New Jersey Pharmacists' Perceptions of the New Jersey Prescription Monitoring Program

Bethany Drimalla, PharmD, MS

Affiliation at the time of project completion: postdoctoral fellow, Rutgers Institute for Pharmaceutical Industry FellowshipsCurrent affiliation: Novartis Pharmaceuticals CorporationRutgers Institute for Pharmaceutical Industry FellowshipsPiscataway, New Jersey

Andrea Wagner, PharmD

Affiliation at the time of project completion: postdoctoral fellow, Rutgers Institute for Pharmaceutical Industry FellowshipsCurrent affiliation: Sunovion Pharmaceuticals Inc

Lucio Volino, PharmD

Clinical Assistant Professor, Ernest Mario School of Pharmacy, Rutgers, The State University of New JerseyThe Great Atlantic and Pacific Tea Company

Donna Feudo, BSPharm, RPh

Professional Experience Program Director and Adjunct Clinical Assistant ProfessorErnest Mario School of Pharmacy, Rutgers, The State University of New Jersey

Michael Toscani, PharmD

Research Professor/Fellowship Director— Rutgers Institute for Pharmaceutical Industry FellowshipsErnest Mario School of Pharmacy, Rutgers, The State University of New Jersey

Funding Support—Financial or Material

Rutgers Institute for Pharmaceutical Industry Fellowships provided financial support to conduct the research survey, prepare a poster, and present the poster at the American Pharmacists Association (APhA) Annual Meeting & Exposition.

Previous Presentations of the Work

A poster summarizing this research survey was prepared and presented at the APhA Annual Meeting & Exposition in Orlando, Florida (March 28-31, 2014).

Conflicts of Interest

The authors have no conflicts of interest to disclose.

ABSTRACT

Objective

To evaluate New Jersey outpatient pharmacists’ knowledge, perceptions, and commentary regarding the New Jersey Prescription Monitoring Program (NJPMP), an interventional tool used by pharmacists and prescribers that collects prescription data on controlled dangerous substances and human growth hormone.

Design

Cross-sectional survey

Setting

Prescription drug abuse has emerged as a national epidemic. To combat prescription drug abuse, misuse, and diversion, 49 states, including New Jersey, have implemented prescription monitoring programs. A 6-week, institutional review board—approved cross-sectional survey was conducted.

Participants

Licensed New Jersey pharmacists (n = 163) practicing in community, mail order, and hospital/clinic outpatient pharmacy settings completed a voluntary, anonymous online survey.

Intervention

The electronic survey assessed perceptions of the NJPMP, including accessibility, benefits and challenges to use, and applicability.

Main Outcome Measure(s)

Responses were analyzed using descriptive statistics, and free-text comments were summarized by the researchers.

Results

The overall response rate was 36.4% (n = 180). Of the 180 respondents, 163 met inclusion criteria and 92.0% were registered to use the NJPMP. Study results indicated 99.4% of pharmacists were aware of the NJPMP and 81.3% frequently used it in practice. Despite high utilization and knowledge of the program, however, pharmacists identified multiple areas for improvement: increased prescriber use, regional interconnectivity of data, and real-time data reporting.

Conclusion

New Jersey outpatient pharmacists are aware of and in favor of using the NJPMP. Although there was high utilization and knowledge of the program, providing better data access was identified as an overarching area for improvement.

Keywords

• Prescription monitoring program
• Opioid
• Pharmacists
• Substance abuse
• Nonmedical use
• Pharmacy practice

With prescription opioid overdoses leading to more deaths in the United States each year than cocaine and heroin combined, prescription drug abuse, misuse, and diversion have become growing concerns. The Centers for Disease Control and Prevention (CDC) estimated that roughly 12 million Americans (12 years or older) reported illegitimate use of prescription painkillers from 2009 to 2010. Further, there were almost 500,000 emergency department visits and approximately 15,000 deaths annually attributed to prescription painkiller overdoses during that time.¹

In 2010, there were more than 7200 reported admissions to state-licensed or certified substance abuse programs secondary to the misuse of prescription painkillers in New Jersey alone. This represented a remarkable increase of over 5000 admissions since 2005, or a 230% increase in prescription drug abuse in New Jersey.

