As almost every state has implemented a prescription drug monitoring program, attention has now shifted to fine-tuning the PDMPs through such steps as expanding the list of drugs that must be reported when dispensed and deciding whether prescribers must check the database.

Nebraska on Jan. 1 became the first state to require reporting of all dispensed prescription drugs to its PDMP. The move follows a state mandate for reporting the dispensing of controlled substances, which took effect in January 2017.

In July, Nebraska will also require that dispensing of veterinary prescriptions for controlled substances be reported to the PDMP.

The state has added a tool that will alert providers if the patient has received high doses of opioids in the past week to 30 days and may be at higher risk of an overdose. Doctors would see the warning if they check a patient’s prescription record in the PDMP — which, under Nebraska law, they are not required to do.

Mark Pew, senior vice president at Prium, said Nebraska’s decision to require that dispensing of all prescription drugs be reported to the PDMP made sense.

“It’s not surprising that they’re going beyond the boundaries of opioids,” Pew said. “It’s not just the opioids that are creating problems.”

For example, Pew said, a patient’s use of muscle relaxants — benzodiazepines — and other drugs used for treating pain, such as gabapentin, should be closely monitored to prevent what he called “inappropriate polypharmacy regimen.”

The PDMPs are a way for doctors to see whether a patient has been “doctor shopping” for multiple opioid prescriptions and are seen as a key tool in combating the opioid crisis.

Workers’ comp attorney Jon Rehm in Lincoln, Nebraska, said the state’s prescription monitoring program effectively balances concerns about drug abuse and addiction with patients’ need for legal medication and doctors’ ability to use their medical judgement in prescribing drugs.

And by gathering information on prescribing, the state can craft laws on opioids and other drugs “based on data rather than anecdote,” Rehm said.

“I want to see how monitoring works before Nebraska considers formularies for opioids in workers' compensation,” Rehm said. “I think the use of drug formularies in workers' compensation adds undue expense into litigation and can limit choice of pharmacies for injured workers. I also believe that formularies act as a way for drug companies to inflate the costs of drugs through the use of pharmacy benefit managers.”

Some consider a requirement for prescribers to check the PDMP essential to the effectiveness of the monitoring programs. In states without a prescriber mandate, doctors checked patient drug history in the PDMP only 14% of the time before prescribing an opioid in 2015, according to an analysis by the PDMP Center of Excellence at Brandeis University.

About a dozen states lacked the prescriber mandate as of Jan. 2, according to the PDMP Training and Technical Assistance Center at Brandeis.

But some states are working toward a mandate for prescribers to query the database.

In Indiana, Senate Bill 221 would phase in a requirement for doctors to check INSPECT, the state’s prescription-monitoring database, before prescribing opioids to a patient.

The requirement would apply to doctors in emergency rooms and pain management clinics in January 2019; clinicians treating patients in a hospital in January 2020; and all practitioners, starting January 2021. The bill’s authors are Sen. Erin Houchin, R-Salem, and Sen. Ed Charbonneau, R-Valparaiso.

Patrick Knue, director of the PDMP Training and Technical Assistance Center at Brandeis, said states typically track prescribing of controlled substances with their PDMPs, but some also include a provision to track “other drugs of concern.” For example, Ohio’s Board of Pharmacy in December 2016 began requiring pharmacies and physicians to report dispensing of gabapentin, a drug used to treat neuropathic pain but is not a controlled substance, to the Ohio Automated Rx Reporting System, or OARRS.

About 15 states require the reporting of controlled substances dispensed for veterinary use, Knue said. Most require the report to include the species of the animal and the name of its owner. The concern is that animal owners might be using the medication themselves.

Knue said a trend he’s seeing in PDMPs is an expansion of the data that’s collected. Some of the systems now include information on patients’ drug-related arrests, overdoses or administration of naloxone.

Pew at Prium predicted that states will invest more heavily in the coming year in the technology behind PDMPs. The databases will be able to process a higher volume of inquiries at a faster rate. And ideally, PDMPs in all 50 states will be interconnected so that a doctor can see what drugs have been prescribed to a patient in any state.

Missouri had long been the only state without a PDMP, as several legislative efforts to create one failed. In July, Gov. Eric Greitens signed an executive order to create a PDMP. However, doctors won’t be able to query the database.

Instead, the state Department of Health and Senior Services will work with private pharmacy benefit managers to analyze prescribing and dispensing data, referring suspicious activity to law enforcement for investigation.

Meanwhile, St. Louis County in Missouri established a PDMP last year, and several cities and counties across the state have joined it.