Law Enforcement Officers’ Perceptions of Florida’s Prescription Drug Monitoring Program

Abstract

Prescription pain medication misuse and abuse is a considerable criminal justice and public health problem in the United States. As a result, prescription drug monitoring programs (PDMPs) have been developed and implemented across the country to monitor patients with high abuse potential and to detect abnormalities in the prescribing of controlled substances. The current study relies on a sample of 87 Florida law enforcement officers to gauge their perceptions of, use of, and perceived effectiveness of Florida’s PDMP. Results indicate that most of the law enforcement officers considered themselves moderate-to-frequent users of the PDMP and considered the PDMP to be an effective system. In addition, many of the officers reported that their communication had increased with prescribers and pharmacists because of the PDMP. These findings notwithstanding, some officers noted a few barriers/limitations of the PDMP such as “false negatives” and an inability to check another state’s PDMP as areas for improvement. Study limitations and implications are also discussed.

Keywords

police drug abuse controlled substances PDMP E-FORCSE®

Researchers have estimated that 11.2% of Americans are affected by chronic pain (Nahin, 2015). Since the late 1990s, in efforts to treat this chronic pain, physicians have prescribed various prescription opioids to patients in the United States (Reisman, Shenoy, Atherly, & Flowers, 2009). These prescription opioid pain relievers can include “oxycodone, hydrocodone, codeine, morphine, fentanyl, and others” (American Society of Addiction Medicine, 2016). Although these medications can be successful in managing pain, there have also been increased incidences of abuse and dependence (Paulozzi, Budnitz, & Xi, 2006). Approximately 2 million of the 20.5 million Americans over the age of 12 with a substance use disorder are addicted to prescription pain medication (Center for Behavioral Health Statistics and Quality, 2016). The U.S. Centers for Disease Control and Prevention (CDC; 2016) has estimated that 20,100 people died in the United States in 2015 with a prescription pain medication present at the time of death. In fact, prescription drug abuse is the leading cause of accidental death in the United States (Griggs, Weiner, & Feldman, 2015).

In addition to public health consequences, this prescription opioid epidemic is also associated with several concerns related to the criminal justice system, including the increased prevalence of illegitimate pain management clinics or “pill mills,” patients engaging in “doctor shopping” (also known as multiple provider episodes or MPEs), inappropriate prescribing practices, and prescription drug diversion to illicit markets (Surratt et al., 2014). In fact, research has suggested that pill mills are the most common source for illicit street dealers to get prescription opioids (Rigg, Kurtz, & Surratt, 2012). The prevalence of this behavior varies widely depending on the study, ranging from 6.3% to 56% (Sansone & Sanson, 2012), and many street dealers have reported engaging in doctor shopping to get their pills (Rigg et al., 2012). These illegal behaviors have further exacerbated the availability and rampant abuse of prescription opioids in the United States (Florida Office of the Attorney General, 2012). It has been estimated that presumed doctor shoppers purchase approximately 2% of all opioid prescriptions (McDonald & Carlson, 2013).

Prescription Drug Monitoring Programs (PDMPs)

In response to this nationwide epidemic of prescription opioid abuse and the associated illicit activities, 49 states (all except for Missouri as of January 2017) and the District of Columbia have legislated and enacted operational PDMPs to provide data and information for health care practitioners, pharmacists, regulatory boards, and law enforcement agencies to identify patients that may abuse prescription pain medication or diverting them (PDMP Training and Technical Assistance Center, 2016). The main goal is to monitor patients on drugs with high abuse potential (e.g., Drug Enforcement Agency [DEA] scheduled opioid pain relievers) and “detect abnormalities in the prescribing of controlled substances (e.g., higher-than-expected doses per unit time, questionable overlapping prescriptions, “doctor shopping” for multiple prescribers and dispensers)” (Delcher, Wagenaar, Goldberger, Cook, & Maldonado-Molina, 2015, p. 64).

Each state has their own PDMP designed to address prescription abuse and overdose with various supervising agencies, features, and requirements. These PDMP systems are sometimes housed in the state department of justice (e.g., California’s Controlled Substance Utilization Review and Evaluation System) and other law enforcement agencies (e.g., Hawaii’s Narcotics Enforcement Division, Oklahoma’s Bureau of Narcotics, Georgia’s Drugs and Narcotics Agency, and New Jersey’s Department of Law and Public Safety). As of now, all states with PDMPs (except for Nebraska) authorize law enforcement officers to request PDMP data for investigative purposes (PDMP Training and Technical Assistance Center, 2016). In some states, these law enforcement officers are able to use this information to investigate unusual prescribing behaviors and individuals suspected of involvement in doctor shopping and/or diversion.

