Evidence-based Changes in Prescription Drug Monitoring Programs

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 Evidence based practice (EBP) is the driving force for many quality improvement initiatives and the standardization of healthcare practices and policies. Motivating factors of using EBP focuses on improving health care quality in order to increase positive outcomes through consistent use of research based knowledge. This research explores a area of interest and develops a PICOT question and use evidence-based research related to my topic.  The paper first explore evidence-based practice, identify my nursing issue, my topic’s relation to my FNP MSN specialty track and further explore the nursing issue in detail.

Overview of Evidence-based changes in Prescription Drug Monitoring Programs

Evidence-based practice is the result when clinical practice and scholarship are integrated into clinical decision-making. Clinical experience is incorporated with the best available research evidence and is used to enhance clinical decisions. The Evidence based nursing practice (EBNP) process consists of five stages: (1) formulating a question that will yield the most suitable answer; (2) gathering the most relevant information by systematic search of the literature or clinical guidelines; (3) performing critical evaluation of the evidence and its validity, relevance and feasibility; (4) integrating research evidence with clinical experience, patients’ values and preferences and (5) assessing treatment outcomes (Mick, 2015).

Implementing EBNP is potentially beneficial for patients and healthcare systems, and for nurses. It enhances patients’ access to and information about effective treatment (Mckeon & Mckeon, 2015). EBNP can improve the healthcare system by facilitating consistent decision- making and advancing cost-effectiveness policies and procedures (Broglio & Cole, 2014). Finally, EBNP can help nurses by facilitating informed and evidence-based clinical decision-making, helping them to keep updated with technologies, and enabling greater efficiency while providing the best patient care (Renolen & Hjalmhurt, 2015).  Research plays a dynamic role in EBP. Systematic research occurs within theory and science. However, it is not the only source of knowledge. Research also occurs within clinical experience and expertise, integrated with patients’ preferences and the available resources in a given situation (Renolen & Hjalmhurt, 2015). Nurses implement treatment based on the woven research between theory, science, clinical experience, expertise and patient preference. EBNP is pulled from both quantitative scientific research and qualitative research.

Evidence-based research is the base that propels my nursing project. The nursing issue I chose to explore is the relationship that exists when prescribers use the Prescription Drug Monitoring Programs (PDMP) over a period of time and determine if the quantity of opiate prescriptions are reduced as a result, and if prescribers make referrals to other pain management disciplines. A rationale for selecting this topic is in part due to the opiate crisis this county is currently experiencing and how proper training and tools for managing people seeking pain control can assist. The struggle of opioid addiction and provider pressures of prescribing is presenting and effecting care.

Prescription Abuse Impact

Misuse of prescription opioids, central nervous system (CNS) depressants, and stimulants is a serious public health problem in the United States. The abuse of and addiction to opioids such as heroin, morphine, and prescription pain relievers is a serious global problem that affects the health, social, and economic welfare of all societies.  The number of prescriptions for opioids (like hydrocodone and oxycodone products) have escalated from around 76 million in 1991 to nearly 207 million in 2013, with the United States their biggest consumer globally, accounting for almost 100 percent of the world total for hydrocodone and 81 percent for oxycodone (Pradin et. al., 2013)

Prescription opioids are associated with chronic constipation and narcotic bowel syndrome, falls and orthopedic injuries in the elderly, neonatal abstinence syndrome, and transition to intravenous drug use with further associated health risks such as HIV and Hepatitis C virus exposure (Rolita, 2013). The costs associated with opioid abuse are considerable. Over the past decade, there has been a general increase in the number of emergency department visits and inpatient hospitalizations related to prescription drug use. From 2004 to 2011, the number of emergency department visits related to opioid abuse or misuse increased by 183% (CDC, 2013). In 2011, there were 420,040 emergency department visits for prescription opioid abuse (CDC, 2013). The increase in patient volume is another burden for the overtaxed health care system. It is estimated that the financial abuse and misuse of prescription opioids are responsible for approximately $53 to $72 billion in costs annually (CDC, 2013).

