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Research Article: Quality Improvement Study

Obstetrician-gynecologist perceptions and utilization of prescription drug monitoring programs

A survey study

Goodin, Amie PhD, MPPa,b,∗; Bae, Jungjun BSd; Delcher, Chris PhDc,d; Brown, Joshua PharmD, PhDa,b; Roussos-Ross, Dikea MDe,f

Editor(s): Desapriya., Ediriweera

Author Information
doi: 10.1097/MD.0000000000024268

Abstract

1 Introduction

The US Centers for Disease Control and Prevention (CDC) issued guidelines in 2016 recommending that clinicians review their state Prescription Drug Monitoring Program (PDMP) data when initiating and/or continuing opioid therapies under certain clinical circumstances.[1] PDMPs provide opioid and other controlled substance dispensing histories and other measures to clinicians for patients in their care. The American College of Obstetricians and Gynecologists (ACOG) and the American Society of Addiction Medicine (ASAM) jointly released a committee opinion to clarify recommendations for obstetrician-gynecologists (OB/GYN) that treat patients who are prescribed or may use opioids during pregnancy, medically or non-medically, following the release of the CDC guidelines.[2] The ACOG-ASAM recommendations endorse OB/GYN usage of PDMPs as a primary prevention tool for opioid-related adverse events.

As of mid-2020, most states now a) mandate that all controlled substance prescribers register with their state PDMP and b) require all or certain prescribers to check the PDMP when initiating controlled substance prescriptions, particularly for US Drug Enforcement Agency (DEA) Schedule II opioids.[3] Physician use of PDMPs increases when administrative registration with the state is mandated,[4] and prescribers reportedly comply with PDMP usage mandates.[5] However, prescribers across multiple specialties report that stand-alone PDMP data is difficult to access and incorporate into their workflow.[6] For OB/GYNs in particular, PDMPs are viewed as less effective, positive, or useful when compared to other primary care physicians.[7] In this literature, OB/GYNs sample sizes are low and they have sometimes been categorized with “other” prescriber specialties [8] making it difficult to understand their nuanced PDMP use and perceptions. One study in Washington Medicaid reported that OB/GYNs had the second lowest uptake in both PDMP registration and usage when compared with other physician specialties.[9]

Since OB/GYNs are the primary source of care for many women and comprise the majority of care during pregnancy;[10–12] they are well-positioned to provide screening and intervention for opioid-related sequelae. The purpose of this study was to assess OB/GYN utilization and perceptions of their state PDMP as stratified by practice location in states with and without mandated PDMP query.

2 Methods

2.1 Instrument development

A workgroup consisting of an OB/GYN, a pharmacist, and health services researchers reviewed survey items from several publicly available state-level PDMP survey instruments.[13] Survey items from previously published instruments were adapted for OB/GYNs to assess the perception of PDMP effectiveness, knowledge of PDMP functions, and self-reported use of PDMPs. The survey instrument was reviewed and approved by the ACOG District XII Committee on Health Care for Underserved Women prior to release and is available in Supplementary Materials, http://links.lww.com/MD/F548.

2.2 Study design and protocol

The study design was a cross-sectional survey. The research team partnered with ACOG leadership, who oversaw dissemination of the survey link and accompanying study description and explanation via email to a random sample of 5000 ACOG members with an active license to practice in the United States in May 2018. A reminder email was sent each week following the initial email invitation for a period of 6 weeks and the survey link remained active for a period of one week following the final reminder in July 2018. Survey responses were anonymous, but email read receipt data from the invitation were collected to calculate an adjusted response rate. Data were collected in Qualtrics (Qualtrics, Provo, Utah, USA). The University of Florida Institutional Review Board reviewed and approved this study.

2.3 Analysis

Response frequencies were calculated for each item and all surveys with >1 item response were included in the analysis (n = 397). State regulatory environment was classified as “mandatory” or “voluntary” based on the legal requirements for PDMP query (as of July 2018) and the physicians primary practice location. Chi square analysis was used to compare differences in response distribution between respondents practicing in mandatory versus voluntary PDMP states. A priori significance was set at 0.05.

