Over the past two decades, prescription drug abuse has been on the rise. The public health dangers associated with this disturbing trend are self-evident. In an ongoing effort to curb this abuse, most states have over the years adopted some form of electronic prescription drug monitoring programs, or PDMPs. While the goal is laudable, some have questioned the efficacy of these programs. A group of researchers associated with Columbia University (Guohua Li, MD, DrPH, James Giglio, MD, Barbara Lang, MPH, Charles DiMaggio, PhD, Hannah Wunsch, MD, MSc and Joanne Brady, SM) recently looked at whether these PDMPs have had a positive effect on curbing inappropriate opioid dispensing. Their conclusion—one likely to disappoint many—is that PDMPs during the study period (up to 2008) didn’t have much overall impact at all. The full study, Prescription Drug Monitoring and Dispensing of Prescription Opioids, is published in the March-April 2014 edition of Public Health Reports.
The researchers note that since the early 1990s, the number of prescriptions for such drugs as methadone, oxycodone and hydrocodone has almost tripled. While this is of concern, much more alarming is the reported statistic than in 2010, approximately 12 million Americans, some as young as 12 years old, reported non-medical use of opioids. Equally disturbing is the reported statistic that unintended drug overdoses nearly tripled in the decade between 1999 and 2009. Most of these overdoses were attributed to prescription drugs—more reportedly than from heroin and cocaine combined.
In light of these statistics, it is important to look at whether efforts put in place to curb such abuse are actually working and, if not, why not. PDMPs have been in place at some level for some time; their progress across the 50 states has, however, been uneven. Studies undertaken to assess whether such PDMPs are effective have reached varying results. Determining that there was a need for a more comprehensive study, the Columbia University researchers set out to look at the following: (1) whether PDMPs were effective at the national level; (2) whether they were effective at the individual state level; and (3) whether certain characteristics of PDMPs could be associated with greater success.
Using government databases set up to monitor the sale and dispensing of prescription drugs, the study looked at data available for the 1999-2008 time period on seven commonly dispensed opioids—fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine and oxycodone. To assure uniformity of analysis, these were each converted to “morphine mg equivalents” (MMEs) based on their potency. State population data was collected from reliable sources including the U.S. Census Bureau and data on PDMP characteristics was collected from the Kentucky All Schedule Prescription Electronic Reporting (KASPER) Program Evaluation Team. The study focused on three characteristics of each state PDMP: (1) the type of governing agency; (2) whether the PDMP was required by state law to operate under some form of committee oversight; and (3) whether the state had any regulations in place governing the use by practitioners of the prescription drug database. Data was compared between states with PDMPs and those without (during the study time period of 1999-2008, the following states were reportedly without operational PDMPs: Alaska, Arkansas, DC, Delaware, Florida, Georgia, Iowa, Kansas, Maryland, Minnesota, Missouri, Montana, Nebraska, New Hampshire, New Jersey, Oregon, South Dakota, Vermont, Washington and Wisconsin.)
Between 1999-2007, the annual MMEs dispensed per capita increased; this began to level off in 2008, the last year studied. Overall, the study found that through 2008, the existence of state PDMPs had no noteworthy impact on the amount of MMEs dispensed. In fact, on the national level, only a 3% reduction in MMEs dispensed per capita could be associated with their implementation. If one were to stop right there, these results would be discouraging. However, the study drilled down further and, in doing so, came up with data that could provide a roadmap for going forward.
As a starting point, the study found a significant variation in PDMP efficacy on a state-by-state basis—from a 66% decrease in MMEs dispensed per capita in Colorado to a 61% increase in Connecticut. So what was going on? What was Colorado doing that Connecticut (and all other states in between) arguably was not? Although there were some regional differences (for example less MMEs were reportedly dispensed per capita in the Midwest than the Northeast) there was one characteristic shared by PDMPs most associated with a reduction in MMEs dispensed—they were each governed by a state health department (as opposed to a state board of pharmacy or other such agency). The other characteristics studied (whether there was committee oversight or requirements that practitioners used the electronic databases) seemed to be not as influential.
The study proffered several factors (albeit ones which were not part of the research) as to why the PDMPs seem to have had limited impact on the national level. These included the following:
> The lack of information sharing between the states. Individuals can fly beneath the radar by purchasing opioids from neighboring states. With more states sharing information on drug dispensing (the study points to the example of Kentucky and Ohio’s program) it should become easier to pinpoint this activity.
> The lack of “real-time” information. The study found that in some cases it could take up to a month for information on drug dispensing to make it into the database. The quicker this data is made electronically available, the more likely it is that anomalies could be spotted.
> The lack of system efficiency. This included such deficiencies as technology-based issues, failure to communicate awareness of the program and restrictions on who could access it.
The study acknowledged several limitations to bear in mind when considering its results. These included the fact it used data from 1999-2008; PDMP implementation has expanded since then and numerous reforms have been put in place, factors which may impact whether the study’s conclusions still hold true for 2014. Additionally, the study looked only at the impact of PDMPs on opioid dispensing. It did not look at other drug misuse occurrences such “doctor shopping” or a change in prescribing practices. Given the scale of prescription drug abuse, the study notes that a comprehensive and multi-faceted effort to combat these and other problems will most likely be necessary.
Efforts are being made at many levels to combat the rise in prescription drug abuse. It is important to periodically assess, as this study does, which of these efforts are actually producing results. While it could be considered discouraging that PDMPs did not (at least through 2008) budge the needle much in terms of reducing MME dispensing on a per-capita level nationally, the study does point out some important factors that can be assessed and implemented in PDMPs going forward.
“PDMP is a collection of tools that states could adopt to reduce the number of inappropriate opioid prescriptions and diversions, as well as the number of overdoses,” says Stuart D. Colburn, Esq., Shareholder at Downs Stanford, P.C., Austin, Texas. “To date, no state has adopted the full set of tools to make PDMP work as intended, and until multiple states do so for a number of years, no study such as this one described above can accurately predict if the tools will reduce the number of inappropriate prescriptions of drugs.”
Colburn strongly believes that the tools do work. He points to Washington and Texas, both of which have adopted drug formularies that have restricted the amount of opiates/opioids with great success. Then there’s Florida, which he says is no longer known as the nation's "pill mill capital", now that it has made modest changes to their physician dispensing of opioids.
Colburn advises that the PDMP tools necessary to make real changes in the battle against opioid abuse and addiction include:
> Real time reporting by dispensers;
> Mandatory use before prescribing opioids;
> Information sharing with neighboring states; and
> Proactive use of the state PDMP to communicate with prescribing doctors based on trends.
Colburn warns that as more tools are utilized, outliers will seek to “game the system.” PDMP changes in response to these new tactics can only be expected. According to Colburn, “more effective use of all available tools will reduce—but not eliminate—the inappropriate use/misuse of opioids.”
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