Prescription Drug Monitoring Programs to Curb Prescription Drug Abuse: Examining the Components of Program Efficacy
IN THIS ARTICLE
In the American healthcare system there have been few trends as persistent, yet avoidable, as the rise in prescription drug overdoses. Between 1999 and 2008 prescription overdoses quadrupled to nearly twenty thousand per year (Paulozzi, Jones, Mack, & Rudd, 2011). It is estimated that nearly six million Americans are abusing or misusing prescription drugs in any given year, and nonmedical prescription use remains one of the most common forms of illicit substance abuse among young adults, second only to cannabis use (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). Unlike many other illicit substances, prescription drugs are unique in that they are made with an established medical purpose yet abused to the point of harm -- the opposite of their intended effect.
55% of abusers get their prescription drugs from friends or relatives. Meanwhile, a small number of doctors are responsible for writing large numbers of prescriptions. In an Oregon program, it was found that the top 8.1% of providers wrote 79% of all Schedule II-IV prescriptions.
Far from the shadowy worlds of heroin smuggling, cocaine dealing, and methamphetamine cooking, prescription drugs have become increasingly ubiquitous and blatant. In the year 2001 alone, Purdue Pharma L.P. spent two hundred million dollars marketing its drug OxyContin (Zee, 2009). Despite large public attention to the more nefarious seeming drugs (heroin, cocaine, meth, etc.), pharmaceutical drugs accounted for 58% of all drug overdoses in 2010; four times greater than cocaine and heroin combined (Jones, Mack & Paulozzi, 2013). Apart from the loss of life, prescription drug abuse incurs a monetary cost: pharmaceutical drugs cost health insurers up to $72.5 billion per year in drug diversion (Mahon, 2007), create $8 billion in criminal justice costs, and result in $42 billion in lost productivity (United States General Accounting Office [USGAO], 2002).
The burden of prescription drug abuse is obvious, but what policies can be put into place to curb the rates or addiction, abuse, and overdose? With an issue as widespread and entrenched as nonmedical prescription drug abuse, it will likely take a long-term approach with an array of policies including Prescription Drug Monitoring Programs (PDMPs), substance abuse treatment (both behavioral and pharmacologic), “Good Samaritan” laws that grant legal immunity to people reporting an overdose, and public education on the issue. Of these tactics, PDMPs have been the most actively pursued by states in the last decade.
In general terms, a prescription drug monitoring program is an electronic database: a network to track the provision of drugs to patients. More specifically, a PDMP looks something like an automated evidence collecting system. This system tracks drug users and abusers, thereby giving prescribers and pharmacies access to a host of pertinent information they would lack otherwise. A doctor with an effective PDMP has an entire list of whatever medications their patient has been prescribed, when they were prescribed, who prescribed them, and when they were last filled. This information can aid the clinician in making the best possible medical decision, and lower rates of prescription drug misuse.
These PDMPs vary widely between states. For example, discrepancies exist in the type of information each system collects, the qualifications needed to access the information, and the enforcement policies in place to act on the information. As evidence of a difference between PDMPs, only 16 states require enrollment and participation by drug prescribers and dispensers; the rest are voluntary, so clinicians and pharmacists have the option to disregard PDMP information (USGAO, 2002). Differences in PDMPs thus create the potential for variation in program efficacy.
This paper begins by outlining the causes of nonmedical prescription drug use and then provides a summary of state PDMP adoption. From there, it makes the case for unsolicited reporting as a mechanism to attract attention to the program and automatically report doctor shoppers and pill mills. Ultimately I argue for widespread adoption of a cross state information exchange that would improve our ability to catch doctor shoppers that cross state lines in addition to short data collection intervals to maximize actionable information available to both clinicians and dispensers.
While PDMPs can be helpful in many situations, such as when elderly patients forget the last time they filled their blood pressure prescriptions, PDMPs may have their most significant benefit in situations involving substance abuse. According to a survey by SAMHSA (2013), 4.6% of Americans over the age of 12 used prescription pain relievers for nonmedical use between 2010 and 2012. In total, more than 20 million Americans have taken pain relievers for nonmedical purposes since 2002. Nonmedical abuse is defined as the use of drugs without a prescription or use that occurred simply for the experience or feeling the drug causes (SAMHSA, 2013).
These high rates can be attributed, in large part, to the pharmacological mechanism of the pain medications. Painkillers target receptors in the brain to reduce pain levels, with a common side effect being the feeling of euphoria (Centers for Disease Control and Prevention [CDC], 2013a). Opioids, for example, target the same brain receptors as heroin. Individuals prone to addiction may experience dependence, the gradual need for higher doses to produce an effect, as well as addiction. For these people, pain medication becomes more than a remedy to physical ailment, it becomes a means towards a high.
Considering that many nonmedical users are pursuing a high, the question can be raised: how are so many people getting their hands on addictive prescriptions in the first place? Part of the issue stems from prescribers’ willingness to give out pain medications. Throughout the 1980s and 1990s doctors were taught to think of pain as the “fifth vital sign.” Studies of today’s most prevalent pain medications claimed that they pose a minimal risk of addiction; in fact, as recent as 2001, Purdue Pharma widely distributed brochures asserting that less than 1% of patients taking opioids become addicted (Seppala & Rose, 2010). This has been proven catastrophically false (Boscarino et al., 2010). Even so, the prescription rate of opioids, for patients complaining of pain, has risen from 11.3 to 19.6% between 2000 and 2010 (Korff, 2013). Somewhere near 219 million opioid prescriptions were made in 2011 alone (Whoriskey, 2012).
Somewhat surprisingly, 55% of abusers get their prescription drugs from friends or relatives; in total, more than three out of four abusers get them from someone else through a practice known as diversion (SAMHSA, 2011). This should be viewed as an oversupply since many patients for whom prescriptions are written, are not actually taking them. More troubling still, recent data indicates that a relatively small number of doctors are responsible for a large volume of prescriptions: Oregon’s Prescription Drug Monitoring Program (2012) found that the top 8.1% of providers wrote 79% of all Schedule II-IV prescriptions.
When prescribing practices become extreme, the physician or clinic can become known as a pill mill. Pill mills represent a significant roadblock in the way of curbing prescription drug abuse. A pill mill is, according to Cichon (2013): “a doctor’s office, clinic, or healthcare facility that routinely conspires in the prescribing and/or dispensing of controlled substances outside the scope of the prevailing standards of medical practice.” These operations are lucrative for the less scrupulous of doctors; those willing to leverage their medical licensure to sell prescriptions.
On the other side of the issue is doctor shopping. The more frequent prescription drug abusers are willing to go to great ends in order to get their hands on the next prescription, despite nearly every state having its own form of anti-doctor shopping laws (CDC, 2012). Doctor shopping is not always a reference to searching with malign intentions, but searching for clinicians willing to write prescriptions for pain relievers is an increasingly common practice as abuse rates rise (McDonald & Carlson, 2013). In a study based upon 2008 data, McDonald and Carlson (2013) found that roughly 3% of opioid purchasers obtained their prescriptions from between 5 and 9 prescribers, 0.35% obtained them from 10 to 19 prescribers, and 0.04% obtained them from more than 19. In cases such as these, the extent of the issue is made clear. Any prescription seeker capable of getting painkillers from more than 19 doctors poses a real threat to both themselves and anyone to whom they may peddle the drugs.Continued on Next Page »