Qualitative and free-text survey items were analyzed and coded for instances of similar thematic content by 3 reviewers, and, in instances of disagreement, our OB/GYN acted as a fourth and deciding vote. All analyses were conducted in Excel and SAS 9.4 (SAS Institute Inc., Cary, North Carolina, USA).[14,16]

3 Results

A total of n = 1470 survey invitations were opened and read, resulting in an adjusted response rate of 27% (n = 397 surveys completed). About a third of respondents were in private practice settings, and few were still considered trainees (60.7% classified as Attending). Most respondents practiced in a mandatory PDMP state (80.6%), 9.6% practiced in voluntary PDMP states, and 9.8% did not indicate their practice location. The majority were currently registered with the PDMP (77.6%). To gauge OB/GYN familiarity and understanding of PDMP data, respondents were asked to identify what information is provided by the PDMP from a list of options. Approximately, 30% were unaware that the PDMP identifies the prescriber writing each prescription and nearly half of respondents were unaware that the PDMP identifies dispensing pharmacies. A summary of other respondent characteristics is shown in Table 1.

Table 1 - Obstetrician-Gynecologist (OB/GYN) Survey Respondent Characteristics.
Respondents (n = 397)
Practice Setting
 Academic/University-affiliated medicine 116 (29.2%)
 Private Practice 144 (36.3%)
 Hospital-based practice 57 (14.4%)
 Federally qualified heath center 16 (4.0%)
 Other settings 8 (2.0%)
 No response 56 (14.1%)
Level of Training
 Attending 241 (60.7%)
 Resident physician 62 (15.6%)
 Fellow 33 (8.3%)
 Other 5 (1.3%)
 No response 56 (14.1%)
Sex
 Female 238 (59.9%)
 Male 100 (25.2%)
 Prefer not to answer or No response 59 (14.9%)
Currently Registered with the Prescription Drug Monitoring Program (PDMP)
 Yes 308 (77.6%)
 No or I cannot access the PDMP 71 (17.9%)
 No response 18 (4.5%)
Census Region of Practice Location
 Northeast 70 (17.6%)
 Midwest 98 (24.7%)
 South 121 (30.5%)
 West 69 (17.4%)
 Missing 39 (9.8%)
Practice Legal Environment
 Mandatory PDMP Use 320 (80.6%)
 Voluntary PDMP Use 38 (9.6%)
 Unknown Practice Location 39 (9.8%)
Mean Years in Practice (SD) 16.14 (12.82)
Last time using the PDMP
 Within last week 81 (20.4%)
 Within the last month 84 (21.2%)
 Within the 6 months 55 (13.9%)
 Within the last year 17 (4.3%)
 Longer than one year ago 10 (2.5%)
 I have never used the PDMP 45 (11.3%)
 I cannot access the PDMP 2 (0.5%)
 No response 103 (25.9%)
PDMP provides the following information
 Prescribed medication type 324 (81.6%)
 The quantity of medications dispensed 311 (78.3%)
 Name of provider on prescription 281 (70.8%)
 The pharmacy dispensing medication 217 (54.7%)
 The PDMP will tell me the primary reason why the medication is prescribed 13 (3.3%)
 None of the above 3 (0.8%)
 No response 58 (14.6%)
Mandatory use indicates that the OB/GYN practices within a state that requires that the prescriber query the PDMP prior to initiation of a new controlled substance prescription; whereas voluntary use indicates that querying the PDMP was not required in the state of practice at the time of data collection.

Those practicing in mandatory versus voluntary states perceived the primary purpose of PDMPs differently (Table 2) and the majority of respondents suspected that 0 to 10% of their patients misuse or abuse opioids (Fig. 1). In free-text responses regarding the primary purpose of PDMPs, a majority of respondents that selected “other” purpose expressed frustration with PDMP usage and/or mandatory use laws (n = 14, Table 2). Three content themes of PDMP purpose emerged from these free-text responses:

