Be Sure to Check the PDMP Before Prescribing Controlled Medications

Norbert von der Groeben

On a Tuesday clinic not long ago, I was delighted to see Mrs. M on my schedule. I walked into the exam room where the psychiatry resident, an understated and able young woman, was jotting down notes on her clipboard.

Mrs. M and I locked eyes and smiled at each other. It was good to see her again. (As one of my wisest supervisors taught me years ago, we get paid to see our patients, but the relationship is real, based on trust, shared intimacies, and mutual affection.)

“Mrs. M is doing well,” said the resident. “No new medications or medical problems. She continues to take Lexapro and finds it helpful for anxiety. She’d like to continue and is also requesting a small dose of Ativan, for the occasional breakthrough anxiety.”

In all the time I’d been treating Mrs. M—nearly a decade by my count—she had never needed to see me more than once or twice a year and had never needed much more than a refill of her stable medications. Having her on the schedule was like an oasis amid a sea of chronically and severely mentally ill patients. Her visits were reliably quick, straightforward, and mutually reassuring. Furthermore, I saw Mrs. M as a role model of sorts—someone I hoped I could emulate as I aged.

In her 60s, Mrs. M was still happily married with well-adjusted grown children, healthy grandchildren, and family reunions where people actually got along. Youthful, trim, and sprightly, she could have graced the cover of Outside Magazine.

“How are your kids?” I asked her. “And your grandkids?” She updated me on the goings-on in her extended family, and the happy tidings were balm to my soul—a reminder that not all families are rife with dysfunction and multigenerational trauma.

“So about that Ativan,” said the resident, breaking into my reverie. “I was just about to check the PDMP when you came in.”

The PDMP (prescription drug monitoring program) is a statewide database listing all the controlled drugs (Schedules 2 through 5) dispensed by a pharmacy to a given patient in a given time period within that state. The purpose of checking the PDMP is to optimize safe prescribing. The PDMP can help clinicians avoid prescribing medications that may have dangerous interactions with other medications and mitigate the risk of prescription drug misuse, overuse, and addiction.

A substantial part of my job as an academic psychiatrist at a large teaching hospital is to supervise medical students and residents in the practice of medicine. In 2011, the same year the Centers for Disease Control and Prevention declared a nationwide prescription drug epidemic, I began to require my students to check the PDMP before initiating or renewing a prescription for any controlled drug.

I teach my residents to check the PDMP right there in the room with the patient. I even have the patients look at the computer screen, so they can see for themselves what kind of data the PDMP includes: prescriber’s name, name and location of the dispensing pharmacy, and the drug (strength and quantity), all neatly linked to the patient’s name, date of birth, and home address. Checking the PDMP during the visit contributes to full transparency in the therapeutic relationship.

There are several pieces of information contained in a patient’s controlled substance prescription history that should serve as a red flag to the clinician:

• Benzodiazepines co-prescribed with opioid painkillers, a combination that increases the risk of accidental overdose

• Multiple prescriptions for the same or similar drug from different doctors (“doctor shopping”), a sign or harbinger of addiction

• Prescriptions for tramadol, an opioid with serotonergic properties that, when combined with selective serotonin reuptake inhibitors, increases the risk of serotonin syndrome

• The combination of a benzodiazepine, a stimulant, and an opioid—a drug trifecta that represents dangerous polypharmacy, with drugs working at cross-purposes and posing a risk for addiction

“No need to check the PDMP,” I said to my resident, as she was turning to the computer to access the database. She didn’t say anything. In retrospect, I imagine her eyebrows rose. “Mrs. M and I go way back, and there’s never been a problem with her Ativan.” Just for good measure, I turned to Mrs. M and added, “Now don’t take these every day, or you’ll build up tolerance and they won’t work.”

“Not to worry,” Mrs. M assured me. “I use them only when I’m getting on an airplane to visit my kids.”

I said goodbye to Mrs. M and moved on to my next patient. I didn’t think about Mrs. M again until my resident later said she’d like to discuss her at our noon interdisciplinary meeting. She had checked the PDMP after all and discovered something unexpected.

Drug-seeking patients use a variety of techniques to get the drugs they want. They engage in these techniques on a somewhat unconscious level, driven by the physiologic imperative that defines the addictive process. One of the most reliable techniques is to flatter the doctor—to tell her how much better she is than other doctors; how much more knowledgeable, able, and compassionate. When I looked back, I realized Mrs. M had frequently regaled me with how incompetent her other psychiatrists had been.

All doctors, even very experienced ones, have blind spots when it comes to drug-seeking patients. One patient type that is especially challenging for me is one I call “The Twin.” The Twin is the patient who is your mirror double—someone who is from the same race or socioeconomic class, went to the same schools, has the same interests and hobbies, or, most challenging of all, is a health care professional. When we see ourselves in our patients, we often assume their motives and intentions are the same as ours.

“Mrs. M has been getting Xanax from another prescriber,” said my resident. She showed me a printed copy of the PDMP.

Mrs. M was back in our office a week later and admitted she had lied to us about her benzodiazepine use. She described a slow and insidious process of dependence on benzodiazepines over the past year, getting them from us and her primary care doctor. Thanks to my diligent resident, Mrs. M’s troubles were caught before her problem grew into a more serious and protracted addiction.

In the weeks that followed, Mrs. M endured a painful taper off of benzodiazepines. Withdrawal is marked by mood lability, extreme emotional fragility, and debilitating anxiety and depression. Between visits there were tearful and angry phone calls from Mrs. M as well as her husband. Mrs. M made it through, and she is now benzodiazepine-free.

We all learned lessons from the experience. Mrs. M learned how addictive benzodiazepines can be, even in the absence of a personal history of addiction. I learned a lesson in humility, again. (Will I ever get this right?) My resident learned how fallible attendings are. (Perhaps she already knew.) She also learned what I myself had forgotten in the face of my own narcissism and wishful thinking—check the PDMP before prescribing a controlled drug, no matter how much you like the patient or feel convinced the patient can’t possibly be misusing the drug you are prescribing. Sometimes an oasis turns out to be just a mirage. ■