David is a 30-year-old male referred by the department of corrections after spending two years in jail for drug possession. On interview, he says he has “extreme social anxiety” that’s kept him out of work for several years. He also cites difficulty concentrating due to “adult ADD.” He looks relaxed and comfortable, and says he can’t recall the name of the doctor who once prescribed him Xanax and Adderall. He asks to restart these medications because “they’re the only ones that work.”

We’ve all seen patients like David—patients who call requesting sedatives or stimulants, “must be seen right away,” are “visiting from out of town,” or have “lost a prescription.” Sometimes it’s just as they say, but often these are cover stories from drug-seeking patients. We’ve been taught in these situations to perform a thorough history and assessment, document, request identification, call previous providers, and—if we do write the prescription—to provide the drug in limited quantities. Now we have another tool: prescription drug monitoring programs, also known as PDMPs. Although PDMPs have been around for a few years, they’ve recently become more user-friendly—and for most controlled-substance prescribers, using them will soon be mandatory.

What are PDMPs?
PDMPs are searchable databases that can help prescribers identify ­potential abuse or diversion of controlled substances. They were created by the U.S. Department of Justice (DOJ) in 2009 to help law enforcement identify drug diversion. In many states, the PDMP is run by the state’s board of pharmacy, but in some states, it may be managed by the department of health, law enforcement, or a professional licensing board. In California, for example, the DOJ manages the PDMP.

In most states, anyone licensed to prescribe controlled substances (including physicians, nurse practitioners, and physician assistants) as well as pharmacists have PDMP access. In fact, as of 2016, 29 states require prescribers to sign up with and use their state’s PDMP. Most states will allow you to sign up online. The recent passage of the Comprehensive Addiction and Recovery Act, or CARA (see this issue’s News of Note), aims to bolster the usefulness of PDMPs by increasing information-sharing between states and by ensuring that the information is up-to-date.

How do PDMPs work?
To search for a patient in a PDMP, all you need to do is enter the person’s name and birthdate and click the search button. The PDMP will generate a patient activity report that will tell you what controlled substances the patient has picked up and where. The report gives you lots of detail, including the address of the patient; the drug names, doses, quantities, and refill information on any controlled substances that have been dispensed; and the applicable prescriber names, DEA numbers, pharmacy names, dispensing dates, and prescription numbers.

PDMPs provide contact information so practitioners can communicate directly with other prescribers and dispensers about a particular patient. Some PDMPs will also alert you with an on-screen pop-up warning if your patient meets pre-designated alert thresholds. For example, if your patient obtains ­controlled substances from 6 or more prescribers or pharmacies within a 6-month period, or is prescribed both a benzodiazepine and an opioid at the same time, you may receive an alert. Some PDMPs further allow you to flag patients with whom you have a controlled-substance contract (an exclusivity agreement that no other prescriber will provide controlled ­substances).

When you query your state’s PDMP, David’s report shows that he filled prescriptions for Adderall and Xanax from two other doctors in the past 30 days, and that he recently received oxycodone from three emergency departments in two ­cities.

What’s the best way to use my state’s PDMP?
Some states have a rule requiring you to check the PDMP before you can prescribe any controlled substance to any patient. Other states are more lax and allow you to decide when to check it.

Here are some commonsense guidelines. You should consider checking the PDMP before prescribing a controlled substance for:

• Patients who are new to your practice
• Patients with a history of substance use disorder
• Patients who refill early or report “losing” medication

In addition, it’s a good idea to check the PDMP any time you have a gut feeling that your patient isn’t telling the truth about controlled-substance use. For established patients, how often you recheck the database will depend on how frequently you see the patient, how much you trust the patient, and what your state laws require.

Since each state’s PDMP is different, you should spend a little time familiarizing yourself with your state’s program. To find your state’s program, check with the PDMP Training and Technical Assistance Center. Be advised, however, that this database may not always be up-to-date because of ever-changing PDMP laws and ­regulations.