  • 1. Increase in physician burden [sample response: “To burden physicians with police work”],
  • 2. Skepticism of government involvement [sample response: “Government bull [expletive]”], and
  • 3. Oversight of prescriber activity [sample response: “So that state government and legislators can say they are doing something about the “opioid crisis””].
Table 2 - Obstetrician-Gynecologist (OB/GYN) Perceptions of the Prescription Drug Monitoring Program Purpose,.
Practice Legal Environment
“The purpose of the PDMP is…” Mandatory Query (n = 290) Voluntary Query (n = 36)
To identify patients who are using medications that they haven’t disclosed to their current provider 98 (33.8%) 11 (30.6%)
To identify patients who are “doctor shopping” for medications 67 (23.1%) 6 (16.7%)
To allow the physician to verify medications that the patient is being prescribed 111 (38.3%) 19 (52.8%)
Other (please specify) 14 (4.8%) 0 (0.0%)
Missing responses (n = 30) were not included in denominators.
Respondents who did not provide their state location (n = 39) were not included.

Figure 1
Figure 1:
Obstetrician-Gynecologist (OB/GYN) Estimates of the Proportion of their Patients Suspected of Abusing Opioids (Top) and OB/GYN Reported Reason for Querying the Prescription Drug Monitoring Program (Bottom), by Practice Legal Environment.

Respondents report most frequently querying the PDMP for patients that are currently using or prescribed opioids, and when they treat patients suspected of drug abuse (Fig. 1). Respondents most frequently report taking action as a result of using the PDMP by confirming prescription fills (31.3% in mandatory states; 23.7% in voluntary states), followed by speaking with patients about controlled substance use (27.8% mandatory states; 26.3% voluntary states). About 1 in 5 respondents indicated they confirmed doctor shopping behaviors as a result of querying the PDMP. No respondents reported referring patients to law enforcement (0%) and Child Protective Services referrals were also rare (1.9% in mandatory states; 0.0% in voluntary states; Table 3).

Table 3 - Obstetrician-Gynecologist (OB/GYN) Actions Taken as a Result of Using the Prescription Drug Monitoring Program (PDMP),,.
Practice Legal Environment
Mandatory Query (n = 320) Voluntary Query (n = 38)
Action
 Spoken with patients about their controlled substance use 89 (27.8%) 10 (26.3%)
 Contacted other providers or pharmacies 44 (13.8%) 9 (23.7%)
 Confirmed patient was filling prescriptions as prescribed 100 (31.3%) 9 (23.7%)
 Confirmed patient was doctor shopping 65 (20.3%) 8 (21.1%)
 Established a controlled substance agreement (“opioid contract” with patient) 29 (9.1%) 5 (13.2%)
 Reduced or eliminated controlled substance prescriptions for a patient 73 (22.8%) 10 (26.3%)
 Changed controlled substance prescriptions to non-controlled substance prescriptions for a patient 42 (13.1%) 4 (10.5%)
 Dismissed patient from practice 11 (3.4%) 3 (7.9%)
 Referred or recommended for substance abuse treatment 30 (9.4%) 7 (18.4%)
 Referred or recommended for pain management 58 (18.1%) 7 (18.4%)
 Referred or recommended for psychiatric management 17 (5.3%) 4 (10.5%)
 Referred or recommended for high-risk obstetric services 26 (8.1%) 1 (2.6%)
 Referred or recommended to Child Protective Services 6 (1.9%) 0 (0.0%)
 Referred to law enforcement 0 (0.0%) 0 (0.0%)
 No action taken or required 24 (7.5%) 2 (5.3%)
 I cannot access the PDMP 6 (1.9%) 3 (7.9%)
 Other (please specify) 9 (2.8%) 0 (0.0%)
 No response 91 (28.4%) 14 (36.8%)
Respondents may select multiple options for this question item, totals do not sum to 100%.
Missing responses (n = 19) were not included in denominators.
Respondents who did not provide their state location (n = 39) were not included.

Overall, 53% of OB/GYNs agreed that “…mandating prescriber use of the PDMP was a good idea.” A greater proportion (58.3%) of respondents practicing in voluntary states agreed or strongly agreed with this statement (Fig. 2).

Figure 2
Figure 2:
Obstetrician-Gynecologist (OB/GYN) Perception of Whether Prescription Drug Monitoring Program Use Should Be Mandatory, by Practice Legal Environment.