Although research on law enforcement officers’ perceptions of PDMPs is rather scant in the literature, Wixson et al.’s (2014) study is one important exception (see also Freeman et al., 2015). Specifically Wixson et al. (2014) offered a descriptive study of 306 Kentucky law enforcement officers’ perceptions of the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system (e.g., Kentucky’s PDMP). Their results indicated that the law enforcement officers perceived the PDMP as being effective as 92% considered the PDMP successful in reducing drug abuse and diversion and 89% considered the PDMP successful in reducing “doctor shopping” in the state of Kentucky.

Florida’s PDMP—E-FORCSE®

Florida’s PDMP is known as the Electronic-Florida Online Reporting of Controlled Substance Evaluation Program, or E-FORCSE. Fully launched in 2011, E-FORCSE is a digital database that collects information on the dispensing of Schedule II to IV controlled substances from physicians and pharmacies and develops patient advisory reports, or PARs (Gershman, Gershman, Fass, & Popovici, 2015). The PARs are available to physicians so they can view a patient’s prescription history prior to prescribing a controlled substance. This program was implemented at a critical time in the state of Florida since, in 2010, 90 of the top 100 physicians purchasing oxycodone were located in Florida and prescription drug overdoses had risen dramatically in the preceding years (Rutkow et al., 2015). Since its inception, empirical evaluations of E-FORCSE have shown evidence of reductions in the number of controlled substances and the average volume of these prescriptions in Florida (Rutkow et al., 2015).

The most recent E-FORCSE annual report demonstrated that mean morphine milligram equivalents (MMEs), a standardized measure of opioid amounts, had decreased 28.9% since 2011 and MPEs had decreased 76.2% (Scott, Phillip, & Poston, 2016). Rutkow and colleagues (2015) found that a year after E-FORCSE’s launch, there were decreases in the number of opioid prescriptions, opioid volume, and the MME per transaction. In addition, Delcher and colleagues (2015) found that oxycodone-related deaths dropped 25% in the first month following the launch of E-FORCSE and this effect remained after controlling for other historical event variables (see also Johnson, Paulozzi, Porucznik, Mack, & Herter, 2014). These evaluations suggest that the PDMP had a significant effect on reducing the number of opioids prescribed, the level of abuse, and resultant overdose deaths in Florida.

The Current Study

Despite this growing emphasis on the clinical use of PDMP systems for patient care and evaluating public health outcomes, less is known about how these systems are perceived and used by law enforcement agents. In Florida, law enforcement agents have access to request “investigative reports,” resembling the PARs that physicians see in the PDMP database to assist with fraud, abuse, and other criminal investigations. Despite this access, no study to date has directly assessed law enforcement officers’ perceptions of Florida’s PDMP. Acknowledging this gap in the PDMP literature, the current study offers a descriptive examination of a sample of 87 Florida law enforcement officers’ perceptions of, use of, and perceived effectiveness of Florida’s PDMP.

Method

In 2016, the University of Florida and Florida PDMP designed a user survey gathering information in multiple domains, including demographic information, knowledge of PDMP, frequency of PDMP use, attitude toward PDMP mandatory use, barriers to PDMP use, how PDMP is used in practice, and the perceived impact of PDMP. Law enforcement and regulatory agencies that registered with Florida’s PDMP as of February 28, 2016, were selected as potential contacts for the PDMP user survey. The Florida’s PDMP sent out the survey invitations along with a brief letter explaining the purpose of the survey through SurveyMonkey (https://www.surveymonkey.com/). For analytic purposes, all responses were collected as anonymous with IP address and email excluded. The invitations with valid email address were successfully sent out on March 21 and two reminders were scheduled on March 25 and March 30, respectively. The survey was open for responses until April 3, 2016. Of the 1,068 invitations, we received 87 responses from law enforcement officers. This study was approved as exempt by the University of Florida Institutional Review Board (IRB).

