Widespread Use of Prescription Drug Monitoring Programs to Reduce Opioid Abuse and Overdoses

By Rebecca Haffajee

It’s established that the U.S. is in the midst of a prescription opioid overdose and abuse epidemic. From 1999 to 2011, the rate of fatal prescription drug overdoses involving opioids quadrupled from 1.4 deaths/100,000 people to 5.4 deaths/100,000 people. The rate of emergency department visits attributable to prescription drug misuse (mostly involving opioids) more than doubled from 214 visits/100,000 people in 2004 to 5.4 deaths/100,000 people in 2011. Although many factors contributed to the escalation of illicit prescription painkiller use, the trend is clearly correlated with the increasing supply of opioids. A heightened focus on pain management starting in the late 1990s liberalized opioid prescribing. But in responding to the public health problem of under-treatment of pain, prescribers paradoxically have facilitated growth in prescription drug abuse. In 2012 alone, over 259 million opioid prescriptions were dispensed by retail pharmacies in the U.S. – enough prescriptions for every adult to have their own bottle of pills. Moreover, physician overprescribing has been identified as a key contributor to the opioid crisis, particularly in sourcing drugs to chronic abusers.

Prescribers, who are uniquely situated to distinguish between appropriate use and abuse of opioids and prescribe accordingly, are a natural target for regulation. Several prominent regulatory interventions recognize prescribers as opioid gatekeepers, such as the establishment of prescription drug monitoring programs (PDMPs), pain clinic laws, and mandatory opioid prescriber guidelines. Many believe that PDMPs, or state-based electronic systems that store controlled substance dispensing information and make the data available to prescribers, pharmacies, and sometimes law enforcement officials, represent a promising tool to combat opioid abuse and overdoses. And all states except Missouri have a PDMP. But prescriber awareness and use of these systems is necessary for them to have an appreciable effect. A recent Health Affairs study, Rutkow et al. used a nationally representative sample of primary care physicians and found that while 72% of physicians were aware of the their state PDMP, only 53% reported having ever used it. A number of barriers to use were identified, including the time-consuming nature of retrieving information, and the lack of intuitive format for the data provided. The authors conclude that PDMP legal mandates may increase prescriber use of the programs.

In a recent JAMA Viewpoint, Scott Weiner, Anupam Jena, and I explore this idea of PDMP mandates further. We describe the benefits of, evidence behind, provider concerns with use mandates, which have been adopted in some form by 22 states. Many objections to mandates are legitimate; perhaps most concerning is the potential unintended consequence of under-prescribing for legitimate pain that could follow. Still, some early evidence shows dramatically increased prescriber use of the systems and decreased opioid prescribing after mandate implementation. Still other emerging evidence suggests that overdoses and abuse began to level off from 2011 through 2013 — right around the time that several robust PDMPs (many of which included mandates) went into effect. But to what degree are these changes in opioid outcomes attributable to PDMPs — and PDMP mandates more specifically? This question deserves serious evaluation, using rigorous, controlled studies. If mandates do make a difference, then this would lend legitimacy to their continued implementation in the name of public health, despite objections or possible incursion into medical practice. But balancing under- and over-treatment of pain, as well as legitimate provider concerns, will be key to the success of this policy going forward.

haffajee

haffajee

Rebecca Haffajee is a Thomas O. Pyle Fellow in Pharmaceutical Policy Research in the Department of Population Medicine at the Harvard Pilgrim Healthcare Institute. After completing her JD and MPH at Harvard in 2006, Rebecca practiced as a health care lawyer for several years. She entered the Harvard PhD Program in Health Policy in 2010 with a concentration in Evaluative Science and Statistics. Her dissertation research is focused on the empirical effects of laws and policies on health outcomes, with particular emphases on public health laws and patient safety/quality initiatives. She is currently working on a longitudinal assessment of the impact of mental health parity laws on mental health treatment and outcomes. Rebecca was a Student Fellow at the Petrie-Flom Center in 2010 - 2011. Her research paper was: "Probing the Constitutional Basis for Distracted Driving Laws: Do they Actually Reduce Fatalities?"

One thought to “Widespread Use of Prescription Drug Monitoring Programs to Reduce Opioid Abuse and Overdoses”

  1. This issue has been one that has long plagued the Veterans Affairs system. Most recently, the Tomah VA has been under investigation for the overprescription of pills. For example, in 2004, the Tomah VA had given out 50,000 pills to 25,000 veterans. By 2012, the number had increased to 712,000 pills for 300k vets. The increase in the patients alone cannot explain the number of pills prescribed. There are some reports of VA patients receiving as much as 800 oxycodone pills per month. And as a result, you see an increase in wrongful deaths as a result of over prescription.

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