MINNESOTA PMP UTILIZATION IN THE EMERGENCY DEPARTMENT

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1 MINNESOTA PMP UTILIZATION IN THE EMERGENCY DEPARTMENT MY EXPERIENCE DONNA CEGLAR, MD EMERGENCY PHYSICIAN ST. LUKE S REGIONAL TRAUMA CENTER

2 I HAVE NO REAL OR PERCEIVED CONFLICTS OF INTEREST

3 MY PMP USE IN THE EMERGENCY DEPARTMENT Personally used for past 6 years with increasing frequency General goal: look up every patient for whom I am considering prescribing a controlled substance from the ED Fairly quick to use Opiates >>> Benzodiazepines > Stimulants, etc. in the ED setting Strategy is different depending on clinical situation

4 ACUTE PAIN Pain is real, and often is appropriately managed with opiate pain medications in addition to other methods (NSAIDs, acetaminophen, ice, etc.) In general I try to prescribe for objectively painful conditions (i.e. broken ankle, ureteral stone seen on CT) and a very limited number of doses. But pain is also subjective and I find PMP particularly helpful in safe prescribing to patient s with more subjective complaints (dental pain, back pain).

5 MY PMP PROCESS Review of last 12 months of prescriptions Look for red flags Frequent prescriptions for controlled substances Prescriptions from multiple different providers Regularly prescribed opiates earlier in year, now no longer filling similar prescriptions Prescriptions for opiates and benzodiazepines together Prescriptions for methadone, Suboxone

6 MY PMP PROCESS No or limited prior prescriptions on PMP and legitimate pain complaint prescription for very small number of doses of controlled substance. Only enough to facilitate PCP or subspecialty follow up If I ve decided against writing prescription discussion with patient

7 CHRONIC PAIN PMP helps identify patients who may be on a controlled substance prescription contract often difficult to ascertain if patient not forthcoming Circumvents limitations of medical record Can identify potential doctor-shopping for patients typically seen outside of clinic system, now presenting to the emergency department

8 MULTI STATE QUERY New patients, patients just visiting town on vacation, patient who typically fills across the bridge Routinely search both Minnesota and Wisconsin database through the MN PMP Colleagues search several states with each query A total of 38 states on my last count

9 CHRONIC PAIN Attempt to consult PMP before patient encounter to help facilitate discussion Generally I do not prescribe controlled substances for chronic complaints in the ED Helps identify what controlled substances patient is or has been prescribed and identify concerning patterns Common scenario a recent drop in prescriptions filled; often related to recent violation of contract

10 CONCERNING PATTERNS Scenario: 50 year old male, history of knee surgery 1 month ago. Prescribed 120 tabs of hydrocodone-acetaminophen from Dr. A on day of surgery 3 weeks later, prescribed 60 tabs of hydrocodoneacetaminophen from Dr. B One week after that, prescribed 40 tabs of Tramadol from Dr. C Now presenting to the ED with ongoing knee pain Facilitates discussion of uncontrolled pain vs potential development of dependence and opioid use disorder

11 INTERVENTION Not uncommon to identify a patient with frequent ED and ambulatory visits for pain complaints and PMP will demonstrate multiple prescriptions from several providers Print out the year-long list and discuss concerns with patient. Occasionally patient upset about not receiving prescription Usually, though, discussion easier (difficult to argue with facts presented visually) Discussion with or referral back to PCP, careful documentation of findings and discussion in the medical record Development of care plan for recurrent ED visits that minimizes opiates when appropriate

12 PMP SUCCESS STORY Emergency department PMP query leads to frank discussion of concerning pattern suggestive of opiate use disorder. One year later, physician receives thank you letter for intervention. Patient now opiate free and doing well.

13 QUESTIONS?