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Pain Medicine 2014; 15: 1179–1186
Wiley Periodicals, Inc.
Original Research Articles
How Clinicians Use Prescription Drug
Monitoring Programs: A Qualitative Inquiry
Christi Hildebran, LMSW,* Deborah J. Cohen,
PhD,† Jessica M. Irvine, MS,* Carol Foley, PhD,‡
Nicole O’Kane, PharmD,* Todd Beran, MA,§ and
Richard A. Deyo, MD, MPH¶**††
*Acumentra Health, Departments of †Family Medicine,
¶
Medicine and **Public Health and Preventive
Medicine and ††Oregon Institute of Occupational
Health Sciences, Oregon Health and Science
University, Portland, Oregon; §Injury and Violence
Prevention Section Public Health Division of the
Oregon Health Authority, Portland, Oregon; ‡Foley
Research, Portland, Oregon, USA
Reprint requests to: Christi Hildebran, LMSW,
Acumentra Health, 2020 SW Fourth Avenue, Suite
520, Portland, OR 97201-4960, USA.
Tel: 503-382-3971; Fax: 503-382-3997;
E-mail: Childebran@acumentra.org.
Disclosure: Supported by the National Institutes of
Health, National Institute for Drug Abuse through
grant number 1 R01 DA031208-01A1 and by the
National Center for Research Resources and the
National Center for Advancing Translational Sciences,
through grant number UL1RR024140. None of the
authors have conflicts of interest to declare.
Abstract
Objectives. Prescription drug monitoring programs
(PDMPs) are now active in most states to assist
clinicians in identifying potential controlled drug
misuse, diversion, or excessive prescribing. Little is
still known about the ways in which they are incor-
porated into workflow and clinical decision making,
what barriers continue to exist, and how clinicians
are sharing PDMP results with their patients.
Design. Qualitative data were collected through
online focus groups and telephone interviews.
Setting. Clinicians from pain management, emer-
gency and family medicine, psychiatry/behavioral
health, rehabilitation medicine, internal medicine
and dentistry participated.
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Patients. Thirty-five clinicians from nine states par-
ticipated.
Methods. We conducted two online focus groups
and seven telephone interviews. A multidiscipli-
nary team then used a grounded theory approach
coupled with an immersion–crystallization stra-
tegy for identifying key themes in the resulting
transcripts.
Results. Some participants, mainly from pain
clinics, reported checking the PDMP with every
patient, every time. Others checked only for
new patients, for new opioid prescriptions, or for
patients for whom they suspected abuse. Partici-
pants described varied approaches to sharing
PDMP information with patients, including openly
discussing potential addiction or safety concerns,
avoiding discussion altogether, and approaching
discussion confrontationally. Participants described
patient anger or denial as a common response and
noted the role of patient satisfaction surveys as an
influence on prescribing.
Conclusion. Routines for accessing PDMP data and
how clinicians respond to it vary widely. As PDMP
use becomes more widespread, it will be important
to understand what approaches are most effective
for identifying and addressing unsafe medication
use.
Key Words. Prescription Drug Abuse; PDMP;
Doctor-Patient Interaction
Introduction
Prescription drug overdoses have reached epidemic pro-
portions [1]. Federal and state governments are eager to
identify strategies to reduce misuse, abuse, and diversion.
The Office of National Drug Control Policy advocates pre-
scription drug monitoring programs (PDMPs) as one strat-
egy for reducing prescription drug abuse [2].
PDMPs have been implemented in nearly every state to
monitor for controlled substances; these statewide
databases collect information on varying schedules of
controlled substances dispensed to patients. PDMPs
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were originally developed with law enforcement in mind to
identify patterns of drug misuse, diversion, or excessive
prescribing (pill mills). However, PDMPs are increasingly
seen as tools for improving health care and may help
clinicians identify patients with a need for mental health or
addiction services or those receiving unsafe doses or drug
combinations.
State administrators were the initial liaison between clini-
cians and the research study; they made first contact with
potential participants, providing them with a letter explain-
ing the study and inviting clinicians to contact the research
team via e-mail. The administrators then provided a list of
interested clinicians to the research team. A master list of
78 clinicians was created.