Chronic nonmedical use of opioids is almost twice as high in men, although women have higher rates of being prescribed types drugs that are prone to abuse. Men also have a higher rate of death related to opioids compared with women (Rolita, 2013)..

Certain socioeconomic and clinical factors appear to play a role in differential opioid prescribing, misuse, and poor outcomes. Patients who have lower educational attainment, are eligible to receive Medicaid, or have history of previous substance abuse and/or psychiatric disease all tend to be prescribed more opioids and a higher doses (Rolita, 2013).

Opioids that are prescribed commonly to treat painful conditions have had a dramatic increase in the rate of abuse, addiction, overdose, and death. The increase in complications corresponds with a dramatic increase in the rate of opioid prescriptions that resulted from pressures placed on practitioners to avoid under-treatment of pain.

Application to Family Nurse Practitioner Track

The MSN specialty track in which I am pursuing my degree is the family nurse practitioner program. Many patients present to their primary care providers to prevent, assess and treat their chronic pain. With NP autonomy being legislated in an increasing number of states, nurse practitioners are able to fill gaps in preventative care and keep Americans healthier (Allred et. al., 2017). More NP availability also decreases the number of citizens not receiving primary care, as well as those seeking treatment for otherwise preventable conditions in emergency rooms around the country.  This increases the primary role Family Nurse Practitioners (FNPs) are taking. With prescription drug misuse growing as a problem in the primary care setting, it is imperative that FNPs have the proper training and tools for managing pain and take their part in reducing the opiate crisis. FNPs role of reducing the opiate epidemic can have an unprecedented effect on health, community, safety, violence, well fare and growth. Limitless benefits are possible with an active role of the FNP. Reduction is possible, but will take an unforeseen amount of time to see the effects and continuity of reducing opiate prescriptions. This study has the ability to provide quantifiable data that can guide prescribers and prompt alternative treatment explorations that display an impact in opiate during daily patient assessments.

Prescription Drug Monitoring Programs and supportive evidence

Prescription misuse has become a nationwide epidemic with deaths. According to the Center for Disease Control and Prevention, deaths from prescription drug overdose have surpassed traffic-related deaths in 2008 as the leading cause of death in the United States (CDC, 2014). The age of highest death rates for prescription drug misuse in the United Sates is between 45 and 49 years of age and occur among American Indians/Alaska Natives, followed by Caucasians then blacks (CDC, 2014). Preventing misuse of prescription drugs by properly prescribing opioid pain medications for patients with a diagnosis of chronic pain may lead to improved health outcomes while maintaining proper pain control.

Many states in the U.S. have utilized the Prescription Drug Monitoring Program (PDMP) to address the issue of prescription drug misuse. PDMP is a database that tracks controlled substances prescribed by healthcare providers and medications filled by patients. Providers can report concerns to law enforcement agencies (Fishman, 2012). PDMP was designed and implemented to collect, analyze and report on the prescription and dispensment of controlled substances (FSMB,2004).  PDMP databases are not a complete solution to the prescription drug problem, however, creating PDMP that operate in real-time, collaborate with interstate and incorporate electronic health records can help FNPs to identify patients that are doctor shopping and recognize potential prescription drug abusers (Drug Abuse, 2013).  Daily use of the PDMP by FNPs can guide patients towards other methods of pain control. Preventing misuse of prescription dugs by properly prescribing opioid pain medications for patients with a diagnosis of chronic pain (non-cancer) may lead to improved health outcomes and referrals to alternative pain treatment. When FNPs adopt a culture of using the PDMP as a daily interaction with patients, the effects of combatting the problem of drug misuse profound. My proposed solution to reduce the opioid crisis is for primary care clinics to adopt an culture transparency when treating patients by actively communicating and voicing the use of PDMP, discussing results, use current CDC guidelines for treatment of pain and explore alternative pain treatment options. If such a culture is adopted, it can be repeated with every interaction everyday during patient and FNP exchanges and be part of their daily dialog with patients. The key stakeholders impacted this are the out-patient clinic practitioner’s and patients. Practitioners have the ability to address opioid abuse daily, however consumer satisfaction often is correlated to the success as a practice. Mindsets must be adjusted and adopt the usage of PDMP along with evidence-based practice guidelines for treatment of chronic pain for the long-term health of the individual and community.