With whom can I share PDMP ­information?
In some states, it’s legal for you to use PDMP information to contact other practitioners who have prescribed controlled substances to your patient. In those states, sharing this information with the other prescribers is usually a good idea, because otherwise the patient may keep getting inappropriate prescriptions. Similarly, some states allow you to share the PDMP reports with your patients. Doing so can be helpful for setting limits and engaging patients in controlled-substance contracts. But be careful—in other states, sharing information from PDMP reports may be a crime.

Regardless of state, if a PDMP report reveals that a patient has been lying to you or receiving controlled substances from multiple prescribers, one thing you shouldn’t do is contact the police. Federal privacy laws prohibit this—under HIPAA, such disclosures can only be made if patients pose an imminent risk of harm to themselves or others. There’s an interesting case-related discussion on Medscape about how to deal with lying patients. Be aware that there may be harsh penalties, such as felony charges, for inappropriate use of PDMPs. Unwarranted activities include checking on people who aren’t your patients or accessing the database without a valid registration. Also, in some states, providing information to anyone else—including the patient you’re querying or anyone to whom you transmit the patient’s medical record—may be a criminal act.

Can I delegate the PDMP-checking chore to an employee?
Some states allow prescribers and dispensers to register delegates whom they authorize to conduct PDMP ­searches on their behalf. But before you ask a staff member to search the database for you, make sure you fully understand the laws in your jurisdiction. In Alaska, for example, asking someone to check the PDMP for you is asking that person to commit a felony.

What are some problems inherent in PDMP use?
While they are excellent tools, PDMPs have several limitations. The first thing to keep in mind is that PDMPs may not be up-to-date at the moment you query them. The report you generate is not necessarily a real-time snapshot of your patient’s controlled-substance access, since pharmacies have varied requirements for reporting the controlled substances they dispense. Updates range from daily to monthly, and most PDMPs contain information for up to 12 months.

The second problem is that there’s a surprising amount of information PDMPs don’t contain. For example, mail-ordered prescriptions from out of state won’t be included in your report. Nor will prescriptions coming from federal healthcare facilities such as Veterans Affairs facilities, the Department of Defense, Indian Health Service, and other agencies that are not required (and often do not) report to state PDMPs. In addition, federally funded methadone programs and some buprenorphine maintenance programs are bound to additional confidentiality regulations. Specifically, 42 CFR Part 2 imposes strict limits on sharing substance abuse treatment information with third parties. For more information, visit this SAMHSA web page.

The third problem is with drug-seeking patients looking to game the system. For example, patients may use a variation of their name to try and secure multiple prescriptions. You may be able to partially counteract this with some clever searching. For example, searching “Ronald McDonald” may result in a report showing only one prescription dispensed, but searching with the patient’s initials and birthdate rather than his full name may generate dispensing records for the same patient under the names Ron McDonald, Ronny McDonald, R. McDonald, etc.

What should prescribers do in light of these problems? A recent Florida Supreme Court decision indicated law prosecutors in controlled-substance cases should not assume that data in PDMPs is accurate, and instead should regard the data as “justification for further inquiry” (Hardy v. State of Florida, 2014 Fla.App. LEXIS 7172; full decision available here). This is probably sound advice for prescribers as well. A good article on this subject can be found here.

When you inform him of the recent prescriptions you found in his PDMP report and express concern he might have a substance abuse problem, David scoffs and walks out of your office without saying a word. [Editor’s note: See our expert interview with Dr. Raskin for suggestions about how to respond in these situations.]

CATR Verdict: As of 2016, the majority of states require controlled substance prescribers to register for and begin using PDMPs, and that number is increasing. While PDMPs can help identify patients at high risk of abusing or diverting controlled substances, they’re not 100% reliable, and they’re subject to confusing regulations that vary from state to state. If you prescribe controlled substances, it’s a good idea to learn about your state’s PDMP laws, consider your search results in the context of all available information, and watch for regulatory changes over the next few years.