Although most states now have active PDMPs, there are We used a purposive sampling approach to ensure varia-

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variations in the ways these programs are designed, how tion on key attributes, including professional credentials
they function, and who can access them [3]. Patterns of (e.g., medical doctors, nurse practitioners, and dentists)
PDMP use may vary state to state depending on whether and clinical practice settings (e.g., pain clinics, emergency
the PDMP operates under law enforcement, public health departments, primary care, inpatient psychiatry). Clini-
agencies, boards of pharmacy, or other state agencies. An cians were contacted by phone by a physician study team
important limitation is that federal health care facilities
(e.g., Department of Veterans Affairs, Department of
Defense and Indian Health Service) are not required and Table 1 Characteristics of the 35 focus group
do not generally report to state PDMPs. While some participants
PDMPs such as California’s and New York’s are
longstanding, most are still relatively new. A few studies Characteristic Frequency
have examined clinical use of PDMPs, focusing on how
PDMPs influence prescribing or on cursory information Female/male 8/27
about how clinicians utilize and respond to PDMP infor- States represented 9 (WY, LA, FL,
mation [3–6]. However, little is known about how clinicians OH, UT, MI,
integrate PDMP use into clinical workflow, and few studies WA, MN, NV)
have tried to identify strategies clinicians use when dis- Credential
cussing PDMP reports with patients. Similarly, little is Physician 26
known about clinicians’ experience with, perceptions of, Nurse practitioner 7
or attitudes toward PDMP systems. Such information Physician assistant 1
could help identify “best practices” regarding PDMPs and Dentist 1
potential enhancements to improve their utility. Further, it Clinical specialty of physicians (N = 26)
could lead to recommendations or guidelines for using Pain medicine 7
PDMP data in clinical decision making, incorporating Emergency medicine 6
PDMP data into clinical workflow and discussing concerns Family medicine 5
about the data with patients. Psychiatry/behavioral health 5
Rehabilitation medicine 2
As a foundation for studying these issues, we conducted Internal medicine 1
online focus groups with clinicians to identify how they use Duration of PMP user (self-report)
PDMP data in clinical decision making, how they integrate Less than 1 year 7
the data into clinical workflow (including communication 1–5 years 22
with the patient), and how they perceive the PDMP More than 5 years 6
systems. Frequency of PMP use/month (self-report)
Fewer than 5 times 3
Methods 5–9 times 7
10 or more times 25
Oregon State Public Health Division and Oregon Health & Settings
Science University Institutional Review Boards approved Emergency department 7
this study. In addition, we obtained a Certificate of Confi- Small private office <5 practitioners 7
dentiality from the National Institutes of Health intended to Hospital outpatient clinic 4
protect participant confidentiality. Hospital inpatient 2
College-based health clinic 1
Focus Group Recruitment Academic practice 2
Solo practice 1
We identified potential clinician participants for the online Large private practice >5 practitioners 5
focus groups through state PDMP administrators. We Community mental health center 3
contacted administrators in two ways: by personal Stand-alone urgent care center 1
contact at the Harold Rogers PDMP national meeting in Safety-net, low-income clinic 2
Washington, DC in June 2012 and by e-mail. Of the 43
state administrators we contacted, 9 assisted with the FL = Florida; LA = Louisiana; MI = Michigan; MN = Minnesota;
recruitment. Table 1 lists the states participating in this NV = Nevada; OH = Ohio; UT = Utah; WA = Washington;
study. WY = Wyoming.

1180

member who confirmed their interest, answered ques-
tions, and obtained verbal consent.
Thirty-five clinicians agreed to participate. We provided
contact information for consenting clinicians to an expe-
rienced focus group moderator who confirmed clinicians’
participation, assigned each clinician an alias and pass-
word, and provided information about using QualBoard, a
proprietary software product owned by 20/20 Research,
Nashville, TN, USA for online focus groups.