Adopting and implementing the daily use of the PDMP along with evidence-based clinical practice guidelines would involve taking a full history and physical of the patient while assessing the functioning of patients when they present to primary clinics with complaints of pain (Hooten et al., 2013). An expected outcome of this would be a reduction in opioid prescriptions, reduction in opioid use and an increase in use of alternative pain management referrals.

Evidence-based PICOT question

Using the PICOT format, below is my evidence-based question I seek to complete using quantitative research. In patients that present to a primary care clinic with a diagnosis of chronic pain (non-cancer pain), when prescribers access the Prescription Drug Monitoring Programs (PDMP) and use evidence based guidelines prior to prescribing treatment compared to not using the PDMP and evidence based guideline, is there a reduction in opiate prescription and referral to non-medication pain management referrals?

P: Prescriber’s (FNP’s)

I: opiate monitoring through PDMP and non-use

C: comparing whether the Prescription Drug Monitoring Program and evidence based guidelines prior to prescribing

O: To analyze whether prescriber’s use of the PDMP reduce long-term opiate prescription and increase referrals to alternative pain management disciplines increase.
T: 12-month period.

Research Literature Support

Prescription drug monitoring programs. A study completed by Green et al., (2012) sought out to examine the associations between prescription drug monitoring program (PDMP) and prescribers responses to suspected doctor shopping in two states (CT and RI).  A cross-sectional study was completed from March to August 2011 and sample of providers licensed to prescribed scheduled medications with an email address (N= 1,385, 998 in CT and 375 in RI) were provided to the research team for the purpose of the study. Anonymous surveys were emailed to providers licensed who used the PDMP and a total of 1,385 prescriber’s surveys were received. Results showed a correlation that prescriber’s use of a PDMP might influence medical practice, especially with opioid detection. Providers perceived that the PDMP was helpful in reducing abuse of prescription opioids within their practice, but may not necessarily reduce diversion. An strength of this study was a large two-state sample with a contrast in time.  A limitation was external validity of the findings is low, despite efforts to recruit clinicians.

In a study performed by Reigler et. al (2012), the question was asked whether prescription drug monitoring programs impact opioid misuse. In this observational study data from a poison center and an opioid treatment center were used to observe whether there were changes in the surveillance of data after implementation of the PDMP (Reigler et al., 2012). The results of the study showed PDMPs are effective in decreasing prescription opioid misuse (Reigler et al., 2012). The data showed the increase of intentional exposures and also the increase of admissions to treatment centers to be lower in the states where providers utilized PDMPs (Reigler et. al., 2012).

In an eleven-year peer reviewed research articles were identified and reviewed assessing implications to practice and its barriers (Worley, 2012). Four themes were evaluated: PDMPs effect on prescribing opioids, PDMPS effects on prescribing benzodiazepines, multiple provider use and patient characteristics and healthcare professionals’ perspectives on PDMP (Worley, 2012). The review concluded that PDMPs limit doctor shopping and reduce prescription drug misuse (Worley, 2012).

A study completed by Khalid et al., (2015) sought to compare adherence to opioid adherence guidelines and potential misuse of opioids of resident’s verses attending physicians. A cross sectional study of N= 1,285 patients who received treatment for chronic opiate use (non-cancer pain) between the age of 18 to 89 years of age was created.  Of the total, 215 were resident patients and 1,070 were attending physicians’. Data was abstracted from their electronic medical records. Analysis showed over one third of patients received multiple early refills, and opioid misuse factors of age <45, drug use disorder, tobacco use and mental health disorder more with resident providers than attending physicians. Strengths of this study yielded the level of monitoring was significantly higher than in previous studies whereas limitations stated the data was abstracted from the EMR and the identified markers used were from billing codes or ICD codes which may be incomplete or unreliable.

