How Bad is the Opioid Epidemic? - PBS

Twelve states have more opioid prescriptions than people

Not every state has seen an equal rise in opioid use. In Hawaii, doctors wrote 52 opioid prescriptions for every 100 people in 2012, the least of any state according to a 2014 CDC study. In Alabama, it was almost 143 prescriptions per 100 people, more than anywhere else.

In all, 12 states had more opioid prescriptions than people 2012:

Alabama: 142.9 per 100 people
Tennessee: 142.8
West Virginia: 137.6
Kentucky: 128.4
Oklahoma: 127.8
Mississippi: 120.3
Louisiana: 118
Arkansas: 115.8
Indiana: 109.1
Michigan: 107
South Carolina: 101.8
Ohio: 100.1

The CDC study found no obvious geographic pattern to high levels of opioid prescriptions. If anything, researchers suspect that the variation shows a lack of consensus among doctors about how much pain medication to prescribe. Further, research shows that higher rates of prescription drug use don’t necessarily lead to better health outcomes or patient satisfaction.

“In fact, “the report says, “high rates of use might produce worse outcomes.”

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PDMPs have many limitations in their current format, including complex access issues, timeliness, and whether the data are presented to the physician automatically or require physician effort to retrieve.

ACEP - Annals of Emergency Medicine – 525

Doctors (and other clinicians) need to know what prescriptions have been given to their patients by other practitioners. This information should be included in the patients’ electronic health care records accessible through a Prescription Drug Monitoring Program (PDMP) that provides immediate information.

Presentation by the Dir., Div. of Epidemiology NIH, National Institute on Drug Abuse, May 2013

Although relieving pain and reducing suffering are primary emergency physician responsibilities, there is a concurrent duty to limit the personal and societal harm that can result from prescription drug misuse and abuse.

Pain Management / Clinical PolicyACEP Annals of Emergency Medicine 525, October 2012

In 2012, both New York and Tennessee required prescribers to check their state’s PDMP before prescribing painkillers.

The results one year later:
New York realized a 75% drop and Tennessee a 36% drop in patients who were seeing multiple prescribers to obtain the same drugs.

PDMP [National] Center of Excellence at Brandeis U, 2014

Effective monitoring systems [PDMPs] will augment clinical judgment, provide evidence of misuse, and facilitate prescription of the most appropriate analgesic for the situation…The Emergency Department is regarded as the nation’s safety net…the last bastion of around-the-clock access to care … Unfortunately, some of the solutions to opioid misuse [limiting ED physicians to 3-day opioid prescriptions] preempts judgments from trained emergency medical providers.

American College of Physicians, Annals of Internal Medicine, 9 April 2013

Use of a state PDMP may help identify patients who are at high risk for diversion or doctor shopping… To quantify the effects of PDMPs, studies were conducted of ED providers who cared for adult patients with pain. Of the patients with complete data in one study, information from the state’s PDMP System altered prescribing practice in 41%.

ACEP - Annals of Emergency Medicine - 525

What prescribers can do to safely and effectively use opioids for CNCP (includes the following)

Screen for prior or current substance abuse/misuse

Do not use concomitant sedative–hypnotics or benzodiazepines

Track daily MED using an online dosing calculator

Use the state Prescription Drug Monitoring Program to monitor all sources of controlled substances

Neurology, 2014; 83; 1277-1284, September 2014

Always check the medical record… and a prescription drug monitoring database.

Federation of State Medical Boards

A study was conducted to estimate the societal costs of prescription opioid abuse, dependence, and misuse in the United States. Costs were grouped into three categories: health care, workplace, and criminal justice.

The results: Total US societal costs of prescription opioid abuse were estimated at $55.7 billion in 2007 (USD in 2009). Workplace costs accounted for $25.6 billion, health care costs accounted for $25.0 billion, and criminal justice costs accounted for $5.1 billion. Workplace costs were driven by lost earnings from premature death ($11.2 billion) and reduced compensation/lost employment ($7.9 billion).

Conclusions: The costs of prescription opioid abuse represent a substantial and growing economic burden for the society. The increasing prevalence of abuse suggests an even greater societal burden in the future.

Pain Medicine, Volume 12, Issue 4, April 2011

You’re not only reducing the supply [of pain medications] for those who use them inappropriately, but also for those in need.

Bob Tillman – Director of Policy and AdvocacyAmerican Academy of Pain Management

Although relieving pain and reducing suffering are primary emergency physician responsibilities, there is a concurrent duty to limit the personal and societal harm that can result from prescription drug misuse and abuse.

Pain Management / Clinical PolicyACEP Annals of Emergency Medicine 525, October 2012

Doctors (and other clinicians) need to know what prescriptions have been given to their patients by other practitioners. This information should be included in the patients’ electronic health care records accessible through a Prescription Drug Monitoring Program (PDMP) that provides immediate information.