Focus Group Procedure
We conducted two focus groups, held approximately 1
month apart. Clinicians participated in one focus group
and were asked to spend approximately 15 minutes per
day for 3 days, responding to questions posed by the
facilitator and to other participants’ posts. We designed
each focus group to span 3 days to reduce the daily
burden on participants. The placement of the questions
followed this sequence: Day 1: introductions, demograph-
ics, credentials and frequency of PDMP use, advantages,
and drawbacks; Day 2: clinical uses of PDMP and how it
is incorporated into workflow; and Day 3: PDMP discus-
sions with patients, patient responses to PDMP reports,
and ongoing training. Each day the focus group modera-
tor posted questions, including clarifying and probing
questions to encourage participants to respond in more
depth, as needed. The give-and-take among focus group
participants stimulated an online conversation similar to an
in-person focus group. As in many face-to-face focus
groups, discussion often ranged widely across topics,
regardless of the day. Additionally, clinician participation
varied, with some logging in once a day and others
logging in multiple times throughout the day to respond to
other participant comments. Participants received a finan-
cial incentive to compensate for their time.
Telephone Interviews
All clinicians were asked if they would be willing to partici-
pate in a follow-up interview. Among those volunteers for
the follow-up interview, we selected seven clinicians delib-
erately to obtain variation by specialty and geographic
location and to gain additional information regarding
unique aspects of PDMP use, including specific protocols
for discussing PDMP data with patients.
Data Management
Text from the online focus groups was downloaded into a
Word document. Telephone interviews were digitally
recorded and professionally transcribed. All data were
de-identified and securely stored on Health Insurance Por-
tability and Accountability Act compliant, password-
protected servers for use in ATLAS.ti™ (version
7.1.3; Scientific Software Development GmbH, Berlin,
Germany), a program for management and analysis of
qualitative data.
Clinicians’ Use of PDMPs
Analysis
A multidisciplinary team composed of two primary care
physicians, PDMP administrator, pharmacist, addiction
therapist, communication scientist and qualitative
research expert, and quality improvement expert analyzed
the data. We used a grounded theory approach [7] and
engaged in two immersion–crystallization [8] cycles to
analyze data and identify findings. In the first cycle, our
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team read data aloud as a group to gain insight into
participants’ experiences and use of PDMP (immersion).
Through this process, we identified important segments of
text and developed a preliminary code list (crystallization).
We refined this list and two team members analyzed the
remaining data. Preliminary codes and new codes that
emerged were discussed with a third research team
member as well as with expert panel members to further
refine codes and identify new findings. In a second
immersion–crystallization cycle, we examined data to
identify patterns that emerged across focus group partici-
pants and that might be related to clinician specialty and
practice setting. In this phase, we read text within each
code (immersion) to identify important features, character-
istics, and patterns related to PDMP use; assess how use
varied by clinician specialty; examine more closely how
clinicians shared PDMP data with patients; and further
identify the barriers and facilitators to PDMP use.
Results
Thirty-five clinicians from nine states participated in the
two focus groups. Participants represented a broad range
of specialties and clinical practice settings (Table 1).
Clinicians’ Use of the PDMP
Clinicians described using the PDMP mainly for clinical
purposes. However, participants noted that, at times, they
used the PDMP for administrative uses, such as making
sure no false prescriptions were written under their names.
Clinical uses of the PDMP included verifying current pre-
scriptions or prescription fill history. As a psychiatric nurse
practitioner working in the hospital setting reported:
I use it to track prescription drug use on any
patient who is admitted to my unit with a positive
urine drug screen for benzodiazepines, opiates or
barbiturates, drug overdoses, chronic pain
managed by prescription pain killers, muscle relax-
ants, barbiturates or benzodiazepines, suspicion
of drug dealing, unusual behavior suggesting
drug withdrawal, suspicion of “doctor shopping,”
and incongruence between history and clinical
exam. (Participant 1, Nurse Practitioner, Inpatient
Psychiatry)
Participants also reported utilizing the PDMP to coordinate
care with other clinicians. Some PDMPs provide informa-
tion about other prescribers, and participants would
contact these clinicians to discuss treatment and pre-
scribing plans and to obtain additional information
when prescribing practices appeared inappropriate. For
example, a clinician wrote: “It is not uncommon for me to
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contact the patient’s primary care provider to discuss
what my plans are for prescribing” (Participant 12, Nurse
Practitioner, Pain Clinic). Another reported that “. . . in a
handful of instances in using the PDMP I have contacted
prescribing physicians in situations in which I feel their
prescribing practices have been inappropriate” (Partici-
pant 14, Physician, Emergency Room).