Results

Sample Descriptives

Table 1 displays the frequencies for the gender and age ranges for the law enforcement respondents. About three quarters (73.6%) of the sample was male. In addition, a little less than a quarter (23%) of the sample was between 30 and 39 years of age, while 41% was between 40 and 49 years of age. A little less than one-third (31%) was between 50 and 59 years old and 4.6% was above the age of 60 years. The respondents worked in over 30 different Florida counties and in various law enforcement agencies. Although the majority responded as simply law enforcement or police officers (66.7%), various specific professions (detective, investigator, analyst), agencies (DEA and Florida Department of Law Enforcement [FDLE]), and command levels (deputy, lieutenant, and sergeant) were represented.

Table 1.

Sample Demographics.

Variable		%
Sex	Male	73.6
Sex	Female	26.4
Age group	30-39	23.0
	40-49	41.4
	50-59	31.0
	60+	4.6

Quantitative Results

Use of Florida’s PDMP

Table 2 shows the responses for a number of items pertaining to the law enforcement officers’ use of the PDMP. Nearly three quarters of the sample specifically reported using the PDMP during an active criminal investigation, which is a requirement to make a request. Among those who reported using E-FORCSE, 40.4% reported a minimal level of use, 42.1% reported a moderate level of use, and 17.5% reported a frequent level of use. Of those who reported using the PDMP, 62.5% reported using it within the past 30 days. Another 14.1% reported using the PDMP in the past 31 to 90 days, and 23.4% reported using it over 90 days ago.

Table 2.

Use of the PDMP.

Variable		%
Reported using the PDMP in a criminal investigation	Yes	73.6
Reported using the PDMP in a criminal investigation	No	26.4
Of those who have used the PDMP, how would you characterize your use of it?	Minimal	40.4
	Moderate	42.1
	Frequent	17.5
Of those who have used the PDMP, how recently did you use it?	In the past 30 days	62.5
	Not in the past 30 days, but in the past 90 days	14.1
	More than 90 days ago	23.4

Note. PDMP = prescription drug monitoring program.

Communication between law enforcement, prescribers, and pharmacists

Table 3 depicts the officers’ perceptions of changes in their level of communication with prescribers, pharmacists, and other law enforcement agencies as a result of using the PDMP. Approximately 35.7% of law enforcement officers indicated they had “somewhat” or “definitely” increased their communication with prescribers, and 46.9% of officers had “somewhat” or “definitely” increased their communication with pharmacists. Finally, 88.6% of officers indicated they had “somewhat” or “definitely” increased communication with other law enforcement groups.

Table 3.

Communication between Law Enforcement, Prescribers, and Pharmacists.

Variable		%
Do you communicate MORE with prescribers?	No	64.3
	Yes, somewhat	25.0
	Yes, definitely	10.7
Do you communicate MORE with pharmacists?	No	53.1
	Yes, somewhat	25.0
	Yes, definitely	21.9
Do you communicate MORE with law enforcement groups?	No	56.2
	Yes, somewhat	21.9
	Yes, definitely	21.9

Barriers for using the PDMP

The survey also asked the law enforcement officers about possible barriers for not using the PDMP more often. These barriers are depicted in Table 4. Specifically, more than 67% of the law enforcement officers reported no such barriers impacting their use of the PDMP. Alternatively, other law enforcement officers noted limitations such as limited Internet access at work (6.8%), not enough time (3.4%), lack of training on how to access the PDMP (1.7%), and frequent password changes (3.4%) were endorsed by some respondents as barriers for using/not using the PDMP. Another 17.0% cited “other” barriers, such as limitations or regulations¹ on access and false negatives in the system.

Table 4.

Barriers Cited for Not Using the PDMP More.

Barrier	%
No barrier	67.8
Limitations with Internet access at work	6.8
Not enough time	3.4
Lack of training on how to access the PDMP	1.7
Frequent password change	3.4
Other	17.0

Note. PDMP = prescription drug monitoring program.

Perceived effectiveness of the PDMP

Table 5 provides the law enforcement officers’ responses to four items related to their perceived effectiveness of the PDMP. Regarding the statement, “E-FORCSE® has a positive impact on reducing prescription drug abuse,” the majority of the respondents either agreed (27.6%) or strongly agreed (36.8%). Another 13.8% neither agreed nor disagreed, while very few disagreed (2.3%) or strongly disagreed (5.7%). Less than 14% either did not know or did not respond to the question.

Table 5.

Perceptions of the Effectiveness of the PDMP.

