biostatistic

jmwh.12942.pdf

Home >Mathematics homework help >Statistics homework help >biostatistic

Journal of Midwifery & Women’s Health www.jmwh.org Original Research

New Mexico Nurse-Midwives’ Controlled Substance Prescribing and Monitoring Practices Katrina A. Nardini, CNM, MSN, MPH, WHNP-BC, Jenny Landen, MSN, APRN, FNP-BC, Mark Parshall, PhD, RN, Kim J. Cox, CNM, PhD, RN

Introduction: New Mexico, a state with a high incidence of opioid overdose deaths, requires certified nurse-midwives (CNMs) who prescribe controlled substances to use the statewide Prescription Monitoring Program (PMP). This study examined how frequently CNMs who practice in New Mexico and prescribe controlled substances use the PMP and the purposes for which they use it.

Methods: All CNMs licensed in New Mexico (N = 210) were sent a link to an anonymous online survey. CNM demographics, practice charac- teristics, and controlled substance prescribing practices were examined.

Results: Approximately 40% of CNMs licensed in New Mexico completed the survey (N = 83), 77% of whom (64/83) were providing direct clinical care services. Nearly all who were engaged in clinical care had a US Drug Enforcement Administration registration number and were registered in the PMP (97%; 62/64). Approximately 90% of those respondents (56/62) reported prescribing controlled substances. Approximately 10% (6/62) never logged into the PMP, 40% (25/62) never ran a self-report, and nearly 30% (18/62) reported never checking the PMP for patient alerts. Among those who reported prescribing controlled substances, the percentages who never logged in, never ran a self-report, and never checked for patient alerts were 7% (4/56), 37% (21/56), and 27% (15/56), respectively. Nearly half of those prescribing controlled substances (26/56) did so monthly or more often, but with respect to their own prescribing, approximately one-third of them (9/26) checked the PMP less frequently than every 6 months.

Discussion: Most CNMs in New Mexico are authorized to prescribe controlled substances, but the frequency of prescribing varies, and some CNMs may not be making optimal use of the state PMP for self-reports, for patient alerts, or prior to prescribing a controlled substance. Additional education pertaining to the PMP is needed, as are best practice recommendations for monitoring CNMs’ controlled substance prescribing. J Midwifery Womens Health 2019;64:28–35 c© 2019 by the American College of Nurse-Midwives.

Keywords: controlled substances, opioids, prescription monitoring program, certified nurse-midwives

INTRODUCTION

Death by opioid overdose is a leading cause of accidental death in the United States.1,2 In 2016, more than 100 deaths per day occurred from an opioid overdose,3,4 and 40% were from commonly prescribed opioids.1 Prescription opioid overdoses are a growing problem among women. Between 1999 and 2010, deaths from prescription painkillers among women in- creased by more than 400%, compared with a 265% increase among men.5 There has also been an increased incidence of opioid use disorder among pregnant women and a rise in the number of cases of neonatal abstinence syndrome.5 Women are more likely than men to have chronic pain and to be pre- scribed opioids at higher doses and for a longer duration.5 Women may become opioid dependent more quickly than men.5 Accordingly, providers of women’s health care services have an important role to play in reducing the risks of sub- stance use disorders.

The death rate from drug overdose in New Mexico (per 100,000 population) tripled between 1990 and 2016 and exceeded the US death rate in every year during that interval.6 Over the past decade, there has been a significant increase in deaths due to overdose of prescription drugs, whereas deaths

Address correspondence to Katrina A. Nardini, CNM, MSN, MPH, WHNP-BC, University of New Mexico, Department of Obstetrics & Gy- necology, MSC10 5580, 1 University of New Mexico, Albuquerque, NM 87131. Email: knardini@salud.unm.edu

from overdose of illicit drugs have remained relatively stable.6 From 2010 to 2014, prescription drugs caused more than half (53%) of drug overdose deaths in the state compared with one-third (33%) caused by illicit drugs (14% involved both).7 During that interval, the death rate for women aged 25 to 64 years was 31 per 100,000 (95% CI, 28.9-33.1).7 Death rates from opioid overdose among women of all ages in New Mexico substantially exceed those for the United States as a whole (Figure 1).8

