: no mandatory-access PDMP or a mandatory-access PDMP with or without a cancer exemption.

    We used linear regression with physician and year fixed effects to assess the association between PDMP mandates with and without a cancer exemption and the percent of oncologists’ patients with any opioid prescription covered by Medicare Part D. This approach measured within-physician changes in opioid prescribing after the implementation of mandated PDMPs compared with physicians in states without mandates, adjusting for secular time trends.

    The institutional review board of Emory University determined that study approval was not required because all data analyzed were publicly available and deidentified.

    Results

    By 2017, 21 states had implemented mandatory-access PDMPs, including 5 states that explicitly exempted the reviewing requirement for patients with cancer (Figure 1). Compared with oncologists in states with no mandated PDMP, the proportion of oncologists’ patients who filled an opioid prescription declined by 1.15 percentage points (95% CI, −1.57% to −0.73%; a 4.8% decline) and by 0.67 percentage points (95% CI, −0.94% to −0.41%; a 2.8% decline) in states that implemented PDMP mandates with and without cancer exemptions, respectively (Figure 2). To protect the privacy of Medicare beneficiaries, this data set suppresses observations when physicians had 1 to 10 Part D claims in a year with an opioid prescription (12 297 of 53 036 [23.1%]). Results from models where we imputed the missing number of patients with any opioid prescription as either 1, 5, or 10 were similar in magnitude and significance to the presented results with missing values omitted.

    Discussion

    The share of oncology patients who filled an opioid prescription declined by 4.8% and 2.8% in states that enacted mandatory-access PDMPs—with and without exemptions for patients with cancer, respectively. Although recent studies3,4 have shown that mandated PDMPs are associated with an 8% to 12% reduction in opioid prescribing, this is the first to show that mandated PDMPs—with or without an explicit exemption for patients with a cancer diagnosis—are associated with decreases in opioid prescribing by medical and hematologic oncologists.

    Implementation of PDMPs was intended to curb inappropriate opioid prescribing, not legitimate use among patients undergoing oncology treatment, who are often undertreated for pain.5 From our early results, we find that exemptions for patients with a cancer diagnosis did not shield Medicare patients treated by a medical or hematologic oncologist from the unintended spillovers of mandated PDMP requirements. This analysis was limited by lack of patient-level data, including cancer type and stage, and short follow-up period. In addition we did not examine changes in per-patient opioid dose. Future studies should examine the effect of PDMP policies with more years of follow-up data and adjusting patient-level characteristics. It is possible that with more time to learn about the nuances of the PDMP mandate, prescriber practices will adjust.

    Conclusions

    Although policymakers are motivated to prevent opioid misuse, there is growing concern that some physicians—burdened by the task of consulting a PDMP and added scrutiny over their prescribing—have reduced their opioid prescribing even for patients with legitimate pain management needs.6 These results show that with or without an exemption for patients with cancer, the percent of patients treated by a medical or hematologic oncologist receiving opioids declined after mandatory-access PDMPs were implemented. As more states contemplate policies to alleviate the opioid crisis, it is critical to understand how they affect both problematic and legitimate opioid use.

    Back to top
    Article Information

    Corresponding Author: Ilana Graetz, PhD, Rollins School of Public Health, Department of Health Policy and Management, Emory University, 1518 Clifton Rd NE, GCR Ste 636, Atlanta, GA 30322 (ilana.graetz@emory.edu).

    Accepted for Publication: February 13, 2020.

    Published Online: May 7, 2020. doi:10.1001/jamaoncol.2020.0804

    Author Contributions: Drs Graetz and Yarbrough had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Graetz, Yarbrough, Hu.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Graetz, Yarbrough, Hu.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: All authors.

    Administrative, technical, or material support: Graetz.

    Supervision: Graetz.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Gellad  WF, Good  CB, Shulkin  DJ.  Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs.   JAMA Intern Med. 2017;177(5):611-612. doi:10.1001/jamainternmed.2017.0147 PubMedGoogle ScholarCrossref
    2.
    Nelson  LS, Perrone  J.  Curbing the opioid epidemic in the United States: the risk evaluation and mitigation strategy (REMS).   JAMA. 2012;308(5):457-458. doi:10.1001/jama.2012.8165 PubMedGoogle ScholarCrossref
    3.
    Dowell  D, Zhang  K, Noonan  RK, Hockenberry  JM.  Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.   Health Aff (Millwood). 2016;35(10):1876-1883. doi:10.1377/hlthaff.2016.0448 PubMedGoogle ScholarCrossref
    4.
    Wen  H, Schackman  BR, Aden  B, Bao  Y.  States with prescription drug monitoring mandates saw a reduction in opioids prescribed to Medicaid enrollees.   Health Aff (Millwood). 2017;36(4):733-741. doi:10.1377/hlthaff.2016.1141 PubMedGoogle ScholarCrossref
    5.
    Bernabei  R, Gambassi  G, Lapane  K,  et al.  Management of pain in elderly patients with cancer. SAGE Study Group: systematic assessment of geriatric drug use via epidemiology.   JAMA. 1998;279(23):1877-1882. doi:10.1001/jama.279.23.1877 PubMedGoogle ScholarCrossref
    6.
    Dowell  D, Haegerich  T, Chou  R.  No shortcuts to safer opioid prescribing.   N Engl J Med. 2019;380(24):2285-2287. doi:10.1056/NEJMp1904190 PubMedGoogle ScholarCrossref
    ×