4 Discussion

Our study is the largest to-date on OB/GYN perceptions and use of their state PDMPs, and is among the first to assess perception of opioid use among the patients in their care. These findings suggest that OB/GYN perceptions may be tied to experience with the PDMP as evidenced by a significantly different stated purpose of the PDMP when examined by practice legal environment. The skepticism expressed by many respondents regarding PDMP effectiveness as a primary prevention tool for several opioid-related sequelae is concerning, despite recommendations. The findings regarding PDMP utility as a primary prevention tool were documented in a separate report analyzing these same data.[7]

A recent survey of ACOG Fellows and Junior Fellows reported that most OB/GYN respondents continue to prescribe opioids for a variety of indications, but few reported adherence to opioid prescribing guidelines.[15] In that ACOG survey, 81% of respondents also reported that they were unaware that the primary source of diverted opioids were prescriptions from friends and family members.

4.1 Clinical and research implications

Many states have recently adopted legislation to restrict opioid prescribing and dispensing by limiting quantities of outpatient prescriptions of opioids for acute pain[16] and several other states have similar legislation under consideration.[17] Additionally, federal legislation has been proposed to limit new opioid prescriptions for acute pain conditions to a 7-day supply.[18] These changes in the medico-legal landscape suggest that all prescribers, including OB/GYNs, will be checking PDMPs more frequently. Of particular importance for OB/GYN clinical practice, pregnancy may be the only time a woman with opioid use disorder or other forms of SUD engage in medical treatment,[19] which suggests that OB/GYNs are optimally positioned for screenings and interventions.

The delegate model, whereby a prescriber assigns responsibility for logging in and obtaining reports to another qualified health professional, for PDMP usage has been demonstrated to be more cost-effective than prescriber-initiated PDMP query and could reduce time and resource burden for OB/GYNs.[20] As of 2020, all states (with the exception of Missouri, which is the only state that has not yet implemented a statewide PDMP) permit prescriber delegates to access the PDMP.[3] After resolving workflow issues regarding PDMP access, however, there is evidence to suggest that physicians are uncertain about how and when to discuss information gleaned from PDMPs with their patients.[21] This uncertainty may contribute to decreased perceptions of PDMP utility.

4.2 Strengths and limitations

This study employed evidence-based practices for maximizing physician response rates, including the use of multiple, timely follow-up invitations,[22] as well as delivery of the invitation via a trusted professional association (here, ACOG). Despite these efforts, the response rate to this survey is in line with typical response rates for web-based surveys to physicians[23] that do not include financial incentives.[22] An additional limitation is that we were reliant on self-reported measures of OB/GYN PDMP usage and were unable to compare these self-reports with patterns of actual PDMP use.

5 Conclusions

ACOG members are diverse in their perceptions regarding the utility and purpose of PDMPs; though, the majority agree that PDMPs are a primary prevention tool for drug abuse and diversion. However, a knowledge translation gap may still exist- as only a third of OB/GYNs report checking the PDMP for their patients with opioid prescriptions. Increased training is needed regarding clinical utility of PDMPs along with practical guidance for incorporating the PDMP into OB/GYN practice.

Acknowledgments

The authors wish to thank the leadership of the American College of Obstetricians and Gynecologists (ACOG) for disseminating the survey to ACOG members and for providing feedback on the survey instrument. Additionally, the authors would like to thank the members of ACOG District XII for providing comment on the preliminary findings. Preliminary findings were presented at the 2019 ACOG Annual Clinical and Scientific Meeting in Nashville, Tennessee.

Author contributions

Conceptualization: Amie Goodin, Chris Delcher, Joshua Brown, Dikea Roussos-Ross.

Data curation: Jungjun Bae.

Formal analysis: Amie Goodin.

Methodology: Amie Goodin, Chris Delcher, Joshua Brown, Dikea Roussos-Ross.

Project administration: Amie Goodin.

Supervision: Amie Goodin, Chris Delcher, Dikea Roussos-Ross.

Visualization: Jungjun Bae.

Writing – original draft: Amie Goodin.

Writing – review & editing: Amie Goodin, Jungjun Bae, Chris Delcher, Joshua Brown, Dikea Roussos-Ross.

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Keywords:

opioid abuse; opioid diversion; prescription drug monitoring programs; primary prevention tools; women's health

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