UPDATE (7/22/2016): Some other research makes me wonder if I spoke too soon. More here.
A few days ago, Senators Klobuchar, Manchin, and King proposed a bill to make federal funding to states for combating the opioid epidemic contingent on their adoption of mandatory prescription drug monitoring programs.
States with mandatory programs—at this point, that’s about half of them—have created databases to compile the opioid prescriptions that physicians write for their patients. Although details of the programs vary from state to state, mandatory programs generally require doctors to consult the database before writing new opioid prescriptions. If a doctor sees that a particular patient has already been prescribed opioids, she may decline to prescribe them again. Licensing boards can also use the prescribing data in disciplinary proceedings, giving physicians an incentive to be cautious in their prescribing.
The new congressional bill is supposed to “encourage states and local communities to pursue a full array of proven strategies in the fight against addiction.” But are these programs “proven strategies”?
Maybe not. Drawing on an enormous database of Medicare claims from disabled beneficiaries, an impressive new study from the New England Journal of Medicine exploits the fact that prescription drug monitoring programs, as well as other anti-opioid laws, have been adopted gradually across the states. Unfortunately, none of the laws appear to make much of a difference.
Laws that restrict the prescribing and dispensing of controlled substances showed few meaningful associations with the receipt of prescription opioids by disabled Medicare beneficiaries in our sample. States that adopted multiple laws between 2006 and 2012 (≥3 types) had lower growth in long-term receipt of opioids and multiple opioid prescribers than states that adopted no laws. However, these associations were not significant after adjustment for the large number of hypotheses examined in this study. In addition, legislative restrictions showed no measurable association with the percentage of beneficiaries filling prescriptions that yield high daily opioid doses or the percentage treated for nonfatal prescription-opioid overdose.
As the authors acknowledge, the study isn’t sufficiently powered to say that legal interventions have made no difference at all. But the study can “definitively rule out large changes in opioid measures associated with these laws.” In other words, it pays to be skeptical of prescription drug monitoring programs.
Or does it? A separate study in Health Affairs is more bullish, finding that a “recent wave of implementations of prescription drug monitoring programs was associated with a sizable reduction in the prescribing of Schedule II opioids—the subset of prescription opioids deemed to be at the highest risk of misuse and abuse.”
I’m not sure I’d characterize the effect as “sizable.” When monitoring programs were in place, Schedule II opioids were prescribed during office visits 3.7% of the time, as opposed to 5.5% of the time. That’s better than nothing, but still. In any event, I’m not inclined to put too much weight on the Health Affairs study since it rests on self-reported survey data. Those aren’t nearly as reliable as the claims data that the NEJM study used.
The best evidence we have to date, then, suggests that prescription drug monitoring programs won’t do much to slow the opioid epidemic. That’s not to say we shouldn’t adopt them anyhow: they may make a difference on the margins and they may be helpful for other reasons. But let’s not kid ourselves that we’re anywhere close to solving the problem. It’s going to take a hell of a lot more.
It’s worth noting, too, that the NEJM study would have been impossible without access to granular data pertaining to substance use disorders—data that, in recent years, Medicare has begun withholding on privacy grounds. The study is thus Exhibit A of the kind of critical research that the data suppression would inhibit.
The Substance Abuse and Mental Health Services Administration has recently proposed a rule to undo the data suppression. That rule should be finalized—and soon—if we want to evaluate the effectiveness of future efforts to combat the opioid epidemic. Right now, what we’re doing isn’t working.