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Medical Practice

Rise in Prescription Drug Overdose Deaths Is Slowing. Do Monitoring Programs Deserve Credit?

chart showing death rates from drug poisoning
CDC
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16,235 Americans died in 2013 from overdosing on prescription opioids like vicodin and oxycodone. The good news is, this was only a one-percent increase in deaths from 2012. After a precipitous rise last decade from 4,400 in 2000 to 16,917 in 2011, prescription opioid overdose deaths are showing signs of leveling off. Researchers are not sure what’s causing the change, but some credit may go to prescription drug monitoring programs,  state-run systems that track prescriptions of opioids and stimulants. These programs seek to flag patients who are filling prescriptions excessively and abusing or dealing the pills.

Between 2003 and 2012, 33 states enacted prescription drug monitoring programs, and now all but one state have some type of program in place. Rebecca Haffajee, a fellow in pharmaceutical policy research at Harvard, wrote a recent article in the Journal of the American Medical Association evaluating the effectiveness of these programs. The results she found were mixed. Sound Medicine spoke with Haffajee about her findings.

Sound Medicine: In what ways can prescription drug monitoring programs be useful for doctors?

Rebecca Haffajee: From the prescriber perspective these programs serve a number of uses. Prescribers can log into the system and search patients' names, and find a patient's prescription history, including the dose, prescriber, and the number of prescriptions that have been filled. These drugs are typically opioids, stimulants, and sometimes benzodiazepine; drugs that are scheduled, and are flagged as potentially harmful if abused.

SM:What would be a common pattern of someone who's trying to get more opioids? What type of behavior are these systems catching?

Rebecca Haffajee: They're catching two forms of misuse. One would be abuse:  [A patient] filling with too many prescribers and too many pharmacies in a short time period. Different thresholds have been proposed. One that I've seen a lot is more than five prescribers, and more than five pharmacies within a three month period. That would be a flag that a patient is probably getting too many drugs.

Another thing that these programs can help flag are "diverters," -- people who are maybe reaching these thresholds, but aren't using [the drugs] for their own use, but are actually diverting them to other users - probably selling them on the street.

SM: Are these programs national, or are they run at the state level?

RH: There have been a number of proposals to have a national program over the years, but they've never been adopted. Forty-nine states have operational prescription drug monitoring programs. Missouri is the only state without one.

Twenty-two states have mandates that require prescribers to use the program. But these vary. Some of the mandates are based on objective criteria. So they require record-keeping every time a prescriber prescribes one of these scheduled drugs for the first time to a patient, or if it's kind of a chronic treatment pattern and they've been prescribing it for three months or six months they have to keep checking. And usually there are exceptions for hospice care or cancer. for example.  

But others have what's called subjective requirements. They defer to the prescriber's judgement. The laws will say something like "if the prescriber suspects abuse." It sort of makes the program essentially voluntary again.

SM:  Are there penalties for providers who don't use the system like they should?

RH: The most typical penalty is disciplinary sanctions by licensing boards. New York has the most stringent penalty requirements that I've seen, which is a fine of $2,000, or one year of jail, or revocations of a license.

Representatives of the New York prescription monitoring program have said that they would never actually impose those penalties. But never the less, they are on the books.

SM: You mentioned in your article that not all healthcare providers like using these systems. What are some of their complaints?

RH: I hear a lot that prescribers have trouble getting logins; the system can be down altogether. Even if they can get information, often the data are incomplete and not updated frequently enough to be useful to providers; they're only updated every month or something like that.  Prescribers often complain that data are not integrated into their clinical workflow, so they have to log in to a separate system. They would much prefer that the system fed into their electronic medical records system, for example. And then they say there's little guidance on how they are to interpret or use the results once they see them. So they see that a patient has filled relatively recently, yet they don't really know: ‘is this enough to raise the flag of abuse, or is it sort of borderline, so I should feel ok about prescribing?’

And then they say this is uncompensated time, that they have to log in to a separate system, that it takes time away from treating the patient.

Some of the complaints are tied to mandates that they use the system. One could be that they compromise adequate pain management. So if I'm a doctor and I say "This is just a hassle, I'm required to check the system, I would rather just not prescribe at all, or I'll refer my patient to other doctors if they want these substances." And that could just result in the patient not being able to get the pain medication that they actually need.

SM: Do we know if prescription drug monitoring programs have actually done anything to help reduce the epidemic of opioid abuse and overdoses?

RH: Recent reports have suggested that overdose deaths, opioid prescriptions and rates of abuse have been flattening or reducing from 2011 to 2013. And that was after a precipitous incline from 2002 to 2010. So, something seems to be working, but we don't know exactly what it is.

There are a number of studies on prescription drug monitoring programs, and the evidence is mixed. There is no evidence they reduce overdoses. But there's mixed evidence that they might reduce prescribing of opioids, overall, reduce, drug diversion [street sales], and reduce doctor shopping. There a number of problems with these studies. They'll often just say "Does this state have a prescription drug monitoring program or not?" instead of trying to gauge the actual strength or effectiveness of the program.

So we don't know if that's the policy lever that's actually doing some of the work. It's very hard to disentangle these components and know whether the programs themselves, or just some features of them are actually contributing to the flattening of this epidemic.