Prescribing Pressures: Large patient volumes, time constraints, patient satisfaction ratings, reimbursement strategies and ethical dilemmas are just a few challenges that face physicians attempting to combat opioid abuse (Kunins, Farley & Dowell, 2013).  Leyy, Johnson & Harbison (2016), recently complete a study that examined the opinions of emergency department physicians to understand if economic and regulatory factors impact their management of patients who display drug-seeking behaviors.  A cross-sectional epidemiological study was completed with (N= 141) ED physicians between 31 – 70 years of age who treated adult and pediatric patients. A survey was conducted utilizing an online survey tool to assess the current opinions of opioid abuse identification factors: physical examination, history, use of the EMR, query of PDMP database and drug screening tools. Survey questions were designed for validity and tested for content by a group of emergency experts. The survey included 39 multiple choice questions with an option for an essay. Results yielded that 71% of ED physicians felt pressure to prescribe opioid medications to avoid administrative and regulatory criticism and 98% felt that institutions highly favor patient satisfaction scores as a means for reimbursement as well as evaluating their patient management.

A strength of the study was after every question an opinion provision was included to allow for participants to provide an opinion not included in the multiple choice.  A limitation was sampling was limited to physicians in Florida and Georgia and  may not be able to generalize to the greater population.

It must be accurately asserted that many physicians face regulatory factors that influence their practice. The Joint Commission reflects hospitals accreditation surveys which is directly linked to reimbursement. The Joint Commission has adopted pain as the fifth vital sign and reviews pain management within their surveys (Wattana, Nelson & Todd, 2013).  Physicians cite failure to treat pain may result in a compliant to the Board of Medicine, formal discipline from their administration and civil liability (Dworkin, 2012). Despite this literature, little has been written about the practical issues providers and patients face when trying to access alternatives to opioids for managing chronic pain and how both patients and their various providers view these issues (Penny et. al., 2016).               Complementary Therapies: Complementary and alternative medicine (CAM) therapies have been shown to be useful in the management of chronic pain (Simpson, 2015).  The present results suggest that an approach grounded in the neurobiology of emotion and nociceptive perception and using CAM therapies in a group setting can reduce pain and medication use among a population of patients previously considered intractable by their physicians (Simpson, 2015). In a recent study, Mehl-Madrona, Mainguy & Plummer (2016) explored alternative complementary strategies for the long-term management of chronic pain and reduce dependence on opiate prescription. To explore patient outcomes when opiate reduction was implicit in the philosophy of the medical group. A non-experimental correlation design with two comparison groups were generated using the electronic health records. N= 42 patients were selected who attended group medical visits who received opiate prescriptions on their current dose. A second comparison group of  N=207 patients was generated for comparison who made initial consultations for alternative pain treatment (Mehl-Madrona, Mainguy & Plummer, 2016). A quality-improvement project was implemented and managed all opiate receiving patients in the group medical visits. Patients were not randomized but with the use of electronic health records, review and comparisons were deduced.  Results showed, group medical visits that incorporated alternative therapies helped patients reduce opioid use. Patients who continued with physicians challenging conventional pain treatment with prescriptions of opioids significantly reduced opiate dosages. A strength of the study was the group structure can serve more patients per month and allow for greater time to incorporate alternative and analysis of the connection between pain and emotions.  A limitation was that patient outcomes were known only until they left the practice.

Evidence based guidelines

The Center for Disease Control and Prevention identified eight guidelines to identify areas for recommendations for prescribing opioids for chronic pain (CDC,  2017). Elements found are: * conducting a physical exam, * urine drug screen, * reviewing treatment options, * starting patients on the lowest effective dose, * implementing pain treatment agreements, *monitoring pain with documentation, and *using safe methods for opioid discontinuation (CDC, 2017).

Theoretical Framework:

Pain management and health are fully connected. The Health Promotion Model was designed by Nola J. Pender to be a complementary counterpart to models of health protection (Schub, 2016). It defines health as a positive dynamic state rather than simply the absence of disease. Health promotion is directed at increasing a patient’s level of well-being. The health promotion model describes the multidimensional nature of persons as they interact within their environment to pursue health. Pender’s model focuses on three areas: individual characteristics and experiences, behavior specific cognitions and affect and behavioral outcomes (Schub, 2016).  The Health Promotion Model incorporates the behavioral aspect, which is needed when addressing the connection of addiction between health and behavior. Using this theoretical framework can address elements of needed alternative pain management alternatives as an active effort to address non-medication pain management. Health Promotion Model addresses the value in patient differences and behavioral aspects to address the nature of persons to pursue health goals. Medical professionals need to be open to support goals in a non-traditional fashion to combat the opiate crisis.