^2,3 To combat this mounting epidemic, the CDC recommends the implementation of state-run prescription monitoring programs (PMPs) to collect data on prescribing and dispensing of controlled substances.¹ The primary goal of PMP utilization is to promote the legitimate use of prescribed medications while curbing fraudulent practices.

To date, all states, except Missouri, have enacted legislation for PMP implementation.⁴ Specifically, the New Jersey Prescription Monitoring Program (NJPMP), which can be accessed by pharmacists and prescribers in good standing with their respective licensing boards, monitors data on controlled dangerous substances (Schedules II-V) and human growth hormone (HGH) dispensed in outpatient settings in New Jersey and by out-of-state pharmacies dispensing into New Jersey.² The NJPMP became operational in 2012 following a 3-phase launch from January through May 2012.⁵

At the time the survey was conducted (approximately 18 months after launch), pharmacies were required to submit data every 15 days; as of March 2014, pharmacies are now required to submit weekly. This information includes, but is not limited to, data identifying the patient, prescriber, and pharmacy; name, strength, and quantity of the drug; form of payment; date prescription was written; and date dispensed.2 While information submitted is similar across states, reporting requirements vary. For example, Oklahoma pharmacies are required to report in real time, while several others submit daily. Pennsylvania, Connecticut, and Alaska are the only states currently requiring monthly reporting.⁴

As pharmacists are at the forefront of dispensing medications, it is imperative for the profession to become fully involved in the fight against prescription drug abuse and to better understand pharmacists’ perceptions related to PMPs. A literature search revealed little has been published^6-8 on pharmacists’ use and opinions of PMPs, particularly in New Jersey. While the NJPMP was independent at the time the survey was conducted, it has since joined the National Association of Boards of Pharmacy (NABP) PMP, InterConnect, which links databases from multiple states. As of February 2014, 26 states have enacted memorandums of understanding with the other states to ensure seamless implementation across the involved states.⁹

Objective

The primary objective of the study was to evaluate New Jersey outpatient pharmacists’ knowledge and perceptions of the NJPMP and to capture commentary related to access, barriers to use, and applicability to clinical practice.

Methods

A cross-sectional, nonexperimental survey study assessing New Jersey outpatient pharmacists’ knowledge and perceptions of the NJPMP was conducted over a 6-week period in 2013 (September 2013-October 2013). This study was reviewed and granted exemption by the Rutgers University Office of Research and Sponsored Programs Institutional Review Board. A list of e-mail addresses on file for current Ernest Mario School of Pharmacy (EMSOP) at Rutgers University preceptors practicing in community, mail order, and hospital/clinic outpatient pharmacies throughout New Jersey was provided to the researchers (n = 495).

The following inclusion criteria were utilized for study participation: pharmacists (1) practicing in New Jersey; (2) practicing in community, mail order, and hospital/clinic outpatient pharmacies; and (3) providing consent. Pharmacists were excluded if they were (1) not licensed and/or not practicing in New Jersey, (2) practicing in inpatient settings or the pharmaceutical industry, or (3) not subject to NJPMP reporting requirements (eg, long-term care pharmacists).

A preliminary survey was developed and pilot-tested by all members of the research team. Based on the pretesting, modifications were made to improve the clarity and intent of the questions. The initial e-mail inviting pharmacists to complete the anonymous, online SurveyMonkey survey was sent on September 12, 2013, and reminder e-mails were sent on October 7, 2013, and October 22, 2013. Due to the blinded nature of the surveys returned, reminder e-mails were sent to all pharmacists on the list, including those who may have already completed the survey. Because no personally identifiable data were collected, it was not possible to preclude participants from completing the survey more than once, although they were asked to disregard the reminder if they had already completed the survey. The survey was closed on October 24, 2013.