Prescription Monitoring Programs

Prescription monitoring programs (PMPs) are statewide databases that collect, monitor, and analyze electroni- cally transmitted information from pharmacies and health care providers on dispensed prescriptions of controlled substances.9–12 The purpose of a PMP is to provide autho- rized users with the ability to review a patient’s controlled substance prescription history to detect and reduce diversion, abuse, and misuse of controlled substance prescriptions and prevent overdose deaths.13,14 PMPs are also used to monitor prescribers and prevent overprescribing and fraudulent prescribing.14 Policies to control overprescribing, such as use of the PMP, are a form of secondary prevention aimed at treating a disease early on. Efforts to identify and treat individuals addicted to opioids early in the course of the disease are likely to reduce the risk of overdose, the transition to injection opioid use, and medical morbidities.15 Additional

https://orcid.org/0000-0002-7978-4172

mailto:knardini@salud.unm.edu

✦ This study examined prescribing practices and compliance with state requirements for controlled substance prescribing among certified nurse-midwives (CNMs) in New Mexico.

✦ More than 25% of respondents who prescribe controlled substances reported doing so at least weekly, and approximately half do at least monthly.

✦ Some CNMs in New Mexico may not be utilizing the state’s Prescription Monitoring Program in optimal fashion.

resources pertaining to prescribing and monitoring of con- trolled substances are included in Appendix 1.

In 2005, the New Mexico Board of Pharmacy imple- mented a PMP that required all nonfederal pharmacies in the state to report all filled prescriptions for controlled substances. Prior to 2017, practitioners authorized to prescribe controlled substances were required to check the PMP when prescrib- ing a controlled substance for a patient with chronic pain. In 2016, the New Mexico legislature enacted a statute requiring all licensed health care practitioners who prescribe controlled substances16 to check the PMP 1) before prescribing or dis- pensing “an opioid for the first time to a patient”16(p2) (if the prescription is for a �4-day supply) and 2) for continual opi- oid prescribing or dispensing, at a minimum, every 3 months. Practitioners are not required to check the PMP “when pre- scribing an opioid to a patient in a nursing facility or in hos- pice care.”16(p3) The statute also directed that licensing boards for practitioners licensed or authorized to prescribe or dis- pense opioids implement the PMP requirements in their re- spective practice rules.17,18

If PMPs are considered part of the solution to reduce the morbidity and mortality of opioid use, it is important for states to understand how PMPs are being used by participating

health care practitioners. Certified nurse-midwives (CNMs) in New Mexico are licensed by the New Mexico Department of Health (NMDOH) and have full prescriptive authority, which includes prescribing controlled substances (New Mexico Ad- ministrative Code [NMAC] 16.11.2).17,18 Investigators from the NMDOH and the University of New Mexico collaborated to survey CNMs practicing in the state about their frequency of prescribing controlled substances and their participation in the PMP. This study aimed to better understand prescribing practices and use of the PMP by CNMs in New Mexico. The research questions were as follows: 1) What are CNMs’ pre- scribing practices of controlled substances in New Mexico? and 2) Are CNMs currently compliant with state regulations concerning controlled substance prescribing and utilization of the PMP?

METHODS

An anonymous online survey was administered to CNMs practicing in New Mexico in February 2017. Study data were collected and managed using Research Electronic Data Capture (REDCap) tools hosted at the University of New Mexico.19 REDCap is a secure, web-based application de- signed to support data capture for research studies. Ethical

Figure 1. Death Rates (per 100,000) from Drug Overdose Among Women in New Mexico Compared with the United States as a Whole, 1999 to 2016.

Source: Kaiser Family Foundation.8

Journal of Midwifery & Women’s Health � www.jmwh.org 29

approval as an exempt study was granted by the University of New Mexico’s institutional review board.

The survey was created and administered by the inves- tigators and consisted of 24 questions (see Supporting In- formation: Appendix S1). Questions were categorical, some of which allowed multiple options to be chosen. Participants who worked as a CNM in only one New Mexico county selected the county from a dropdown list; an open-ended question allowed participants working in more than one county to write them in. Branching logic was used where appropriate (eg, CNMs who did not have a US Drug En- forcement Administration [DEA] registration were not asked questions about prescribing practices). Because there were no validated surveys with this focus, survey questions were developed by the investigators to address concerns raised by the Certified Nurse-Midwives Advisory Board and the NMDOH. The survey was tested prior to launch of the study by the research team and members of the NMDOH. There was no formal assessment of reliability or content validity.