Participants identified pharmacists, who also have access
to the PDMP programs, as important partners in handling
PDMP information. Clinicians reported that pharmacists
verified data in the PDMP report and were valued for
proactively calling clinicians if they noticed a patient using
multiple prescribers for controlled medications, a ques-
tionable prescription dose, or suspected alteration.
I communicate with pharmacies mainly when the
PDMP doesn’t match up with what the patient is
saying, such as the dates that the prescriptions
were filled. Also, when a patient says that they filled
a prescription at the pharmacy and it hasn’t shown
up on the PDMP, we will typically call the pharmacy
for verification. (Participant 8, Physician, Pain Clinic)
How clinicians integrated PDMP into workflow varied, and
prescribers from different specialties described different
approaches. Clinicians who practice in settings where
substance abuse issues and use of opioids to treat pain
were common and who had a more continuous relation-
ship with patients (e.g., psychiatry and pain clinics)
described a consistent and rigorous process for using the
PDMP. For instance, a pain specialist wrote, “PDMP
reports are run the business day before a visit during our
chart prep. Of course another can be run the day of the
visit if needed . . . Responses are received within seconds
via email and a report is printed for the physician to review
during the patient visit” (Participant 2, Physician, Pain
Clinic).
In contrast, participants working in a setting where they
treat patients on an episodic basis (e.g., emergency
rooms) reported accessing the PDMP with less frequency
or only when a red flag emerged during the visit:
Our approach is usually to address the primary
reason for the ED visit, then obtain the PDMP report
if there is concern or patient behavior that’s incon-
sistent. For example, patients demanding specific
pain medications, especially when no allergies are
indicated on triage, but allergies are reported when
initial medications are ordered that patient doesn’t
like or want. Sometimes patients will say a certain
medication “doesn’t ever work.” (Participant 3,
Physician, Emergency Room)
Sharing PDMP Information with Patients
Participants reported sharing PDMP data with patients in
variety of ways. For example, clinicians reported discuss-
ing PDMP data with patients to understand information in
the report and identify issues of potential addiction or
medication safety (e.g., potentially risky doses). Providers
reported using language to normalize (italicized below)
checking data from the PDMP to frame this investigation
into the patient’s medication use as a practice routine.
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If the PDMP is not problematic then I don’t bring it
up. If it is problematic, I get the patient history then
bring into the discussion a standard report that we
routinely pull when controlled substances are a
consideration . . . I use it to raise questions about
missed information. For example: “You have been
to 6 practices over the past 3 months for pain
medication. This is unusual. Can you help me
understand this?” (Participant 4, Nurse Practitioner,
Family Medicine)
When discussing PDMP data with patients, participants
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reported seeing this as an opportunity to address issues
of potential addiction or medication safety. For example, a
psychiatrist noted:
I usually start by stating, “I review the state’s PDMP
to make sure I have an understanding of everything
you are taking. Something concerns me about
what is in your report. Can you help me understand
________?” The blank could be: Why are you
getting medications from so many different
doctors? Why are you paying cash to get some of
your prescriptions and use insurance for others?
Why do you use different pharmacies? Then I would
follow up with, “These things make me concerned
. . . Have you ever thought you might have prob-
lems with this medication?” I usually end with,
“because of what is in the report it is not safe for me
to prescribe a controlled drug. I can treat your
problem with . . .” This usually works pretty well.
Sometimes patients will become defensive in the
process and might accuse me of not trusting them.
(Participant 5, Psychiatrist, Community Clinic)
Clinicians also reported completely avoiding the discus-
sion of PDMP information by coaxing patients to leave the
office quietly. For example:
Most of the time I do a quick old NSAID script that
a lot of them don’t recognize. I tell the nurse that I’m
working with, “Hey, I’m giving this guy a script for an
old NSAID, if he says anything just play dumb and
come get me.” You know, if they ask what it is then
I go and have “the talk.” In about 95% of the cases,
they never say anything, and . . . I don’t know if they
don’t know what it is, or they didn’t see what it was
until they go out to the pharmacy or until they got
out in the parking lot. But they’re quietly and quickly
walking out the discharge doors and we are turning
over that room to get it cleaned. The nurse is happy.
