Story originally published in Issue 6 of the WSDA News.

In 2007, the Prescription Monitoring Program (PMP) was created as a plan to improve patient care and reduce prescription drug misuse by collecting dispensing records for Schedule II, III, IV, and V drugs, and making the information available to medical providers and pharmacists as a tool in patient care. Since then, the misuse of opiates has become a national epidemic. 

While the PMP looks good on paper, the problem is accessing it can be a challenge, something the state is working to improve. If you frequently prescribe opioids and are in the system regularly, it can work reasonably well, but for dentists who don’t prescribe often, the experience could be rockier, with reports of up to a 30-minute process to access the site. 

We’ll provide some tips and tricks that should help practitioners use the system, but we’re issuing an advisory: The first log in could well be an exercise in frustration. Regardless, it can improve patient safety and will likely be required soon, so you might want to explore it now and establish a system for your office, rather than wait. 

We reached out to Dr. Rolf Christensen, Director of the Dental Urgent Care Clinic at the University of Washington School of Dentistry, Chris Baumgartner, Director of Drug Systems at the Washington State Department of Health, and Jennifer Santiago, Program Manager for the Dental Quality Assurance Commission, to talk about the benefits of the program, find out how it works and have an honest discussion about some of the program’s challenges.

Taking the PMP from should to must

“Currently, the DOH rule for chronic non-cancer pain says that providers should review the PMP. We can’t enforce ‘should,’ but it will change eventually,” says Jennifer Santiago. The Department of Health has been working on implementing legislation (HB1427) for the past year. It is described by the state as an aggregation of multiple bills that has several intended effects, primarily to implement safe opioid prescribing rules, expand access and use of PMP data, and improve access to medication-assisted treatment. Santiago says, “HB1427 requires five boards and commissions to create rules around opioid prescribing. The five boards and commissions created a task force to draft consistent rules. It’s no longer just chronic non-cancer pain, it’s opioids across the board. The Opioid Prescribing Task Force is made up of two members from each board/commission (medical, nursing, osteopath, podiatry, and dental) who worked for several months to create draft rules. The current version requires mandatory PMP checks at certain times of patient care, and it does require registration with the PMP if you prescribe opioids to patients.”

Until the draft is adopted and codified, the PMP will remain a suggestion, but oral surgeons and other dentists who routinely prescribe opioids are going to have to use the PMP eventually, so the state would like to see them get on board sooner rather than later. Santiago explains, “If they start using the PMP, they’ll become more familiar with it, and it becomes easier to use. HB1427 required the boards and commissions to adopt rules by January 2019, and they have all committed to finalizing their rules by the end of October 2018. Finalizing the rules and educating practitioners and the public is the goal, it all has to play out that the boards and commissions adopt the rules and move forward.” 

Much of this work falls under a broader state plan – the Opioid Response Plan – to address the opioid epidemic (stopoverdose.org). Pushed forward by the executive order signed by Gov. Jay Inslee in October 2016, the plan has four goals: prevent inappropriate opioid prescribing and reduce opioid misuse and abuse; treat individuals with opioid use disorder and link them to support services, including housing; intervene in opioid overdoses to prevent death; and use data and information to detect opioid misuse/abuse, monitor morbidity and mortality, and evaluate interventions. 

Identifying the blue pills

According to Chris Baumgartner, the state currently collects about 1 million records a month for controlled substances. However, he stresses that the PMP is about much more than identifying patients who suffer from opioid abuse disorder. It’s also a key component to securing basic patient safety and medication reconciliation.

Baumgartner explains, “The PMP is often most beneficial to the elderly patient who shows up and says, ‘I take the blue pills,’ or the person who is unconscious in the ER. They may not have overdosed, they may not be addicted, but they may have controlled substances they take regularly that could impact how you choose to treat them. It’s also great information to use for coordinating care, which is why it is important for the dental community. I don’t know that patients always do a great job of informing their dentist or primary care provider about medications they’re getting from each other. Dentists must rely on patients to reveal the medications they’re already on prior to a procedure, and that’s not always happening. A lot of times it’s just about being better informed, providing better care, and coordinating with the other healthcare providers.” 

Dr. Rolf Christensen sees far more patients using opiates than a typical general practice, and is well versed in the pros and cons of the PMP. He says, “I give better care using the PMP. I know the landscape, and I especially want to know if my patients aren’t disclosing or are misrepresenting information. If they’re not disclosing, they’re either a less-reliable reporter, or there is a manipulative component. We rely on patient self-disclosure for medical information, so if they don’t disclose, I may not be aware unless I check the PMP or do a physician consult. If I telephone a physician’s office, I usually request a list of medications and their current diagnoses be faxed to our clinic.” General practitioners may argue that their experiences are unlikely to mirror those of Christensen’s in an acute care clinic. Baumgartner says that practitioners have told him about patients they would have sworn did not have an opioid abuse disorder problem, only to find out through the PMP that they did. “They didn’t have a clue that their patients were in trouble and needed help,” he says.

