PRESCRIPTION DRUG MONITORING PROGRAMS
The United States is in the midst of a historic public health crisis. Each day, well over 100 Americans die of drug overdose, driven increasingly by street opioids. In line with other “epidemics” of grave public concern, this crisis has spurred an expansion of public health surveillance. This article focuses on the principal element of this expansion—prescription drug monitoring programs (PDMPs). By collecting information on who is prescribing, dispensing, and receiving scheduled drugs, PDMPs are intended to detect—and deter—problem patients, rogue prescribers, and pharmacists who may be diverting potentially addictive and otherwise risky drugs.
PDMPs are far from new, but the recent scale-up in the number, scope, funding, and legal mandates of these systems has occurred without sufficient scrutiny. The lens of public health law research has just begun to be trained on PDMPs. By integrating empirical and theoretical perspectives, our research adds to this nescient discourse. We argue that the zeal with which we have traditionally pursued supply reduction measures to address drug-related harms reflects the legal and system design of PDMPs, as well as the street-level implementation of these programs. This also explains why the success of PDMPs has been measured primarily by their impact on suppressing medication supply with little regard for truly meaningful metrics. But, when it comes to improving patient care and addressing drug-related harms, the evidence of PDMP benefit is far from clear.
Our research presents a narrative review of the 34 peer-reviewed studies evaluating PDMPs published since 2010. Only 11 (32%) considered any overdose outcomes. Of studies assessing overall mortality, three found PDMP deployment to be associated with reduced overdose rates, four reported a null result, and three reported PDMPs to be associated with an increase in overdoses. These findings stand to challenge the kind of unbridled enthusiasm, generous investment, and cavalier policy emphasis that has buoyed PDMPs since the onset of the overdose crisis.
Given mixed evidence of impact, the unintended harms of these systems warrant urgent examination. This includes deterring proper prescribing practices; chilling help-seeking among patients, especially those made vulnerable by a history of trauma in the healthcare settings and criminal justice involvement; and further fraying the fabric of provider-patient trust. Original qualitative data presented here give voice to stakeholder concerns about surveillance, privacy, and pervasive monitoring by law enforcement. A special focus on their privacy dimension is especially timely in view of recent appellate decisions allowing broad warrantless disclosure of PDMP data to law enforcement. Although the perils of expansive government monitoring and predictive technologies are recognized in national security, criminal justice, and other realms, a critique of PDMPs as dragnet electronic surveillance is long overdue. At the population level, these collateral impacts can hamper much-needed surveillance and control efforts, aggravating the very problems these policies and programs were intended to ameliorate.
Ultimately, however, our research is sober to the reality that PDMPs are here to stay. As we urge a more deliberate focus on privacy protections, we argue for PDMP integration with electronic health records; user-driven design that reimagines PDMPs as a care coordination, clinical decision-making, and public health prevention tool; and meaningful training on how to deploy PDMP functionality to improve individual and public health.
What We Are Doing
Qualitative interviews with PDMP stakeholders
Reddit scraping for stakeholder and patient perspectives on use and implementation
Aggregating and analyzing articles on PDMP efficacy in curbing Rx prescribing, diversion and overdoses
Research briefs with policymakers, researchers and journalists
Articulating to policymakers and PDMP stakeholders opportunities to improve PDMP functionality as a public health prevention tool
Physicians Are Fighting on the Front Lines of the Opioid Crisis
AMA Wire, August 7, 2018
Insights on Law Enforcement Engagement with the MA PDMP
These data were obtained pursuant to a Freedom of Information request by the ACLU of Massachusetts to the Massachusetts Department of Health in 2017. Data aggregation and graphic development was completed at the HIJ Action Lab.
PDMP Proliferation Across All States
Narrative Review of PDMP Effectiveness
Call for Public Comment!
"Confidentiality of Substance Use Disorder Patient Records" §2.36
SAMHSA is proposing major changes to 42 CFR Part 2, a federal regulation that protects the medical records of patients with substance use disorder (SUD) by limiting unauthorized disclosures of sensitive information. Since substance use disorders are heavily stigmatized and criminalized, this confidentiality regulation was initially implemented to encourage people to enter treatment without fear of it ever being used against them.
Now, the federal government is proposing to change this critical privacy protection by allowing patient records (such as whether someone is on methadone maintenance) to be shared with entities such as prescription drug monitoring programs (PDMPs), which are accessible by law enforcement agencies conducting investigations. This proposal has a comment period that ends on October 25 at 11:59 pm.