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.