Email addresses of all CNMs licensed to practice in the state of New Mexico were provided by the NMDOH. An in- troductory email with a brief description of the study was sent to all CNMs on the list (N = 210). A follow-up email included the approved consent letter, an invitation to participate in the study, and a link to the study. Participation in the survey was voluntary. Consent was obtained by including a statement in the survey invitation indicating that by answering the sur- vey online, the CNM was agreeing to participate in the re- search study. A reminder email was sent out at the halfway point of the survey time frame. The survey was open for a to- tal of 6 weeks. Data were evaluated using SPSS version 24.0 (IBM Corporation, Armonk, NY) and reported as descriptive statistics.

RESULTS

A total of 83 CNMs answered the survey (39.5% response rate). More than 85% of respondents identified as white; His- panic or Latina and American Indian respondents each con- stituted approximately 5% of the sample (Table 1). Most re- spondents held a master’s degree, and relatively few reported dual certification as a nurse practitioner. Almost two-thirds of respondents reported being in practice for more than 10 years.

Approximately three-fourths of respondents (64/83) pro- vided direct, clinical care to patients in New Mexico, and 20% of these respondents worked in a rural area (Table 2). Most re- spondents worked in practices that provided gynecologic care, prenatal care, in-hospital birth care, and reproductive health services, all of which the respondents provided and which fell within their scope of practice. Six respondents worked in ser- vices that provided substance use disorder services, but only 2 of them provided this care as part of their own scope of practice.

All but 2 respondents providing clinical care in New Mex- ico (62/64) had a DEA registration number (Table 2) and were registered in the PMP (97%, 62/64). Table 3 shows data per- taining to PMP registration and use by CNMs currently prac- ticing in New Mexico who had DEA registration numbers and

Table 1. Demographic Information from CNMs Licensed in New Mexico (N = 83) Survey Items n ()

Race and ethnicity

American Indian or Alaska Native 4 (4.8)

Asian 1 (1.2)

African American 2 (2.4)

Hispanic/Latina 4 (4.8)

White 69 (83.1)

Other/none of the above 3 (3.6)

Highest level of education

Certificate only 3 (3.6)

Master’s degree 70 (84.3)

DNP, PhD, or other doctorate 10 (12.0)

Location of midwifery traininga

University of New Mexico 37 (45.1)

Out-of-state program (on the ground; non-distance

education or “in-person” program)

39 (47.6)

Distance/online education program 6 (7.3)

Dual certification as CNPa

Yes 12 (14.5)

No 70 (84.3)

Total years in practice as CNM or CNP

�5 19 (22.9)

5-10 10 (12.0)

�10 54 (65.1)

Years in practice as CNM or CNP in New Mexico

�5 26 (31.3)

5-10 18 (21.7)

�10 39 (47.0)

Provide clinical care to patients in New Mexico

Yes 64 (77.1)

No 19 (22.9)

Abbreviations: CNM, certified nurse-midwife; CNP, certified nurse practitioner; DNP, Doctor of Nursing Practice; PhD, Doctor of Philosophy. an = 82 because of missing data.

were registered in the PMP (n = 62) and the subset of that group who were currently prescribing controlled substances (n = 56). Approximately one-quarter reported logging into the PMP less frequently than every 6 months for any reason, and 7% reported never logging in. Approximately 40% had never run a self-report, and more than one-quarter had never checked the PMP for patient alerts.

More than half of those who prescribed controlled substances reported prescribing from all schedules; for those who did not, Schedule II and III drugs were prescribed to a greater extent than Schedule IV or V drugs.20 Slightly more than half prescribed a controlled substance infrequently (every 2 to 6 months) or very infrequently (less than every 6 months; Table 4). With respect to prescriptions for controlled substances for their own patients, fewer than 30% (16/56) reported checking the PMP every time they

30 Volume 64, No. 1, January/February 2019

Table 2. Practice Characteristics of New Mexico Certified Nurse-Midwives Providing Direct Patient Care (n = 64) Survey Items n ()

No. of counties in New Mexico in which

participants provided clinical care

1 55 (85.9)

�2 9 (14.1)

Geographic area of practicea

Urban (Metro: RUCC 2 or 3) 48 (75.0)

Rural (Nonmetro: RUCC 4-9) 13 (20.3)

More than one county (not specified) 1 (1.6)