Promising results

Early metrics on the states’ efforts to curb opioid abuse are promising, but at the same time, with so many different initiatives aimed at curbing opioid abuse, it can be hard to know which effort is having the greatest effect. Baumgartner says, “We want to be very careful not to draw lines that aren’t there, and while there is a correlation between all the things and the change, it is hard to say the exact effect of the PMP on its own. All we can say is that everything we’ve done since 2009 has resulted in a 30 to 40 percent decline in prescription-related opioid deaths. We still have about 700 opioid deaths a year because of an increase in heroin-related deaths. We’d like to think that if we can prevent someone from developing opioid abuse disorder when they’re taking prescription drugs, they’re not going to be as likely to transition to heroin later in life. That’s why the use of the PMP is so important in helping providers ensure that patients don’t get hooked on these medications on the legal side, and then turn to the illegal alternatives down the road.” Baumgartner says the state has seen significant improvements in its morbidity and mortality data related to prescription-related opioid deaths, and improvements in the number of individuals who have multiple provider episodes each month – patients who are seeing multiple providers for controlled substances every quarter. 

Getting started can be the hardest part

In recent PMP stakeholder meetings, one thing is certain: the initial onboarding process can be challenging and frustrating, even for a seasoned user like Christensen.

“The initial enrollment can be pretty rough if you try to do it yourself,” he says. “It can easily take two hours. However, if you gather your information and call the Department of Health, it should take about 20 minutes. You need your license numbers, addresses, and answers to security questions, which you should write down. The security questions are good, and you won’t always remember the answers you gave. The interface can be very fussy, especially if you haven’t logged in for a month or two. You’ll have to re-authenticate, and if you have to do that, I would again recommend calling in for assistance. I’ve heard that some folks have had a problem, but to me they’ve been great and very beneficial. I’ve never had a problem with the support staff. They’re easy to get through to, as well. The area of difficulty is that there are two layers. One is the Secure Access Washington (SAW) site, which is separate from the PMP, and you have to know which one you’re looking at. To be honest with you, I think dentists should renew their licenses online because if they do, they’re accessing their SAW account. Being familiar with SAW will help facilitate smooth PMP utilization.” 

As an example of how easy accessing the system can be, Christensen asked us to time his PMP login. Start to finish, it took 23 seconds, including the time to get through SAW. Christensen’s praise notwithstanding, many dentists have had different experiences accessing the PMP help desk. Members shared their stories of not being able to get through at all, or waiting for 30 minutes or more to speak with someone. Additionally, when the DOH solicited feedback from users about the site, they got an earful — everything from “laborious and inconsistent” and “not user friendly and clunky,” to “I use the website and have no issues with it at present” — with negative feedback outweighing the positive. 

Gov. Jay Inslee admits there’s work to do, saying, “The prescription monitoring program is an important tool, and we’ve done a lot to help make it easier for you to use. Yet, we know there’s more work needed with your medical record vendors to get the PMP integrated as part of your workflow, and my administration is committed to helping make that happen.”

Barriers, tricks, and tips

Christensen says that one of the biggest impediments to widespread use of the PMP is dentists’ resistance to behavior change. Another issue hindering the PMP is that it is not a “real time” system. As one dentist pointed out in a stakeholder survey, “If a patient were to have an appointment at their MD’s office on a given day, then they had another appointment at another medical/dental provider a little later on the same day, and then an appointment at my office at the end of the same day, the PMP will not have updated. The patient could conceivably have gotten an opioid prescription at each of these offices, and none of us would know it.”

Baumgartner admits that ease of access is the state’s biggest challenge to acceptance of the PMP, but likens its use to riding a bike. The more frequently you utilize it, the easier it becomes. The state has been trying to mitigate some of the frustration by encouraging practitioners to delegate access authority to dental team members. However, under current rules, those accessing the PMP must be credentialed, meaning only licensed hygienists, EFDAs, and assistants are allowed. Christensen is amenable to changing that part of the law, saying, “I cannot delegate to students, but I want that. I would support some type of license for front office people so that they could access the system.” Both Christensen and Baumgartner say that delegates can look up patients during a two-day period, or even a week, to streamline the process. Since most practitioners have a good idea of their patient schedules for the week, this could really help. Still, there will always be changes and emergencies that occur, so being well versed in the system is important, says Baumgartner. 