I’m happy. Let’s go onto the next patient. So, that’s
95% of my encountered situations. (Participant 9,
Emergency Room Physician)
Clinicians also discussed confronting patients with infor-
mation obtained in the PDMP, sometimes with the aim of
“catching patients in a lie.”
Usually I’ve asked them a few times have you seen
other doctors, have you gotten any further prescrip-
tions . . . If it does not seem legitimate . . . I will
leave the room to get something and pull it [PDMP
report] and then look at it. I may confront them if it
seems like they’re lying and say, “Well here’s what I
got here. It seems like you haven’t been very honest
with me and so I’m not going to provide you with
prescriptions. (Participant 10, Emergency Room
Physician)
Patient Responses to PDMP Information
Once a clinician decides to share PDMP information,
patients may respond in a range of ways. Participants

reported that patients’ responses include denial, justifica-
tion, or rationalization of prescription history. This parti-
cipant’s description exemplifies a number of these
responses:
The most common response is indignation. “That’s
not me!” or “There must be some mistake!” or “Who
do I talk to about this report, since it is obviously
wrong.” Occasionally, they try to deny that they
have seen the providers on the list or that they have
actually visited the pharmacies. (Participant 11,
Emergency Room Physician)
PDMP information can also result in patients acknowledg-
ing a problem and requesting help. For instance, a family
medicine physician reported, “They often start out defen-
sive, but later ask for help. I usually come across as quite
non-judgmental and they ask for help a number of times
before the interaction ends” (Participant 10, Family Medi-
cine Physician).
Participants also reported that patient responses might
have an emotional element ranging from anger to indig-
nation to guilt and embarrassment. The following excerpts
illustrate the range of patients’ emotional responses that
participants described:
I share the PDMP information at the end of the
exam. I explain that I am willing to help them with
physical therapy, injections, membrane stabilizers,
etc., just not with controlled medications. They
aren’t usually angry with me, but rather feel guilty
and embarrassed. (Participant 8, Physician, Pain
Clinic)
When I show them the actual list of recent activities
[on the PDMP] they sort of wilt . . . After the initial
indignation, they are quiet. I always tell them I am
happy to provide care and non-narcotic prescrip-
tions, but that based on the data I am unable to
provide narcotic prescriptions. (Participant 11,
Emergency Room Physician)
Barriers, Recommendations, and Training for
PDMP Use
One important barrier to using the PDMP data to change
prescribing practices is patient satisfaction ratings, such
as Press-Ganey scores. Some organizations take these
scores very seriously (e.g., align clinicians’ financial incen-
tives with such scores), and clinicians perceive that with-
holding narcotic prescriptions and taking the extra time to
review PDMP data can worsen scores. For instance, one
emergency room physician reported, “ED wait times are a
big driver of customer satisfaction, and something that the
hospital keeps an eye on. Thus, it is much easier for a
couple of doctors to just write for Vicodin, as opposed to
sitting down to discuss the PDMP report with the patient
and deal with an ensuing argument” (Participant 9, Emer-
gency Room Physician). Another clinician noted:
Pain is so subjective so often you just have to give
out narcotics when the patient states they are
10/10 pain. But the environment that you work in
makes a difference. I have worked in settings where
the Press-Ganey scores are more important than
patient safety or even staff safety. (Participant 13,
Physician’s Assistant, Emergency Room)
Clinicians’ Use of PDMPs
Participants also described barriers related to training,
noting that training for the PDMP was limited to how to
access the system. They did not receive guidance on how
to interpret findings, integrate the PDMP into workflow, or
talk with patients about the results. For instance, one
nurse practitioner working in a pain clinic reported, “I had
no formal training in how to use the PDMP or how to
communicate with patients when there was an issue. For
me, it was learn as you go” (Participant 12, Nurse Prac-
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titioner, Pain Medicine). Participants’ desire for additional
training varied, with some reporting a desire for additional
training and others reporting that their training on the
PDMP was sufficient, stating that they know how to talk
with patients about these types of issues.