No county reported 2 (3.1)

Type of practiceb

Independent/private practice 19 (29.7)

Community hospital or hospital-affiliated clinic 18 (28.1)

University-affiliated hospital or clinic 12 (18.8)

Federally Qualified Health Center/Rural Health

Clinic

8 (12.5)

Federal 7 (10.9)

Other 5 (7.8)

Scope of practiceb

Gynecologic care 58 (90.6)

Prenatal care 58 (90.6)

In-hospital (birth) care 44 (68.8)

Reproductive health services 34 (53.1)

Family practice 11 (17.2)

Substance abuse 2 (3.1)

Other 15 (23.4)

Percentage of patient panel with substance use

disorders

None 1 (1.6)

�5 23 (35.9)

5-20 33 (51.6)

�20 but �50 5 (7.8)

�50 2 (3.1)

DEA number

Yes 62 (96.9)

No 2 (3.1)

Registered in PMP

Yes 62 (96.9)

No 2 (3.1)

Abbreviations: DEA, US Drug Enforcement Administration; PMP, Prescription Monitoring Program; RUCC, Rural-Urban Continuum Code. aBased on US Department of Agriculture RUCCs. bMultiple responses permitted; denominator for percentages was 64.

prescribed a controlled substance unless an exception applied (eg, a prescription of no more than 4 days’ duration); the remaining 70% did so less often or not at all (Table 4). Among the subset who reported prescribing controlled substances at least once a month (n = 26), fewer than half (11/26;

Table 3. Prescription Monitoring Program Participation by New Mexico Certified Nurse-Midwives Providing Direct Patient Care Who Have a DEA Registration Number and by the Subset Currently Prescribing Controlled Substances

With DEA

Registration

and in PMP

(n = )

Prescribing

Controlled

Substances

(n = ) Survey Items n () n ()

Frequency of login to

PMP for any reason

Daily 0 0

Weekly 2 (3.2) 2 (3.6)

Monthly 13 (21.0) 13 (23.2)

Every 6 months 23 (37.1) 23 (41.1)

Less frequently than

every

6 months

18 (29.0) 14 (25.0)

Never 6 (9.7) 4 (7.1)

Frequency of running

self-report from PMP

More frequently than

every 6 months

4 (6.5) 4 (7.1)

Every 6 months 14 (22.6) 14 (25.0)

Less frequently than 6

months

17 (27.4) 15 (26.8)

Never 25 (40.3) 21 (37.5)

Did not answer 2(3.2) 2 (3.6)

Frequency of PMP

checks for patient

alerts

More frequently than

every 6 months

11 (17.7) 11 (19.6)

Every 6 months 11 (17.7) 10 (17.9)

Less frequently than 6

months

21 (33.9) 19 (33.9)

Never 18 (29.0) 15 (26.8)

Did not answer 1 (1.6) 1 (1.8)

Prescribe controlled

substances

Yes 56 (90.3) 56 (100.0)

No 5 (8.1) NA

Did not answer 1 (1.6) NA

Abbreviations: DEA, US Drug Enforcement Administration; NA, not applicable; PMP, Prescription Monitoring Program.

42%) reported logging into the PMP at least monthly, 38% (10/26) replied that they never ran a self-report, 27% (7/26) replied that they never checked the PMP website for patient alerts, and, with respect to their own prescribing, 35% (9/26) checked the PMP less frequently than every 6 months.

Journal of Midwifery & Women’s Health � www.jmwh.org 31

Table 4. Controlled Substance Prescribing by New Mexico Certified Nurse-Midwives (n = 56)a Survey Items n ()

Schedule of drugs prescribedb

All schedules 31 (55.4)

Schedule II 21 (37.5)

Schedule III 20 (35.7)

Schedule IV 7 (12.5)

Schedule V 12 (21.4)

Frequency of prescribing a controlled substance

to at least one patient

Daily 2 (3.6)

Weekly 13 (23.2)

Monthly 11 (19.6)

Infrequently (at least once every 2-6 months or

less)

20 (35.7)

Very infrequently (less often than once every

6 months)

10 (17.9)

Frequency of PMP check with prescribing of

controlled substance

Every time prescribe controlled substance or

every time unless exclusions apply

16 (28.5)

At least every 6 months 14 (25.0)

Less frequently than every 6 months 18 (32.1)

Never 4 (7.1)

Did not answer 4 (7.1)

Abbreviation: PMP, Prescription Monitoring Program. aThese items were delivered only to participants engaged in clinical practice, with US Drug Enforcement Administration registration, who were currently prescribing controlled substances. bMultiple responses permitted; respondents who selected “all schedules” excluded from numerators for Schedules II through V.