At the beginning of the survey, participants were asked for consent based on introductory language describing the survey and its anonymous format, and they had the option to agree or disagree. The first question was intended to confirm the participant met inclusion criteria by asking whether he or she was a pharmacist currently licensed in New Jersey and practicing primarily in an outpatient setting. For those who responded “No,” the survey ended; for those who responded “Yes,” the survey continued to the second item.

The survey consisted of 21 items, but employed skip logic methodology; therefore, the number of items that each participant received varied based on their responses, with each participant receiving 1 through 17 items. Respondents were permitted to skip any question and continue with the survey, as each item included the selection, “I choose not to answer.” Response types for the survey questions were a mixture of “Yes/No,” multiple choice, and Likert scale. The final question was free response, inviting the participant to provide any comments regarding the NJPMP. The study survey collected basic pharmacy-related demographic data and information regarding access frequency, knowledge, awareness, and perceptions of the NJPMP, and associated dispensing habits (Table 1). Descriptive statistics were utilized to report data, and comments were summarized by the researchers.

Responses were collected from 180 participants (response rate, 36.4%). Following the initial question designed to confirm survey eligibility, 17 respondents did not meet inclusion criteria (1 [0.6%] skipped the question and 16 [8.9%] were either not currently licensed New Jersey pharmacists or were not practicing primarily in the community or outpatient settings), 163 (90.6%) met inclusion criteria, and 150 (92.0%) were registered to use the NJPMP. More than half of the respondents had been practicing pharmacy in New Jersey for at least 20 years and over 75% had practiced at least 10 years. The top 3 reported practice areas were chain/mass merchandiser (54.9%), grocery store (22.2%), and independent pharmacy (18.5%). Over 99.4% of the pharmacists were familiar with the NJPMP, and the majority attributed awareness to the New Jersey Board of Pharmacy (NJBOP) newsletter and/or their employers.

Frequent Users of the NJPMP

Altogether, 122 respondents (81.3%) were considered frequent users, defined as those who accessed the NJPMP at least multiple times per week (Figure 1). Overall knowledge of the program was rated as good or very good by 89% of subjects, while less than 4% reported poor or very poor knowledge.

Of the frequent users, the following were selected as common triggers (more than 1 could apply) to using the NJPMP: uneasy feeling (73.3%), new patient (72.6%), medication class (71.2%), patient paying out of pocket (70.6%), and suspicious-looking prescription (65.1%). Response rates for the top 3 categories of prescription drugs that prompt the use of the NJPMP are provided in Table 2. The majority of respondents (83.6%) indicated they would not dispense a prescription if the NJPMP suggested potential misuse (Table 3).

When asked to select which (all that apply) additional features they would like implemented in the NJPMP, respondents indicated they would like to see reportable data linked to bordering states (77.4%), linked nationwide (68.5%), or provided in real time (71.2%); a training program on how to access/utilize the database (6.2%); and a database that was easier to use (11.0%). Two respondents (1.4%) chose not to answer, and 3 (2.1%) selected “Other.” Notably, 1 free-form response revealed pharmacy technicians should be able to access the database and inform pharmacists of potential issues. Despite these, 97.3% of respondents agreed that the NJPMP was useful in helping to reduce the risk of misuse of controlled substances. Most indicated the PMP made them more alert to appropriate dispensing of controlled substances.

Infrequent Users and Nonregistrants of the NJPMP

Of the 16 respondents who accessed the database never or less than once a week, 29.4% did not believe the program applied to their patient population and 17.7% felt they were too busy at work to utilize the database more frequently. Only 9 participants were nonregistrants of the NJPMP. Potential reasons for this included not knowing how to register (33.3%), their place of work did not require or allow use (33.3%), and the registration process was too complicated (22.2%). Of the nonregistrants, 55.6% suggested that an easier registration procedure would likely prompt utilization.

