Dr. Vivek H. Murthy, our Surgeon General, recently released a report that, among other things, highlights the gap between the widespread substance use disorder problems the country faces and the relatively small amount of abuse treatment. Here’s an excerpt from the New York Times article.

The majority of people who misuse substances do not develop a use disorder, the report said. But roughly one in seven Americans — 14.6 percent of the population — are expected to develop such a disorder at some point.

Only about 10 percent of people with a substance use disorder receive any type of specialty treatment, the report said. And while more than 40 percent of people with such a disorder also have a mental health condition, fewer than half receive treatment for either.

This problem touches everyone. We can change our approach to detect this sooner and get at-risk patients into treatment. Checking every patient, every time, for their prescription history helps find these at-risk patients sooner and more often.

How do you find at-risk patients? Do you check everyone, every time? Let me know how you identify your 14.6%.

Effective monitoring systems [PDMPs] will augment clinical judgment, provide evidence of misuse, and facilitate prescription of the most appropriate analgesic for the situation…The Emergency Department is regarded as the nation’s safety net…the last bastion of around-the-clock access to care … Unfortunately, some of the solutions to opioid misuse [limiting ED physicians to 3-day opioid prescriptions] preempts judgments from trained emergency medical providers.

American College of Physicians, Annals of Internal Medicine, 9 April 2013

Prescription drug monitoring programs (PDMPs) are now active in most states to assist clinicians in identifying potential controlled drug misuse, diversion, or excessive prescribing. Little is still known about the ways in which they are incorporated into workflow and clinical decision making, what barriers continue to exist, and how clinicians are sharing PDMP results with their patients.

Design
Qualitative data were collected through online focus groups and telephone interviews.

Setting
Clinicians from pain management, emergency and family medicine, psychiatry/behavioral health, rehabilitation medicine, internal medicine and dentistry participated.

Patients
Thirty-five clinicians from nine states participated.

Methods
We conducted two online focus groups and seven telephone interviews. A multidisciplinary team then used a grounded theory approach coupled with an immersion–crystallization strategy for identifying key themes in the resulting transcripts.

Results
Some participants, mainly from pain clinics, reported checking the PDMP with every patient, every time. Others checked only for new patients, for new opioid prescriptions, or for patients for whom they suspected abuse. Participants described varied approaches to sharing PDMP information with patients, including openly discussing potential addiction or safety concerns, avoiding discussion altogether, and approaching discussion confrontationally. Participants described patient anger or denial as a common response and noted the role of patient satisfaction surveys as an influence on prescribing.

Conclusion
Routines for accessing PDMP data and how clinicians respond to it vary widely. As PDMP use becomes more widespread, it will be important to understand what approaches are most effective for identifying and addressing unsafe medication use.

Pain Medicine, Volume 15, Issue 7, July 2014 
Prescription Advisory Systems & Technology

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