DISCUSSION

To our knowledge, this study is the first to describe prescrib- ing practices and compliance with state prescription monitor- ing requirements among CNMs. Results from this study show that CNMs in New Mexico are aware of the PMP and that nearly all who are required to have a PMP account do. How- ever, some are not checking the PMP as often as required by statute.16 For example, more than 40% of the participants who prescribed controlled substances did so at least monthly, but more than half of that subset ran PMP self-reports or checked for patient alerts less often than every 6 months, and approx- imately one-third of them checked the PMP less often than every 6 months when prescribing a controlled substance. It is possible that PMP use by some CNMs is in accordance with earlier practice regulations, which required checking the PMP only when prescribing controlled substances for patients with chronic pain.17 The newer statutory requirements that went into effect in January 201716 have been incorporated into practice regulations for physicians (NMAC 16.10.14),21 den- tists (NMAC 16.5.57),22 and advanced practice nurses other than CNMs (NMAC 16.12.9),23 whereas the corresponding changes for CNMs are still in rulemaking.18 However, we

found that nearly all respondents who should have been registered with the PMP were, and the statutory change was well publicized.

Data on the impact of state policy and system-level interventions related to prescribing practices and PMP use are limited and inconsistent,24 with some studies showing improvements in prescribing practices and others showing no difference.25,26 For example, one study found that imple- mentation of a PMP was associated with a more than 30% reduction in the rate of prescribing of Schedule II opioids, but prescribing of Schedule III opioids was unchanged.9 The effect of PMPs varied significantly when state-by-state data were examined.25 Across states, PMPs have different designs, requirements, and operations, making it difficult to evaluate their overall effectiveness.27 There is also con- siderable variability in PMP legislative components as well as in states’ implementation strategies.28 Almost every state has a PMP, and as of January 2018, 37 states reported having legislation requiring opioid prescribers or dispensers to re- port to PMPs.10,29 An examination of 3 states that mandated PMP use showed a rapid increase in provider enrollment and utilization of the PMP, better identification of potential physician-shoppers and those in need of intervention for opioid use disorders, and improved medically indicated opioid prescribing.30

Limitations

This study has several limitations. Because the study was conducted in a single state, the extent to which results may be generalizable to CNM prescribing practices or PMP use elsewhere is unknown. All CNMs licensed to practice in the state were invited to participate, but the response rate was approximately 40%. Several studies have shown that response rates to electronic surveys of health care providers are signif- icantly lower (7%-15% less) than response rates for mail or mixed-media studies.31 Some CNMs may not have responded because they were not currently practicing in the state, not currently engaged in clinical practice, or not prescribing controlled substances. However, it is likely that other CNMs actively practicing and prescribing controlled substances did not participate for unknown reasons. Therefore, participants constituted a self-selected convenience sample with attendant risks of response biases.

We developed the survey questions ourselves because we could not find a validated survey with this focus. Because the survey used a combination of single items and branching logic items, assumptions for conventional assessment of internal consistency reliability were not met, and we did not formally assess content validity. We thought that by using the term pre- scribing, the intent and focus of the survey on prescribing in an outpatient setting or at hospital discharge would be clear. However, we received 2 inquiries requesting clarification of whether prescribing controlled substances also included con- trolled substances used in an inpatient setting (eg, parenteral opioids for pain management during labor). Therefore, it is possible that some participants took prescribing to include or- dering pain medication in labor. If so, this may have resulted in some estimates indicating that CNMs were prescribing con- trolled substances more often than they actually do.

32 Volume 64, No. 1, January/February 2019

In hindsight, several questions were vague or ambiguous in intent. For example, a question intended to assess knowl- edge about the PMP merely asked if respondents understood what it was, and all respondents who were asked that question (ie, those in clinical practice who had DEA registration numbers) indicated that they did, which was uninformative because of zero variance. With respect to prescriptions for controlled substances for their own patients, it is possible that some respondents routinely limited prescription duration to 4 days or less to avoid having to check the PMP before prescribing. Therefore, the observed percentages for less- frequent checking in Table 4 are not necessarily indicative of noncompliance with statutory requirements, despite apparent discordance with reported frequency of prescrib- ing controlled substances. Whether some CNMs might be underprescribing for pain management to stay below the threshold for checking the PMP cannot be determined from the survey.