Variable		%
The PDMP has a positive impact on reducing prescription drug abuse.	Strongly disagree	5.7
	Disagree	2.3
	Neither agree nor disagree	13.8
	Agree	27.6
	Strongly agree	36.8
	Don’t know/missing	13.8
How useful has the PDMP been for identifying “doctor shopping” (i.e., patients seeking to inappropriately obtain controlled substances from multiple sources?	Not useful	1.1
	Somewhat useful	18.4
	Very useful	60.9
	Don’t know/missing	19.5
The PDMP has altered patterns of prescribing for Schedule II opioid pain relievers in a manner beneficial to public health.	Strongly disagree	4.6
	Disagree	1.1
	Neither agree nor disagree	8.0
	Agree	18.4
	Strongly agree	27.6
	Don’t know/missing	40.2
Would you recommend peers in your profession to use the PDMP?	Yes	98.0
	No	2.0

Note. PDMP = prescription drug monitoring program.

In addition, more than 60% of respondents indicated that the PDMP was “very useful” when responding to the question, “How useful has E-FORCSE® been for identifying ‘doctor shopping’ (i.e., patients seeking to inappropriately obtain controlled substances from multiple sources)?” Another 18.4% found it “somewhat useful” and only 1.1% indicated that it was “not useful.” About 20% either did not know or did not respond to the question.

Many respondents either agreed (18.4%) or strongly agreed (27.6%) with the statement, “E-FORCSE® has altered patterns of prescribing for Schedule II opioid pain relievers in a manner beneficial to public health.” Another 8% neither agreed nor disagreed with the statement, while only about 6% disagreed (1.1%) or strongly disagreed (4.6%). More than 40% of respondents did not know or did not respond to this question. Finally, when asked whether or not they would recommend their peers in law enforcement to use the PDMP, 98% indicated that they would and only 2% indicated they would not.²

Qualitative Results

In addition to the quantitative responses, this survey also allowed law enforcement officers to provide answers to certain key open-ended questions regarding the PDMP. For example, one question offered the respondents the opportunity to list what they like most about the PDMP. Common responses pertained to its “ease of use,” “turn-around from time of request to response,” “communication,” and “the detailed information provided.” Law enforcement officers indicated they liked that the PDMP granted them the ability to request information to “identify controlled substance users” and “to see what is being prescribed, to whom, and how much.” One officer continued to state that “the generated PAR’s tell a story which cannot be denied especially after follow-up with the Doctors and Pharmacies.” Another officer indicated that this process “makes drug abuse and drug trafficking much harder,” and an additional officer commented on the belief that the PDMP would “prevent patients from receiving unwarranted controlled medications.”

Another question allowed respondents to indicate what they liked least about the PDMP. Common responses noted among the law enforcement officers included “false negatives,” restrictive and limited searching capabilities (e.g., “limited to Florida” and “limited historical search range”), and turn-around time for results (e.g., “time lapse to get data” and “time it takes to receive that critical information”). Finally, the officers were also asked open-ended questions regarding their recommendations for improving the PDMP. The law enforcement officers made several such recommendations concerning various aspects of the PDMP. Notable responses include (a) “flagging previous doctor shoppers and prescribers in violation of issuing prescriptions,” (b) “expanding drugs required to be entered into the database,” (c) “producing educational seminars/webinar for practitioners to encourage use and improve patient care,” and (d) “make it mandatory for everyone to use it in Florida.” Overall, the notion that the PDMP should be mandatory for all patients in Florida was endorsed by 79.3% of the sample.

Discussion

Law enforcement officers have an important role in reducing the availability of controlled substance medications with high abuse potential. To our knowledge, this descriptive study of law enforcement officers, using the third largest state PDMP in the United States, is one of the first of its kind, with Wixson et al.’s (2014; see also Freeman et al., 2015) study of law enforcement officers’ perceptions of Kentucky’s PDMP being a notable exception. Several of our findings are noteworthy.

The majority of respondents comprised law enforcement officers who had recently used the PDMP for criminal investigations and who considered themselves to be moderate-to-frequent users of the system. We found that for a substantial proportion of these law enforcement officers, communication increased with prescribers and pharmacists because of PDMP use. It is important to objectively assess the nature of this communication for both harmful and beneficial effects. For example, the medical community has long-standing concerns over the “chilling effect” that law enforcement questioning, even when only perceived, may have on prescribers’ legitimate medical practice (Fishman, 2006). The communication may result in a newly identified problematic patient and/or represent opportunities for law enforcement to increase trust among the medical community.