Change Model:

There are many ways of implementing change. However, planned change, which is a purposeful, calculated and collaborative effort to bring about improvements. Lippitt’s change theory is based on bringing in an external change agent to put a plan in place to effect change. There are seven stages in this theory and they are diagnose the problem, assess motivation, assess change agent’s motivation and resources, select progressive change objects, choose change agent role, maintain change, terminate helping relationships (Mitchell, 2013). This theory can be used in nursing to effect change. Due to pain management being such enormous industry affection millions of lives, a systematic calculated effort must transform society from prescription based pain treatment to openly addressing pain management and addiction without fear of repercussion. Once that society and awareness exists and is supported institutionally, change can be promoted in a progressive model that tackles various problems at each stage in my PICOT question.

Research Approach

This study will use a non-experimental correlational design, which explores the relationship between variables using statistical analysis.  Quantitative correlation design

explores the relationship between variables using statistical analyses. Variables will come from the history and physical documentation and include the following: completed history and physical, nature of pain, intensity of pain, past pain treatments, co-existing conditions, effects of pain on physical functioning and past history of substance abuse. Variables from evidence-based guidelines will include the following: PDMP accessed, patient agreement, urine drug screen, opioid prescribed, opioid dose lowered, referred to other discipline, and documentation of opioid education.

A quantitative correlational design approach will allow me to systematically investigate and explain the nature of the relationship between quantifiable data. An advantage of correlational design is that it allows researchers to analyze the relationships among a large number of variables in a single study (Comiskey & Dempsey, 2013). It provides a measure of degree and direction of relationship. A disadvantage of correlational research is that a correlational relationship between two variables is occasionally the result extraneous variables, so caution is needed as correlation does not necessarily tell us about cause and effect (Comiskey & Dempsey, 2013)  .

Sampling

Quantitative research designs including correlational studies usually use large samples that have been attained by a precise process. This is important because the purpose of sampling in quantitative studies is to produce statistically representative data that permits generalization of findings to the target population (Comiskey & Dempsey, 2013). In this proposal, the target population is the prescribers, both MD’s and FNP’s in out-patient primary care settings. In non-probability sampling not all members of the population has a chance of participating in the study. Male and female patients will be identified that reflect the Ninth revision of International Classification of Disease (ICD-9) of chronic pain (code 338.2), pain due to trauma (code 338.21) and other chronic pain (code 338.29).

Purposive sampling will be completed, where patients between the ages of 18 and 70 years old receiving medical services in an primary out-patient population have a primary diagnosis of chronic pain, non-cancer type, chronic pain due to trauma and other chronic pain. Patient’s meeting the criteria would be hand-picked through electronic databases records. The design of the project is descriptive. The project would be a chart review of prescribers’ documentation in the medical record to determine if the PDMP was accessed and if evidence based protocols were used when prescribing opioid pain medications to patients diagnosed with chronic pain.  The number of records assessed will be determined by the number of patients that present for services during the data abstracting time period from January 2017 to December 2017. Two people will be reviewing and extracting data from the review of medical records. To ensure internal reliability the two data collectors will be randomly assigned to medical records and will have a data collection sheet to score data using a quantitative scale. The randomization and collecting tool to score results provide a strength of the evidence that a relationship between the variables exist.

Advantages of purposeful sampling are that it saves time, money and effort. It is flexible and meets multiple needs and interests. It enables researchers to select a sample based on the purpose of the study and knowledge of a population. They choose subjects because of certain characteristics. A disadvantage of purposive samples is that they can be highly prone to researcher bias. FNP’s and prescribers can be chosen at random to review and the use of a data collection table will allow for any biases to be minimized.The subjectivity and non-probability based nature of unit selection in purposive sampling means that it can be difficult to defend the representativeness of the sample.