Presentation by the Dir., Div. of Epidemiology NIH, National Institute on Drug Abuse, May 2013

In 2012, both New York and Tennessee required prescribers to check their state’s PDMP before prescribing painkillers.

The results one year later:
New York realized a 75% drop and Tennessee a 36% drop in patients who were seeing multiple prescribers to obtain the same drugs.

PDMP [National] Center of Excellence at Brandeis U, 2014

Thirteen multi-state PDMP projects were sponsored in 2012-13. While providers indicated that PDMPs gave them more confidence for prescribing pain medication, the study concluded that the easier the data is to obtain, the more they will be used, and the safer the practice can be.

Substance Abuse & Mental Health Services AdministrationOffice of the National Coordinator for Health IT, & MITRE Corp

Always check the medical record… and a prescription drug monitoring database.

Federation of State Medical Boards

When a clinician is prescribing a controlled substance, readily available information about the drugs that a patient is receiving from other providers can be a critically important component of the decision-making process…Increasingly, these [PDMP] programs have evolved into a useful tool for the clinician who must incorporate careful risk management into the prescribing of opioid analgesics or any other controlled substance.

Increasingly, these programs have evolved into a useful tool for the clinician who must incorporate careful risk management into the prescribing of opioid analgesics or any other controlled substance Prescription Drug Monitoring Programs Serve a Vital Clinical Need.

Editorial Pain Medicine, The American Academy of Pain Medicine; 2011;12:845

Use of a state PDMP may help identify patients who are at high risk for diversion or doctor shopping… To quantify the effects of PDMPs, studies were conducted of ED providers who cared for adult patients with pain. Of the patients with complete data in one study, information from the state’s PDMP System altered prescribing practice in 41%.

ACEP - Annals of Emergency Medicine - 525

A study was conducted to estimate the societal costs of prescription opioid abuse, dependence, and misuse in the United States. Costs were grouped into three categories: health care, workplace, and criminal justice.

The results: Total US societal costs of prescription opioid abuse were estimated at $55.7 billion in 2007 (USD in 2009). Workplace costs accounted for $25.6 billion, health care costs accounted for $25.0 billion, and criminal justice costs accounted for $5.1 billion. Workplace costs were driven by lost earnings from premature death ($11.2 billion) and reduced compensation/lost employment ($7.9 billion).

Conclusions: The costs of prescription opioid abuse represent a substantial and growing economic burden for the society. The increasing prevalence of abuse suggests an even greater societal burden in the future.

Pain Medicine, Volume 12, Issue 4, April 2011

Attention to patterns of prescription requests and the prescribing of opioids as part of an ongoing relationship between a patient and a healthcare provider can decrease the risk of diversion. Periodic review of state PDMP, where available, is also a useful tool to monitor compliance. Evaluation should initially include…a drug history… Documentation is essential.

February 2013 American Academy of Pain Medicine

Prescription drug monitoring programs (PDMPs) are now active in most states to assist clinicians in identifying potential controlled drug misuse, diversion, or excessive prescribing. Little is still known about the ways in which they are incorporated into workflow and clinical decision making, what barriers continue to exist, and how clinicians are sharing PDMP results with their patients.

Design
Qualitative data were collected through online focus groups and telephone interviews.

Setting
Clinicians from pain management, emergency and family medicine, psychiatry/behavioral health, rehabilitation medicine, internal medicine and dentistry participated.

Patients
Thirty-five clinicians from nine states participated.

Methods
We conducted two online focus groups and seven telephone interviews. A multidisciplinary team then used a grounded theory approach coupled with an immersion–crystallization strategy for identifying key themes in the resulting transcripts.

Results
Some participants, mainly from pain clinics, reported checking the PDMP with every patient, every time. Others checked only for new patients, for new opioid prescriptions, or for patients for whom they suspected abuse. Participants described varied approaches to sharing PDMP information with patients, including openly discussing potential addiction or safety concerns, avoiding discussion altogether, and approaching discussion confrontationally. Participants described patient anger or denial as a common response and noted the role of patient satisfaction surveys as an influence on prescribing.

Conclusion
Routines for accessing PDMP data and how clinicians respond to it vary widely. As PDMP use becomes more widespread, it will be important to understand what approaches are most effective for identifying and addressing unsafe medication use.

Pain Medicine, Volume 15, Issue 7, July 2014

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David Stengle

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David is Prescription Advisory's Chief Marketing Officer. Software startups are his passion.

He also serves as the Director of Startup Grind Princeton and a mentor for the Princeton University eLab.

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PastRx Partners with athenahealth’s ‘More Disruption Please’ Program to Fight Substance Use Disorder Epidemic - August 22, 2017
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How often do you check your PDMP? - June 20, 2017

How Bad is the Opioid Epidemic? – PBS

Twelve states have more opioid prescriptions than people

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David Stengle

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