Important barriers that law enforcement officers identified included “false negatives” and no ability to check another state’s PDMP. There are ongoing efforts to improve the accuracy of the record matching process to improve the ability to correctly identify individuals and their medications. The process is error-prone in that pharmacy transaction records do not always contain consistent identifiers when sent to the PDMP. This is a critical issue for health care providers as well when faced with the need to make rapid decisions to prescribe based on a patient’s prior medication history (Horowitz, Loden, & Neiman, 2016). Although efforts to provide legal access to multiple states’ PDMPs are ongoing, as of January 2017, Florida’s PDMP only allows for one-way data sharing with Alabama. There are currently efforts to expand to Kentucky and other states. Research has shown that doctor shoppers will frequently travel long distances to get medications and often across state lines (Cepeda et al., 2015; Cepeda, Fife, Yuan, & Mastrogiovanni, 2013)

Law enforcement officers have mixed feelings when asked to consider the effectiveness of the PDMP in both the public health and public safety domains. For example, a substantial proportion agreed with the public health benefits of the program, largely in Schedule II opioid medications, but another large group was unsure. To a certain degree, this is expected as law enforcement officers may not frequently ruminate on public health outcomes associated with the PDMP. However, the same dichotomy was noted for their opinion of the PDMP’s impact on “doctor shopping,” which is likely a more familiar law enforcement concept. This uncertainty about reductions in potential doctor shopping may indicate a need for the PDMP to increase educational efforts, supported by data, on effectiveness toward this goal. Interestingly, despite the bimodal nature of the perceived effectiveness, nearly 80% still thought PDMP use should be mandatory. This is compared with approximately 42% and 57% of medical doctors and pharmacists, respectively (data not shown).

It is important to note a series of study limitations. First, law enforcement officers’ use of Florida’s PDMP may not represent the experience of other states (e.g., see Freeman et al., 2015; Wixson et al., 2014). Second, the items from the survey used for the current study were not originally designed for law enforcement officers but rather a clinical audience. These results are largely descriptive and based on a small sample. Future research is encouraged to examine similar research questions with a larger sample from multiple states and use multivariate methods to determine predictors of law enforcement officers’ perceptions and perceived effectiveness of the PDMP when data permits.

Ultimately, prescription pain medication misuse and abuse represents perhaps one of the most salient public health issues that exist today, and the results from this study offer some encouraging support from law enforcement officers for the utility of the PDMP to combat this growing epidemic. The law enforcement officers also noted some areas for improvement in the PDMP system such as implementing mechanisms to reduce the number of “false positives” and to enable the sharing of PDMP information across state lines/databases. Future continued efforts to tweak and improve the PDMP system will likely yield demonstrable benefits for law enforcement, doctors, pharmacists, and all who contribute to and access the PDMP.

Footnotes

Acknowledgements

We would like to thank Rebecca Poston and Erika Marshall of the Florida Prescription Drug Monitoring Program for providing the data and manuscript review.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Partial funding for this study was provided by the Bureau of Justice Assistance grant “Seizing the Momentum: A Multidisciplinary Approach to Reduce Rx Drug Abuse” (2013-PM-BX-0010). The funders provided financial support only.

Notes

Author Biographies

Nicholas M. Perez is an assistant professor in the School of Criminology, Criminal Justice, and Emergency Management at California State University, Long Beach (CSULB). He received his doctorate degree from the University of South Florida. His main research interests involve the development of delinquency, policing, and childhood adversity & trauma.

Wesley G. Jennings, PhD, is professor and doctoral program coordinator in the School of Criminal Justice at Texas State University. In addition, he also has a courtesy appointment in the Department of Health Outcomes & Policy and is a faculty affiliate of the Institute for Child Health Policy in the College of Medicine at the University of Florida. He received his doctorate degree in criminology from the University of Florida.

Yanning Wang is a data management analyst in the Department of Health Outcomes and Policy at the University of Florida. She works closely with the Florida Prescription Drug Monitoring Program (PDMP) to understand the current and emerging trend of prescription drug abuse in Florida and enhance PDMP best practices by analyzing big data.

Chris Delcher is an assistant professor in the Department of Health Outcomes and Policy at the University of Florida. His current projects include evaluating prescription drug monitoring programs and the role in reducing prescription drug abuse, identifying and characterizing Medicaid superutilizers and the prescription drug related outcomes associated with multiple provider episodes, and implementing and evaluating surveillance systems in high and low resource environments.

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