Implications and Recommendations

The NMDOH is aware of the results of this survey. Results of the study suggest a need for greater attention to the PMP requirements. Educational programs and facility- or practice- based quality improvement projects could be developed to ad- dress the importance of adherence to PMP requirements and to improve consistency of reporting. They could also empha- size the importance of the PMP for reducing risks of diversion or unauthorized use of controlled substances.

Because of the lack of research on CNM prescribing prac- tices for controlled substances and the epidemic levels of opi- oid misuse and overdose nationwide, we recommend that a national survey on CNM controlled substance prescribing practices be conducted. Although differences in state regula- tions would need to be accounted for, a national survey could help to inform licensing boards about the prescribing prac- tices of CNMs and assist legislators and regulators in imple- menting best practices nationwide.32

Statewide monitoring of opioid prescribing is an impor- tant component of reducing illicit opioid use.33 Improving prescribing practices of health care providers by consistent use of PMPs is only one tool for reducing risks of prescrip- tion overdose and death from opioids and other controlled substances. Other secondary prevention strategies include pain clinic laws to decrease inappropriate prescribing and im- proved screening techniques for substance abuse as well as mental health problems.5,34 Primary prevention strategies are also necessary. For example, among surgeons, wide variation has been reported in the amount and dosage of postoperative opioid prescriptions for the same procedure, and patients took far fewer doses than had been prescribed.35 Development of evidence-based clinical guidelines for prescription amounts and durations and educating patients on safe disposal of un- used pills are among recommendations for decreasing oppor- tunities for misuse.35 Lastly, ensuring the provision of harm reduction strategies, such as wider availability of opioid antag- onists and greater access to effective and affordable treatment services, are key aspects of tertiary prevention for those with existing substance use disorders.15

CONCLUSION

It is important that CNMs educate themselves about statu- tory requirements for PMP participation as a component of best practices for treating pain and prescribing opioids. CNMs need to be in the forefront of best prescribing prac- tices to help save the lives of women, prevent complications with their newborns, and prevent substance use disorders and overdose. Based on these research findings, we recom- mend that the NMDOH implement an educational program to ensure that CNMs licensed in the state are aware of the statutes and regulations that affect their prescribing of con- trolled substances and the associated PMP reporting require- ments. More research is needed by regulatory boards in other states to determine whether CNMs across the United States are prescribing controlled substances in a safe and effective manner.

AUTHORS

Katrina A. Nardini, CNM, MSN, MPH, WHNP-BC, is Asso- ciate Chief of the Midwifery Division of the University of New Mexico Health Sciences Center, Albuquerque, NM. She is a CNM Consultant for the New Mexico Department of Health’s Maternal Health Division.

Jenny Landen, MSN, APRN, FNP-BC, is Dean of the School of Sciences, Health, Engineering, and Math at Santa Fe Community College in Santa Fe, NM. She is also a doctoral candidate in nursing at the University of New Mexico.

Mark Parshall, PhD, RN, FAAN, is a professor and Interim Chair for Research at the University of New Mexico College of Nursing, Albuquerque, NM.

Kim J. Cox, CNM, PhD, RN, FACNM, is an associate professor and PhD Program Director at the University of New Mexico College of Nursing, Albuquerque, NM.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

ACKNOWLEDGMENTS

We thank the New Mexico Department of Health and the Maternal Health Program Manager, Catherine Avery, MS, CFNP, for their cooperation and support of this project. We also thank Anne Mattarella, MA, ELS, for technical assis- tance with manuscript preparation. Access to Research Elec- tronic Data Capture (REDCap) tools, hosted at the University of New Mexico Health Sciences Center Clinical and Trans- lational Science Center, was possible through grant support (5UL1TR001449-04).

SUPPORTING INFORMATION

Additional supporting information may be found online in the Supporting Information section at the end of the article.

Appendix S1. Survey Items

Journal of Midwifery & Women’s Health � www.jmwh.org 33

REFERENCES

1.The Opioid Epidemic by the Numbers. Washington, DC: US Depart- ment of Health and Human Services; January 2018. https://www.hhs. gov/opioids/sites/default/files/2018-01/opioids-infographic.pdf. Accessed February 8, 2018.