Participant rights will be protected in a number of ways. Data will remain anonymous via de-identification and protected using coding and cannot be associated with individuals. Coding will ensure loss of privacy and confidentiality are not at risk. Any data abstracted will not contact any identifying information and data collected will be entered into an excel spreadsheet. Providers will be ensured by the project director that no fear of occupational consequences will be placed and that the benefits of this project are to improve evidence-based prescribing practices. The association between the providers and data results will not be displayed and only known to the project director.

Data Collection Methodology:

This project involves collecting original data in an outpatient primary care setting serving patients between the age of 18 and 70 years old from medical records between the time period of January 2018 to December 2018. Original data collection will demonstrate an accurate and real-time analysis of the impact of PDMP use and opiate prescriptions. No identifying information will be recorded on the data collection form (Appendix A). Confidentiality of the data will be maintained by utilizing an identification number (as opposed to a medical records or name) on the collection form. Confidentiality of the data will be maintained by utilizing an identification number (ID) as opposed to names. Each question will be numbered with a bivariate response. Yes will coded as and “I” and no will be coded as a “2”. Information will be coded and collected within a tool and the result will be documented in an excel spreadsheet utilizing codes for each of the variables identified. Two tables will be created displaying data collection results of the history and physical and use of evidence-based guidelines and whether there was an effect to minimizing risk for opioid pain medication misuse. These tables and identification of variables will be discussed in detail in the next section.

Analysis:

Descriptive analysis is the term given to analyze data that helps describe, show or summarize data in a meaningful way, such as patterns might emerge from the data. Descriptive statistics do not allow conclusions beyond the data that has been analyzed.  Descriptive statistics are very important because if raw data was presented it would be hard to visualize what the data was displaying. Descriptive research involves gathering data that describe events and then organizes, tabulates, depicts, and describes the data collection (Glass & Hopkins, 1984). It often uses visual aids such as graphs and charts to aid the reader in understanding the data distribution. Because the human mind cannot extract the full import of a large mass of raw data, descriptive statistics are very important in reducing the data to manageable form.  This design of quantitative research aimed at discovering inferences or causal relationships.

In this research design, data will be retrieved through a review of the medical records and extracted using a collection tool (Appendix A) will reflect the collection of variables from the H&P. The variables measured from the H & P are: History and Physical: nature of pain; intensity of pain, past pain treatment; co-existing conditions; effect of pain on physical function and past history of substance abuse; PDMP accessed; urine drug screen; was an opioid prescribed; was opioid lowered; was patient referred to other discipline, was education documented on safety; and provider information: MD, PA or FNP.   Frequency distribution is used to arrange values within a range from lowest to highest of percentage scored in the identified data collection variable during the history and physicals. Appendix A identifies the frequency distribution during the data collection of the history and physical review and calculates how many times each value occurs. The frequency distribution makes it easy to see the highest and lowest scores and where patterns are identified in a sample. Frequency data is often displayed in graphs that count percentages (see Appendix A).  Creation of such a table will display whether evidence-based guidelines were followed (such as urine drug screens, pain documentation ect) to minimize the risk of using evidence-based guidelines, table one

In this descriptive design, multiple variable relationships will be evaluated, therefor utilizing a bivariate descriptive statistics.  Information collected with the created data extraction tool and answers to each question will be coded and entered into an excel spreadsheet with a key for explanation’s. Due to multiple variables a frequency distribution cross-tabulation will be created comparing results of men and women to FNP’s, PA’s and MD prescribers, chronic pain diagnosis, use of and non-nonuse of PDMP, alternative treatment referrals and opiate prescription increase, decrease or maintenance.              Analysis of the data in a cross tabulation table will allow the relationship between the variables to be explored.

Solution impact

The implication for future practice are to increase provider awareness of evidence-based guidelines when prescribing opioid pain medications. Implementation of evidence-based guidelines will be imperative in the fight for minimizing risk of opioid misuse. As prescribers are educated and evidence-based guidelines are implemented, the risk of over prescribing or improper prescribing should show a decrease in misuse of opioid pain medications.