Additional barriers to using the PDMP included difficulty
accessing and navigating the PDMP (e.g., time to run a
patient query), and difficulty interpreting PDMP data for
use in patient care. Delays in pharmacy reporting, data
errors, and data gaps were among the concerns (Table 2).
Participants also made recommendations for addressing
these barriers (Table 3). In particular, participants wanted
access to PDMP data from other states (i.e., interstate data
sharing). A pain physician noted, “I have several patients
who work out of state for weeks at a time throughout the
year. There is no way of me knowing if they are seeing other
doctors out of state. Having a nationwide PDMP would be
helpful” (Participant 8, Physician, Pain Medicine).
Table 2 Barriers to PDMP use identified by focus
group participants and recommendations for
facilitating use
Accessing the System
• Clinicians having to register on multiple computers
• Not having 24-hour access to the PDMP in some states
• Frequent changes of passwords
Using the System
• Lag time from when a prescription is dispensed to when
it shows up in the PDMP
• The time it takes to log into the system, run a query,
and receive the report
• Data entry errors—wrong providers listed
Interpreting the Information
• Missing data in the PDMP (information not reported by
certain pharmacies, Indian Health Service, VA system)
• Not all clinicians use the system, so patients may
obtain prescriptions from clinicians who are unaware of
other prescribers
• No consistent recommendations on when to check
PDMP; no financial incentive to do so
PDMP = prescription drug monitoring program; VA = Veterans
Affairs.
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Table 3 Recommendations by participants that
would optimize the use of PDMPs
General Recommendations
• More detailed information in the PDMP reports (number
of days dispensed; whether drug is long acting or short
acting)
• Delegated access in states where unavailable (although
clinician opinion varied)
• Ability to access neighboring states or have national
PDMP database
• System or policy changes that would optimize the use
of the PDMP, (e.g., proactive alerts, mandatory review
under certain circumstances, integration into electronic
health record, inclusion of other drugs [e.g., tramadol,
cyclobenzaprine])
Training Recommendations
• How to talk with patients about PDMP findings
• What to do with patients when the PDMP suggestions
are misuse, abuse, or diversion
• Education to increase the use of the PDMP by
clinicians
PDMP = prescription drug monitoring program.
Discussion
This focus group study identified clinicians’ strategies for
using PDMP data. These included not only making pre-
scribing decisions but also coordinating care and identi-
fying falsified information. Some clinicians accessed the
PDMP with every patient, while others described using it
only when suspicious of drug abuse. Discussion with
patients regarding PDMP findings ranged from
nonjudgmental discussion to avoidance to confrontation.
Our participants generally found the PDMP to be useful,
but identified some barriers to use and a need for addi-
tional training on how to manage patients with a worri-
some PDMP profile.
Some of our findings echo those of a survey of toxicolo-
gists, many of whom practiced emergency medicine [9].
For example, that study also identified time constraints
and navigation challenges as important barriers. However,
our inclusion of clinicians from multiple specialties and
settings uncovered a wider range of approaches to
accessing and using PDMP data and new information on
the range of resulting conversations that occur between
doctor and patient. As it was described by Perrone and
Nelson, the Drug Enforcement Agency’s concept of ideal
PDMPs mirrors the findings from our focus group partici-
pants. That concept includes ease of access, real-time
updates, mandatory pharmacy reporting, and interstate
accessibility [10].
Although some participants reported relying on subjective
patient impressions in deciding when to access the
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PDMP, provider impressions of potential misuse or diver-
sion do not always correspond with more structured data
[11,12]. Thus, steps may be needed to encourage more
consistent PDMP use, even in settings with a lower
volume of pain care and opioid prescribing. This may not
be for every patient at every visit, but for certain routine
situations, such as every new patient or whenever con-
sidering a prescription for a controlled drug. Future
research should explore these complexities, as optimal
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patterns of use will likely vary with setting and specialty.