2.Opioid Addiction: 2016 Facts & Figures. Rockville, MD: American Society of Addiction Medicine; 2016. https://www.asam.org/docs/ default-source/advocacy/opioid-addiction-disease-facts-figures.pdf. Accessed February 8, 2018.

3.What is the U.S. opioid epidemic? US Department of Health and Human Services website. http://www.hhs.gov/opioids/about-the- epidemic/index.html.Published December 4, 2017. Accessed February 8, 2018.

4.Kochanek KD, Murphy S, Xu J, Arias E. Mortality in the United States, 2016. NCHS Data Brief. 2017;(293):1-8.

5.Prescription painkiller overdoses: a growing epidemic, especially among women. Centers for Disease Control and Prevention web- site. https://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/ index.html. Published March 23, 2017. Accessed February 8, 2018.

6.Health indicator report of drug overdose deaths. New Mexico Indicator-Based Information System (NM-IBIS) website. https:// ibis.health.state.nm.us/indicator/view/DrugOverdoseDth.Cnty.html. Updated February 12, 2018. Accessed April 9, 2018.

7.Complete health indicator report of drug overdose deaths. New Mexico Indicator-Based Information System (NM-IBIS) website. https://ibis.health.state.nm.us/indicator/complete_profile/DrugOver doseDth.html. Updated February 12, 2018. Accessed April 9, 2018.

8.Opioid overdose deaths by gender, 1999-2016. Kaiser Family Founda- tion web site. https://www.kff.org/other/state-indicator/opioid-over dose-deaths-by-gender/?dataView=2&activeTab=graph&current Timeframe=0&startTimeframe=17&selectedDistributions=female &selectedRows=%7B%22wrapups%22:%7B%22united-states%22: %7B%7D%7D,%22states%22:%7B%22new-mexico%22:%7B%7D% 7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort% 22:%22asc%22%7D. Published 2018. Accessed August 22, 2018.

9.Bao Y, Pan Y, Taylor A, et al. Prescription drug monitoring pro- grams are associated with sustained reductions in opioid prescribing by physicians. Health Aff (Millwood). 2016;35(6):1045-1051.

10.Wickramatilake S, Zur J, Mulvaney-Day N, Klimo MC, Selmi E, Har- wood H. How states are tackling the opioid crisis. Public Health Rep. 2017;132(2):171-179.

11.State prescription drug monitoring programs. Diversion Control Di- vision, Drug Enforcement Administration, US Department of Justice website. https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm. Updated June 2016. Accessed May 4, 2018.

12.What states need to know about PDMPs. Centers for Disease Control and Prevention website. https://www.cdc.gov/drugoverdose/ pdmp/states.html. Published October 3, 2017. Accessed April 7, 2018.

13.Ryba P, Gonzales M. New Mexico Board of Pharmacy Prescription Monitoring Program (PMP). Paper presented at: New Mexico Phar- macists Association 2018 Mid-Winter Meeting; January 27, 2018; Al- buquerque, NM.

14.Islam MM, McRae IS. An inevitable wave of prescription drug moni- toring programs in the context of prescription opioids: pros, cons and tensions. BMC Pharmacol Toxicol. 2014;15:46.

15.Kolodny A, Courtwright DT, Hwang CS, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health. 2015;36:559-574.

16.An act relating to health care; requiring a practitioner who prescribes or dispenses an opioid to a patient to obtain and review reports from the State’s prescription monitoring program and from adjacent states, if accessible, for such patient. S 263, 52nd Leg, 2nd Sess (NM 2016). http://www.sos.state.nm.us/uploads/files/SB263-CH46-2016-AA.pdf. Accessed September 17, 2018.

17.Occupational and professional licensing. Midwives. Certified nurse midwives. 16.11.2 NM Admin Code. http://164.64.110.134/parts/title 16/16.011.0002.html. Accessed September 20, 2018.

18.Rules and regulations. Pending rulemakings 2018: Certified nurse midwives—NMAC 16.11.2. Proposed NMAC 16.11.2. New Mex- ico Department of Health website. https://nmhealth.org/about/asd/ cmo/rules/. Accessed September 20, 2018.