Open Responses

Pharmacists provided commentary regarding the NJPMP (n = 31). A noticeable trend in the comments described the program as helpful to assess patterns of medication use and valuable as a validation tool to confirm medication history, especially with new patients. The most commonly suggested areas for improvement were use of a real-time system that links data with bordering states’ programs and mandatory use for all pharmacists and prescribers. Greater physician utilization was frequently mentioned as a means for increased collaboration to improve patient care.

Discussion

With a rapidly growing prescription drug—abuse epidemic occurring nationwide, it is becoming more evident that pharmacists have a unique opportunity and responsibility to help combat this concerning situation. State-operated PMPs have the potential to be very useful tools to promote public health. With proper and frequent use, they may promote the recognition, early intervention, and prevention of prescription drug abuse and misuse.

This survey, which was conducted roughly 18 months after the NJPMP became operational, provided an important glimpse into daily pharmacy practice and is particularly relevant since pharmacists are the health professionals most affected by PMPs. Study results indicated very high awareness (>99%) and registration (>94%) among respondents; these figures are likely inflated compared with the approximate 16,000 pharmacists licensed in New Jersey (Matthew Wetzel, NJBOP, e-mail communication, August 2014). Additionally, most respondents reported almost daily, or more frequent, use of the program, and most considered themselves knowledgeable about the program.

As expected, Schedule II analgesics were the most common medications to trigger use of the program, with 97.2% of respondents indicating this category was among their top reasons for accessing the NJPMP. Given the staggering amount of known prescription opioid abuse and misuse, Schedule II analgesics, in particular, may have served a primary role in spurring the development of a state PMP. Schedule III-V analgesics outweighed Schedule II stimulants as the second highest trigger for use, with 59.0% of pharmacists selecting this as a top reason for using the NJPMP compared with 47.9% for Schedule II stimulants. There was limited indication that pharmacists were concerned with HGH abuse. Survey results demonstrated a greater concern for opioid misuse compared with other scheduled substances.

Pharmacists not using the NJPMP frequently believed the program was inapplicable to their patient population (ie, long-term care settings exempt from reporting), they were too busy to incorporate it into their workflow, or they were unfamiliar with how to use the program. Of those not registered, onethird did not know how to register and one-third indicated their place of work does not require or allow use of the program. Meanwhile, over half of those unregistered suggested they would do so if the registration process was easier. These insights highlight the importance of educating pharmacists and employers on the utility of the program, as well as how to register and efficiently incorporate it into their daily practice.

Overall, most respondents would take action by contacting a prescriber if the NJPMP suggested a potential for prescription misuse or abuse. When asked for open commentary, remarks were generally positive, stating the NJPMP was useful to better understand and verify patients’ medication patterns. However, many respondents were dissatisfied with the lag time in reporting and lack of ability to monitor prescription data in bordering states. Many believed prescribers should be mandated to utilize and document NJPMP use when prescribing controlled substances. Finally, a limited number of respondents, via free-text comments, displayed reluctance in confronting patients about potential prescription misuse due to safety concerns.

Based on the findings of this study, we believe it is necessary to continually engage pharmacists because they often serve as “gatekeepers” between patients and controlled substances. Pharmacists are in need of tools such as PMPs to track prescription use to help curb abuse, misuse, and diversion. One of the greatest recent advances is the link to 25 other states through the NABP InterConnect.⁹ Future utilization of PMPs will be augmented when pharmacists and prescribers can access data in real time, from one state to another and eventually across the nation. Although New Jersey is part of NABP InterConnect, not all neighboring states are registered and/or actively participating. As of October 2014, Delaware and Connecticut are active, New York is pending, and Pennsylvania is not registered.⁹