Participants described three general ways of sharing wor-
risome PDMP data with patients: nonjudgmental discus-
sion, avoiding discussions entirely, and using a more
confrontational approach if patients do not appear to be
candid. While clinicians did not make an explicit connec-
tion between the strategies they use to discuss PDMP
data and how patients responded (e.g., embarrassment,
indignation, anger), such a connection seems likely. If
patients need addiction treatment or mental health care,
certain approaches may be more successful than others.
Thus, the different communication styles may lead to dif-
ferent patient responses, as well as a range of immediate,
short and longer term outcomes. Likely, there is not a “one
size fits all” approach to individual patients, and clinicians
will need to consider the goal of the interaction and patient
needs (e.g., treating addiction; keeping the patient alive)
and balance this with time constraints, organizational
demands, and available resources.
Examining the various approaches to discussing PDMP
data and associated patient responses is a fruitful area for
future research. For example, strategies used for alcohol
abuse such as Screening, Brief Intervention, and Referral
to Treatment (SBIRT) [13] could potentially be adapted for
opioid and other prescription drug use. Motivational inter-
viewing, which facilitates positive behavior changes, is
typically part of SBIRT and has been helpful in reducing
substance use and promoting positive behavior changes
in other chronic health conditions [14,15]. Future studies
should aim to identify the most, and least, productive
ways of communicating with patients about PDMP data
to optimize clinician–patient interactions and patient
outcomes.
Our study has several strengths, such as varied clinician
specialties and practice settings, and the use of in-depth
qualitative methods. However, there are also important
limitations. Although participants represented nine states
and a range of credentials and settings, the sample and
data collection are from a relatively small group. We pur-
posively selected participants because they reported sub-
stantial use or interest in their PDMP systems. This was
important for ensuring we would be conducting focus
groups with clinicians who had used the PDMP system,
but their experiences may not generalize to the general
clinician population, who may use the system less. Addi-
tionally, PDMP policies are evolving. Some states mandate
PDMP checks in certain circumstances, and this may
influence clinicians’ use of the PDMP. In February 2014,
16 states had legislation mandating use of the PDMP in

certain circumstances, such as suspicion that a patient is
seeking a controlled substance for nonmedical reasons
[16]. Such rules may increase the consistency of PDMP
use, but the actual impact on clinician behaviors is an
important area for future research. Further, we did not
collect data on pharmacists’ use of PDMPs. Although our
focus in this study was on active prescribers who use
PDMPs to make clinical decisions about whether to pre-
scribe, pharmacists are an important user group of inter-
est in future research. Controversies over recent rules
proposed by some pharmacy chains highlight the impor-
tance of optimizing the complementary roles of clinicians
and pharmacists [17,18].
Other limitations include the potential biases inherent in all
research, such as influences of our own predispositions
and beliefs. We mitigated these by involving a multi-
person, multidisciplinary team in developing focus group
and interview questions and avoiding leading questions. In
addition, this team was engaged throughout the analysis
process. While we identified a wide range of experiences
in using the PDMP, we cannot assess the frequency of the
occurrences. Nonetheless, our findings may be useful for
developing future large-scale quantitative surveys
designed to determine the prevalence of experiences and
behaviors regarding the PDMP. Finally, this study is based
on clinician self-report. There may be discrepancies
between what people say and what they actually do, and
we did not directly observe PDMP use or patient–clinician
interactions.
Our study identified a range of strategies for deciding
when to access PDMP data and how to respond to it. As
use of PDMP data becomes more ubiquitous, it will be
important to learn which of these strategies constitute
“best practices” that optimize patient outcomes. Clinicians
appear to be receptive to such information and, along with
improving the ease of use, such information seems essen-
tial if PDMPs are to achieve their potential. Further
research on how PDMPs can best be used in practice will
help to maximize them as tools to improve quality of care
and patient outcomes.
Acknowledgments
The authors wish to thank Ruth Medak, MD, Acumentra
Health, who conducted the recruitment phone calls and
provided information about the study and consent of the
participants, Susan Yates-Miller, BA, Acumentra Health,
who provided essential budgetary and administrative
support, and Shireen Mitchell, BS, Acumentra Health,
who contributed to the analysis of the focus group
transcripts.
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