19.Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research Electronic Data Capture (REDCap) - a metadata-driven methodology and workflow process for providing translational re- search informatics support. J Biomed Inform. 2009;42(2):377-381.

20.Drug scheduling. US Drug Enforcement Administration website. https://www.dea.gov/drug-scheduling. Accessed October 29, 2018.

21.Occupational and professional licensing. Medicine and surgery prac- titioners. Management of pain and other conditions with con- trolled substances. 16.10.14 NM Admin Code. http://164.64.110. 134/parts/title16/16.010.0014.html. Accessed October 3, 2018.

22.Occupational and professional licensing. Dentistry (dentists, den- tal hygienists, etc.). Management of pain with controlled sub- stances. 16.5.57 NM Admin Code. http://164.64.110.134/parts/title16/ 16.005.0057.html. Accessed October 3, 2018.

23.Occupational and professional licensing. Nursing and health care related providers. Management of pain with controlled sub- stances. 16.12.9 NM Admin Code. http://164.64.110.134/parts/ title16/16.012.0009.html. Accessed October 2, 2018.

24.Haegerich TM, Paulozzi LJ, Manns BJ, Jones CM. What we know, and don’t know, about the impact of state policy and systems-level interventions on prescription drug overdose. Drug Alcohol Depend. 2014;145:34-47.

25.Brady JE, Wunsch H, DiMaggio C, Lang BH, Giglio J, Li G. Prescrip- tion drug monitoring and dispensing of prescription opioids. Public Health Rep. 2014;129(2):139-147.

26.Paulozzi LJ, Kilbourne EM, Desai HA. Prescription drug moni- toring programs and death rates from drug overdose. Pain Med. 2011;12(5):747-754.

27.Lin HC, Wang Z, Boyd C, Simoni-Wastila L, Buu A. Associations between statewide prescription drug monitoring program (PDMP) requirement and physician patterns of prescribing opioid analgesics for patients with non-cancer chronic pain. Addict Behav. 2018;76: 348-354.

28.Suffoletto B, Lynch M, Pacella CB, Yealy DM, Callaway CW. The ef- fect of a statewide mandatory prescription drug monitoring program on opioid prescribing by emergency medicine providers across 15 hos- pitals in a single health system. J Pain. 2018;19(4):430-438.

29.Prescription drug monitoring programs. National Alliance for Model State Drug Laws website. http://www.namsdl.org/prescription- monitoring-programs.cfm. Accessed August 2, 2018.

30.Mandating PDMP Participation by Medical Providers: Current Sta- tus and Experience in Selected States. Waltham, MA: Prescription Drug Monitoring Program Center of Excellence, Brandeis Univer- sity; 2014. https://www.ncjrs.gov/pdffiles1/bja/247134.pdf. Accessed February 8, 2018.

31.Sebo P, Maisonneuve H, Cerutti B, Fournier JP, Senn N, Haller DM. Rates, delays, and completeness of general practitioners’ responses to a postal versus web-based survey: a randomized trial. J Med Internet Res. 2017;19(3):e83.

32.Doyle S, Leichtling G, Hildebran C, Reilly C. Research to support op- timization of prescription drug monitoring programs. Pharmacoepi- demiol Drug Saf. 2017;26(11):1425-1427.

33.Schuchat A, Houry D, Guy GP Jr. New data on opioid use and pre- scribing in the United States. JAMA. 2017;318(5):425-426.

34.Dowell D, Zhang K, Noonan RK, Hockenberry JM. Mandatory provider review and pain clinic laws reduce the amounts of opi- oids prescribed and overdose death rates. Health Aff (Millwood). 2016;35(10):1876-1883.

35.Hill MV, McMahon ML, Stucke RS, Barth RJ Jr. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2017;265(4):709-714.

34 Volume 64, No. 1, January/February 2019

https://www.hhs.gov/opioids/sites/default/files/2018-01/opioids-infographic.pdf

https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

http://www.hhs.gov/opioids/about-the-epidemic/index.html

https://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html

https://ibis.health.state.nm.us/indicator/view/DrugOverdoseDth.Cnty.html

https://ibis.health.state.nm.us/indicator/complete_profile/DrugOverdoseDth.html

https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-gender/?dataView=2&activeTab=graph&currentTimeframe=0&startTimeframe=17&selectedDistributions=female&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D,%22states%22:%7B%22new-mexico%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D