Prescription Monitoring Program
As a class of drugs, opioids include some prescription medicines commonly referred to as painkillers, and street drugs such as heroin. When prescription drugs are misused or overprescribed, they can contribute to dangerous drug interactions, substance use disorder, overdoses and deaths. And Washington has not been spared the consequences of opioid misuse.
Researchers no longer consider prescription medicines the top contributor to opioid-related deaths in Washington. For example, by 2021, the rate of patients prescribed opioids in our state had dropped by 45 percent since its height in 2015. In that year, nearly one in 10 people were prescribed an opioid.
Nonetheless, more than 9,000 Washingtonians died from opioid prescription drug overdoses over the last two decades, according to Department of Health (DOH) data. In 2020, more than a quarter of opioid-related deaths in Washington involved commonly prescribed opioids. (The Addictions, Drug and Alcohol Institute at the University of Washington developed this estimate.) And many more people have had their lives affected by opioid-use disorders.
DOH’s Prescription Monitoring Program began operating more than 10 years ago. Its goals include: to improve patient care, reduce the abuse of controlled substances and help medical professionals reduce overprescribing. This independent, in-depth performance audit identified detailed steps that will help DOH improve the effectiveness of this program.
Read a two-page summary of the report.
The audit found that DOH could improve its processes and monitoring to ensure pharmacies comply with the program should be improved. These process improvements include confirming available prescription information is complete, and that pharmacies correct errors. The agency should also check the appropriateness of waivers it grants to non-participating pharmacies.
One goal of this audit was to identify problematic prescribing and dispensing patterns. However, we could not do so due to restrictions around who may access the data needed to perform such analyses. State and legislative auditors in other states, such as Colorado, Louisiana and Oregon, have used their access to this type of data to identify:
- Instances of doctor and pharmacy shopping by patients
- Severe cases of overprescribing by health care providers
- Prescriptions involving dangerous drug combinations
When auditors have access to such data, the public is assured of an independent review of government systems that are essential to supporting public health and safety.
A successful prescription monitoring program must fulfill three essential requirements. The data it contains – about the drug, patient, prescriber and pharmacist – should be complete, accurate and available to prescribers in a timely manner. The law defines “timely” as within one day of distributing a prescription. By accessing their state’s PMP system, medical professionals can review medications their patients received in the past before prescribing or dispensing new or additional medicines.
Washington’s PMP began operating in 2011 and is administered by the Department of Health (DOH). State law requires pharmacies to submit to the PMP system all Schedule II-V controlled-substance prescriptions that they give to a patient. In addition, most medical professionals must check the PMP before prescribing controlled substances. The Washington State Hospital Association and the Washington State Medical Association jointly oversee the Better Prescribing, Better Treatment Collaborative. The Collaborative uses PMP system data from DOH to create opioid prescribing reports. The Collaborative distributes these reports to educate medical professionals about their prescribing practices and how they compare to their peers.
Complete, timely data
Prescription records should be complete, and the data uploaded within the time set out in law. Up-to-date entries in the PMP database help reassure prescribers they have a full view of the patient’s prescriptions for other controlled substances. Monitoring the database for complete and timely submissions forms an important part of that reassurance.
The audit found that roughly one-quarter of prescriptions were uploaded to the system late. In addition, it found DOH does not monitor PMP data to see if pharmacies submit prescription records within one day of distributing to a patient. Instead, starting in January 2022, DOH initiated a process to check for pharmacies that have not submitted any prescription records to the PMP on a given day. The agency performs this review a couple of times a month. DOH then contacts some of the pharmacies that have not submitted data for the highest number of consecutive days, alerting them to the gap in reporting dates and helping them resolve the issue.
In addition, DOH lacks a process to determine whether pharmacies have submitted all required prescriptions to the PMP system. At the moment, neither DOH nor the Pharmacy Commission has established requirements for pharmacies to perform an independent review and reconciliation of their own systems to the PMP database. For this reason, the state lacks an assurance pharmacies submit all the records they should.
The PMP system automatically blocks prescription records with data errors from uploading into the system. Until recently, DOH did not contact pharmacies that failed to correct prescription records with such errors.
We analyzed PMP data on records that did not upload to the PMP database due to uncorrected errors. We found about 12,000 uncorrected records, out of an estimated 12 million uploaded to the PMP system in the past year. This is about 0.1 percent of records submitted in a year — a very small percentage. But most of the uncorrected errors came from a very small number of pharmacies. If DOH worked with the handful of pharmacies with the most errors, doing so would lead to the correction of thousands of errors. In turn, that would mean that many more correct, complete records would be available to prescribers within the PMP system.
Expanded prescribing reports
Opioid prescribing reports contain information about the prescribing activity of the health care professionals who prescribe them. These reports help some, but not all, of Washington’s medical professionals understand their own prescribing behavior. They can readily see how their prescribing activity compares to their peers. Since 2019, the Better Prescribing, Better Treatment Collaborative has used PMP data to send opioid prescribing reports to medical professionals. Further enhancements to the reports could increase their usefulness to prescribers. The Collaborative would need to work with other professional associations to expand the reach of these reports. It is likely the Collaborative would need extra resources to reach more health care professionals in other fields.
As the lead state health agency, DOH is well positioned to help. It can bring together stakeholders to help the Collaborative improve the reports and expand their reach.
Restricted data access
State law restricts access to PMP data to protect patients, prescribers and pharmacies. The restrictions curtail independent oversight that might identify opportunities for improvement. Auditors in other states used PMP data to identify prescribing and dispensing patterns of concern. We could not replicate the work in their audits due to the data restrictions in Washington. Additionally, our ability to examine certain system processes was limited. For example, we could not view data that identified pharmacies, so we could not see which might have been persistently late uploading data. These restrictions in state law inhibited our ability to complete this planned audit work. Furthermore, neither DOH nor the regulatory licensing boards and commissions analyze PMP data in search of those concerning patterns.
We recommended DOH update its administrative rules in the Washington Administrative Code (WAC). Doing so can help ensure pharmacies submit all required prescriptions records in a timely manner. The agency could also improve its internal processes to check that pharmacies have submitted prescription records promptly.
To expand the reach of opioid prescribing reports to more medical professionals, we recommended DOH take part in a workgroup with the Better Prescribing, Better Treatment Collaborative. We also recommended the Pharmacy Commission make some additions to pharmacy inspection processes that will help ensure completeness of PMP data. Finally, we made a recommendation to the Legislature to amend state law so that independent auditors can have the authority to access identifiable PMP data.