In applying Lippitt’s change theory, as discussed above, is based on bringing in an external change agent (PDMP monitoring system) and effect change. There are seven stages in this theory and I will apply each of these stages to the EBP project. Lippitt’s change theory first states to diagnose the problem: increased opioid addiction misuse and dependence. Secondly, assess motivation: The motivation to reduce opioid abuse is clear cut to me. Misuse of prescription opioids is a serious public health problem in the United States. The abuse of and addiction to opioids such as heroin, morphine, and prescription pain relievers is a serious global problem that affects the health, social, and economic welfare of all societies. As a future FNP, I hope to   , assess change agent’s motivation and resources, select progressive change objects, choose change agent role, maintain change, terminate helping relationships (Mitchell, 2013).

 

P: Prescriber’s (FNP’s)

I: opiate monitoring through PDMP and non-use

C: comparing whether the Prescription Drug Monitoring Program and evidence based guidelines prior to prescribing

O: To analyze whether prescriber’s use of the PDMP reduce long-term opiate prescription and increase

 

 

Translation of results

Conclusion

The misuse of opioid pain medications has become an epidemic in the United States. Implementation of evidence-based guidelines include the PDMP to aide in minimizing opioid pain medication misuse. PDMP is a promising area to evaluate where prescribers are consistent and whether adoption of consistent behavior of providers show a reduction of recognizing misuse and prescribing less as a result. The project proposal will evaluate the use of evidence-based guidelines by providers in a primary care setting. Expected outcomes are when prescribing opioid pain medications, the PDMP should be accessed to aide in recognizing misuse, thereby decrease opioid prescriptions and increase alternative treatment referrals. My goal within this proposal is to create a sound non-experimental design with purposively sampling chronic pain patients and providers using the PDMP and produce relevant information on its usefulness and possible impact it can have on the opioid epidemic.

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Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings,                                           NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD:                                           Substance Abuse and Mental Health Services Administration, 2013.

Wattana, M.K., Nelson, L.S., & Todd, K.H. (2013). Prescription opioid guidelines and                                           the emergency department. Journal of Pain & Palliative Care Pharmacotherapy,                                           27(2), 155-162.doi:10.3109/15360288.2013.78602

Worley, J. (2012). Prescription drug monitoring programs, a response to doctor shopping:               purpose, effectiveness, and directions for future. Issues in Mental Health Nursing, 33, 319-328.

APPENDIX A

DATA COLLECTION TOOL

Identification number: ______________________________

History and Physical Yes No
  • Nature of pain
  • Intensity of pain
  • Past pain treatment
  • Co-existing conditions
  • Effect of pain on physical functioning
  • Past hx of substance abuse
PDMP accessed
Urine Drug Screen
Was an opioid prescribed
Was an opioid reduced
Was an opioid maintained at same dose
Was patient referred to other discipline
Was education documented on safety
Provider
MD provider
PA provider
FNP provider

Appendix B:

Research Critique Table

Author & Title &Permalink Purpose Sample Design Data Collection Methods Results Strengths (S)

Limitations (L)

Khalid, L., Liebschutz, J., Xuan, Z., Dosssabhoy, S., Kim, Y., Crooks, D., Shanahan, C., Lange, A., Heymann, O., & Lasser, K.. (2015)

Adherence to Prescription Opioid Monitoring Guidelines among Residents and Attending Physicians in the Primary Care Setting

http://proxy.chamberlain.edu:8080/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=25529863&site=eds-live&scope=site

Prescription opioid misuse remains a growing epidemic. The purpose of this research was to compare adherence to opioid adherence guidelines and potential misuse of opioids of resident’s vs attending Physicians. Cross Sectional Study

N= 1,285 patients who were receiving treatment for chronic opiate use (non-cancer pain) between the age of 18 to 89 years of age. 215 were resident patients and 1.070 were attending physicians patients.

Comparison of guideline coordinated care of potential misuse of opioid prescriptions between the resident’s patients and the attending physician patient’s. Opioid misuse factors are age <45, drug use disorder, alcohol use disorder, tobacco disorder and mental health disorder. Analysis showed over one third of patients received multiple early refills, and opioid misuse factors of age <45, drug use disorder, tobacco use and mental health disorder more with resident providers than attending Physicians. S- The level of monitoring was significantly higher than in previous studies.