Pharmacists may also benefit from training on how to handle a situation when the database indicates potential misuse. Training could focus on how to manage these potentially risky and uncomfortable situations along with providing community outreach opportunities and recommendations for prevention of prescription abuse and misuse. Consistent with these findings are results from a separate survey that assessed the opinions of New York pharmacists towards the modernization of state PMPs prior to the program launch. Pharmacists practicing in New York believed implementation of a real-time PMP would help reduce prescription drug abuse and that training programs for prescribers and pharmacists would be beneficial.¹⁰

Future research should be directed toward outcomes of PMP implementation, specifically assessing whether PMPs have been effective in reducing abuse, misuse, and diversion. It is also advisable to consider how collaboration between pharmacists and prescribers, via PMPs, can further reduce prescription drug abuse to improve patient safety and overall well-being.

Limitations

With a moderate response rate of 36.4%, this study was limited by nonresponse bias as pharmacists opinionated about using PMPs may have been more inclined to respond and those who were not registered or not aware of the program may have declined participation. Furthermore, the study population was restricted only to pharmacists serving as EMSOP preceptors. Overall, the number of pharmacists who participated was relatively small compared with the population of outpatient pharmacists currently licensed in New Jersey. Particularly, the small number of infrequent users and nonregistrants may be significantly underrepresented if expanded to the overall population. The targeted population of EMSOP preceptors was also likely to be more interested in and knowledgeable about the program compared with other outpatient pharmacists because of the instructive nature of a preceptor’s role; however, this may not be indicative/representative of the entire population of outpatient pharmacists practicing in New Jersey.

Conclusion

As statistics have shown an ever-growing epidemic of prescription drug abuse on national and state levels, it is imperative for pharmacists and prescribers to work together using tools such as PMPs to assist with curbing drug abuse, misuse, and diversion while maintaining access for legitimate use. Based on the limited study findings, surveyed New Jersey outpatient pharmacists appeared to be aware of and in favor of using the NJPMP. With the expanded access and link to 25 states, pharmacists have resources to better identify legitimate prescription use, which may lead to an overall improvement in patient care and safety. Despite high utilization and knowledge of the program, however, areas for improvement remain.

References

• Prescription painkiller overdoses in the US. Centers for Disease Control and Prevention website. www.cdc.gov/vitalsigns/painkilleroverdoses/ index.html. Accessed July 28, 2014.
• NJ prescription monitoring Program (NJPMP). New Jersey Division of Consumer Affairs website. www.state.nj.us/lps/ca/pmp/FAQ.htm. Accessed July 28, 2014.
• Public policy and information: position paper no. 8/215th Legislature. National Council on Alcoholism and Drug Dependence website. www.ncaddnj.org/file.axd?file=2012%2F5%2F Position082012.pdf. Accessed July 28, 2014.
• Prescription drug monitoring programs. National Alliance for Model State Drug Laws website. www.namsdl.org/prescription-monitoring-programs. cfm. Accessed July 28, 2014.
• Attorney General Chiesa announces New Jersey prescription monitoring program a vital tool in fighting prescription drug diversion and abuse [press release]. Newark, NJ: The State of New Jersey Department of Law & Public Safety Office of the Attorney General; January 28, 2012. www.nj.gov/oag/newsreleases12/ pr20120118a.html. Accessed February 18, 2015.
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• American Pharmacists Association. Pharmacists’ role in addressing opioid abuse, addiction, and diversion. J Am Pharm Assoc. 2014;54(1):e5- e15. doi: 10.1331/JAPhA.2014.13101.
• NABP PMP InterConnect. National Association of Boards of Pharmacy website. www.nabp.net/ programs/pmp-interconnect/nabp-pmp-interconnect. Accessed July 28, 2014.
• Weiland AW, Wrobel MJ, Brown J, Khadem TM, McEvoy AM. Perceptions of New York pharmacists towards the modernization of the state prescription drug monitoring program. Poster session presented at: 2013 American Pharmacists Association Annual Meeting & Exposition; March 1-4, 2013; Los Angeles, CA.