Coaching and counseling

We wondered, what happens when you look up patients and discover there may be a problem? It can be tricky, Baumgartner says, adding, “The thing we try to stress with providers is not to make their gut reaction to kick the patient out of their clinic, but to try and help them. We understand that sometimes you have to, and that sometimes you’re going to offer them help and they’re going to throw it back in your face. The last thing we want is for the PMP to become the source of information for ‘who do I turn away or kick out of my practice.’” Baumgartner recommends contacting their primary care provider to get to the root of the issue, yet cautions about jumping to conclusions. He says, “Do a little verification and ensure that there weren’t data entry errors. We would hate to have a patient kicked out of a clinic due to a mistake. We also really encourage practitioners to share with the other providers listed on the report. In the case of dentists, we really encourage them to identify who the primary care provider is, because that is probably the best person to have that critical conversation with the patient about the controlled substance history. Sometimes, through no fault of their own, patients have developed opioid dependency because prescribing practices were very different a few years ago.” 

Christensen often accesses the PMP in front of patients to share the information as he sees it, noting, “I ask open-ended questions like ‘Is there anything I should know about?’ I remind them that we check the prescription database for everyone, and that I want them to be aware. If something pops up I can say, ‘Oh! You didn’t mention that you just got 90 Percocet. I understand you shouldn’t be using your chronic meds for this acute stuff, so why don’t we do a physician consult, or maybe we should have the person who prescribes for the chronic pain prescribe for this, and we will consult with him or her.’ They can watch my thinking process, and it’s an opportunity for me to counsel them.”

Additionally, Christensen is actively working to change his patients’ expectations. He says, “Patients come in and they really expect an opiate, and can get offended if you suggest an NSAID and acetaminophen. There are arguments that occur, and many times I will supplement with an opiate, but you have to counsel them on how to use the NSAID and acetaminophen because a lot of people don’t think it’s going to work, so they don’t even try. That is one of my biggest frustrations. We’re developing some handouts that may help.” 

Program benefits

Properly used, the PMP can be an effective tool in the battle against opioid abuse. Christensen says, “I like the evidence the PMP provides. I often print up the report and attach it to my dental record. Another benefit is that I can write on the prescription that I have looked at the PMP, and I know the patient is on a chronic pain contract. If the pharmacist wants to know why I’m prescribing, I can say it’s for an extraction. I get a lot fewer calls that way.” 

On the horizon: EDR/EMR integration

Electronic medical record (EMR) hospital systems like EPIC, one of the most widely used systems in the country, can pull up the PMP, effectively accomplishing two goals. It meets the state’s security and privacy laws, and provides better, faster ease of access. Baumgartner calls it “the utopia scenario,” and the state is working toward integration of the PMP with electronic medical record (EMR) and, eventually, electronic dental record (EDR) systems. “We don’t have a lot of health systems involved in that yet,” Baumgartner explains. “Some dentists who work in large-care settings may already have access. Obviously, the portal improvement work group is trying to see what it can do to make improvements, but again, another part of that will require working collaboratively with groups like the dental association. We need to know how to distribute information on best practices to your members, so they can know about workarounds to make the program work more smoothly, like using delegates and creating the ideal IT setup from a security perspective. We’ve been educating people about all of this, but it’s hard. Washington is a huge state with many providers, and trying to find avenues to disseminate hasn’t always been easy.” The state hopes to work with dental software vendors on integration in the future but nothing has happened yet. Part of the issue is that there are many different types of dental software, unlike hospitals, which tend to use one of just a few programs, like EPIC. 

Another issue the state is working on is interstate data sharing for border providers. For instance, if you’re a provider in Spokane, you could have patients picking up prescriptions in Coeur D’Alene or Post Falls, Idaho. The state is looking at ways to get a complete prescription history for patients. “Those are the two biggest issues from a healthcare provider perspective that we’re focusing on currently,” Baumgartner said. “Beyond that we’re looking at ways to encourage providers to make accessing the PMP a more standardized practice of their workflow because that’s something that is important, given the rule changes that are currently under consideration. It’s best to get used to the system now, while it is optional.”

Going forward

Consider enrolling in the PMP now, before it becomes required. Steel yourself and go into the process knowing that onboarding can take time and be frustrating. We recommend following Christensen’s advice: enlist a trusted assistant, EFDA, or hygienist to work with you on the initial sign in, keep a record of the questions, addresses, and other information required in a safe place that you can easily access in the case of re-authentication, and call the state’s help line when you have questions. If anecdotal evidence is correct, you’ll run into problems when you don’t use the system regularly, so you might consider trying a system where you check patients in advance. If you start before the PMP is required, you may minimize your frustration with the system, and avoid the inevitable logjam of providers across the state trying to reach the help line. To that end, the state is working to get more help line staff, but in the event that doesn’t happen, you’ll want to be comfortable with the PMP before everyone comes on board!