L- Data was abstracted from the EMR and the identified markers used were from billing codes or ICD codes which may be incomplete or unreliable.

Green, G., Mann, M., Bowman, S., Zaller, N., Soto, X., Gadea, J., Cordy, C., Kelly, P., Friedmann, P. (2012).

How Does Use of a Prescription Monitoring Program Change Medical Practice?

http://proxy.chamberlain.edu:8080/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=22845339&site=eds-live&scope=site

The purpose of this study was to test for differences in prescription monitoring program (PMP) in two states (CT and RI) and examine the associations between PMP and prescribers responses to suspected doctor shopping. Cross-sectional study

The sample survey of  N= 1,385, 998 in CT and 375 in RI were completed. Anonymous surveys were emailed to providers licensed to prescribed Schedule II medications in CT (N=16,929 and RI (N=5,567) from March to August 2011

Correlational research to examine the relationship between provider use of PMP and impact on clinical practice in opioid prescription. A total of 1,385 prescriber’s surveys were received. PMP patient reports were used to screen for drug abuse 36.2 % in CT and 10.0% in RI. Results showed a correlation that prescriber’s use of a PMP might influence medical practice, especially with opioid detection. S- Large, two-state sample with a contrast in time.

L- External validity of the findings is low, despite efforts to recruit clinicians.

Author & Title &Permalink Purpose Sample Design Data Collection Methods Results Strengths (S)

Limitations (L)

Kelly, S., Johnson, G., & Harbison, R. (2016).

“Pressured to prescribe” The impact of economic and regulatory factors on South-Eastern ED physicians when managing the drug seeking patient

http://proxy.chamberlain.edu:8080/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edsdoj&AN=edsdoj.0a2f5cfd9940079db0b4282b34142d&site=edslive&scope=site

The purpose of this study was to examine the opinions of emergency department physicians to understand if economic and regulatory factors impact their management of patients who display drug seeking behaviors.  Cross-sectional epidemiological study.

The study, N= 141 ED physicians between 31 – 70 years of age who treated adult and pediatric patients. A survey was conducted utilizing an online survey tool to assess the current opinions of opioid abuse identification factors: physical examination, history, use of the EMR, query of PDMP database and drug screening tools.

Survey questions were designed for validity and tested for content by a group of emergency experts. The survey included 39 multiple choice questions with an option for an essay. Questions were designed using a four column Likert-type scale. Results yielded that 71% of ED physicians felt pressure to prescribe opioid medications to avoid administrative and regulatory criticism and 98% felt that institutions highly favor patient satisfaction scores as a means for reimbursement as well as evaluating their patient management. S- After every question an opinion provision was included to allow for participants to provide an opinion not included in the multiple choice.

L- Sampling was limited to physicians in Florida and Georgia and  may not be able to generalize to the greater population.

Mehl-Madrona, L., Mainguy, B., & Plummer, J. (2016).

Integration of Complementary and Alternative Medicine Therapies into Primary-Care Pain Management for Opiate Reduction in a Rural Setting

http://proxy.chamberlain.edu:8080/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=117380215&site=ehost-live

To explore alternative complementary strategies for the long-term management of chronic pain and reduce dependence on opiate prescription. To explore patient outcomes when opiate reduction was implicit in the philosophy of the medical group. Non-experimental correlation design

Two comparison groups were generated using the electronic health records. N= 42 patients were selected who attended group medical visits who received opiate prescriptions on their current dose. A second comparison group of  N=207 patients was generated for comparison who made initial consultations for alternative pain treatment.

Two groups were created. A quality-improvement project was implemented and managed all opiate receiving patients in the group medical visits. Patients were not randomized but with the use of electronic health records, review and comparisons were deduced. Group medical visits that incorporated alternative therapies helped patients reduce opioid use. Patients who persisted in an environment where physicians challenged conventional pain treatment with prescriptions of opioids significantly reduced opiate dosages. S: The group structure can serve more patients per month and allow for greater time to incorporate alternative and analysis of the connection between pain and emotions.

L: Patient outcomes were known only until they left the practice.

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