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The Man-Made Opioid Epidemic: Part 2 – Prescription Drug Monitoring Programs.

Posted on | November 19, 2015 | 2 Comments

pdmpgraphic-600wCDC

Mike Magee

In part 1 of this 5-part series, the focus was on responsibility, which is multiple and shared by pharmaceutical companies, physicians and their representative organizations, state legislators and state medical boards coerced to ease regulatory oversight, and criminal profiteers. The scope of the problem was also writ large: a 5-fold increase in opioid related overdose death rates since 1980; 2.1 million opioid addicts, and an additional 2.5 million pain patients “who may be suffering from an opioid use disorder”.

In a landmark effort by Johns Hopkins to assess the problem, it was clear at the outset that:

1. An overwhelming majority of the prescription drugs abuse in this opioid epidemic originate from legitimate physician prescriptions.

2. Prescription opioids are frequently diverted to others illegally.

3. 70% of those abusing prescription opioids accessed their most recent supply through a friend or family member.

Can we track the early movement of this “abuse trail”, from health prescriber to prescription to patient to acquaintance? If so, where do we start? Well, the good news is we are not starting from scratch. According to the Hopkins study, there are 51 Prescription Drug Monitoring Programs (PDMPs) in the US and territories. Almost every state (except Missouri) has one. State controlled and regulated, almost all collect precription data from state pharmacies and most also capture prescriptions drugs imported into the state through mail order outlets.

Health professional prescribers and pharmacists can access these state databases to check on a potential abusers activity (at least in that one state). Drug name, dose, quantity, and date. It’s all there in black and white. But studies show that about half of physicians have never accessed their state PDMP and over a quarter don’t even know it exists. Pharmacists are much more likely to access PDMPs. For example, a study of Indiana pharmacists found that 94% were aware of the program, and 71% had accessed it. What prevents prescribers and pharmacists from accessing PDMPs? Studies reveal a range of deterrents including time required, legal ramifications, and absence of reimbursement for the activity.

The value of PDMP’s is well-established, were they to be utilized properly. Here is a list of deliverables:

1. Reveals multiple doctor and pharmacy shopping.

2. Reveals prescription forgery.

3. Reveals risk of addiction or overdose.

4. Can quantify potential risk of overdose (7X normal for doctor shoppers; 13X normal for pharmacy shoppers; 9X normal for those with daily use 100mg morphine equivalents).

Faced with this well publicized crisis, and a potential (at least partial) solution, states have begun to catch up. A few examples from the recent Johns Hopkins study:

1. 36 states now allow precribers “delegates” to access PDMP information for them.

2. 16 states have grants to integrate PDMP databases with their ACA health information exchanges and EHR record system.

3. PDMP “Push Reporting” is beginning. Database managers push reports of potential abusers to prescribers, unsolicited, for their review. Early reports show prescriber acceptance and utilization of this technique.

4. Move toward real-time data collection. 22 states now require daily downloads. 27 others require weekly downloads.

5. 11 states have comprehensive mandates that PDMPs be accessed when opioids are prescribed. 16 other states mandate access under certain circumstances.

6. 28 states are experimenting with sharing of interstate PDMP data.

The Hopkins study reviews in detail the benefits that accrued to Kentucky, the first state to mandate prescribers comprehensive access of their PDMP. Their clinicians are required to check the PDMP before a patient’s first opioid prescription, and every three months after for continued refill. What happened?

1. Opioid prescriptions dropped 8.6% in the first year.

2. Opioid overdose hospitalizations decreased 26%.

3. Opioid related ER visits dropped 15%.

4. Prescription opioid deaths dropped 25%.

In Part 3 of this five part series, the role of pharmacists and Pharmacy Benefit Management organizations will be explored.

Comments

2 Responses to “The Man-Made Opioid Epidemic: Part 2 – Prescription Drug Monitoring Programs.”

  1. Kathleen Meade MD
    November 20th, 2015 @ 3:29 pm

    As a physician who sees first-hand the destructive nature of young people addicted, I am over and over amazed that nearly nowhere is the “H” word mentioned (heroin).
    Why is this?
    Heroin overdoses, heroin causing the deaths of our children, the all-to-easy access of heroin by young people everywhere(!) – these problems are not worth a mention?
    Why is this?
    Is it too big to tackle?
    Is it easier to tackle prescription opioid “over-prescribing?”
    Easier to concentrate ALL resources, ALL media, ALL finger-pointing at the “over-prescribing” “epidemic?”
    The wolf at the door is Heroin; it’s out there, and society is afraid to address this “H-word” epidemic.
    It is sad.
    Young people addicted to heroin are pariahs; people addicted to prescription opioids are victims of the “over-prescribing” problem.
    It is more than sad; it’s reprehensible.

  2. Mike Magee
    November 20th, 2015 @ 7:15 pm

    The connection between massive over-prescribing of prescription opioids (like oxycontin) and subsequent conversion to lower priced heroin has been well documented in peer review publications and by the press (http://www.theatlantic.com/health/archive/2014/10/the-new-heroin-epidemic/382020/). To draw a distinction between the two at this point, other than the fact that the former originates with a physician prescription, simply distracts from the reality. The surge in narcotic overdose deaths originated with the liberalization of opioid prescribing by physicians which began in earnest in 1997.

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