The following originally appeared on The Upshot (copyright 2017, The New York Times Company).
The opioid crisis is so complex and so large — drug-related deaths now exceed those caused by cars, H.I.V. or guns — that there is no single solution. Among the partial ones: prescription drug monitoring programs, an approach highlighted in the draft report from President Trump’s Commission on Combating Drug Addiction and the Opioid Crisis.
The epidemic has led every state but Missouri to establish one of these programs, which allow doctors and regulators to track how many opioid medications and other controlled substances have been dispensed to patients. A new analysis shows that prescription drug monitoring programs can reduce the overuse of narcotics — but that many states have adopted relatively weak versions.
Opioid medications, like Vicodin, Percocet or OxyContin, can be useful in treating pain. But when patients receive many prescriptions — whether from multiple doctors at the same time or from the same one for a long period of time — it can signal a problem. Patients with more pills than they need could endanger themselves or divert them to the black market. Longer-term use increases the risk of addiction and other bad outcomes.
Data from the Centers for Disease Control and Prevention show that opioid overdoses and prescriptions grew in parallel between 1999 and 2010. Though prescriptions have fallen more recently, they have been written for longer durations. Black-market opioids — heroin and, in particular, fentanyl — also contribute to overdose deaths. But many who use these drugs also use prescription opioids and may have become dependent on them first.
That’s where prescription drug monitoring programs come in. They collect data from pharmacies to track what prescriptions for controlled substances patients have filled. The databases can be used to assess whether patients are getting more opioids than they can safely use. In addition, they can be used to tell if patients are getting other drugs, like a benzodiazepine, that are dangerous to use in combination with an opioid.
According to research summarized by the Leonard Davis Institute of Health Economics at the University of Pennsylvania, prescription drug monitoring programs can help reduce the amount or strength of opioids prescribed and dispensed. When physicians or dentists check the database and see a worrisome pattern of dispensed opioids, they can deny or change a prescription, screen for an opioid or other substance use disorder, and even counsel the patient to seek other forms of pain management or addiction treatment, if warranted.
Dr. Zachary Meisel, an author of the Leonard Davis review, uses a drug database when he practices in the Hospital of the University of Pennsylvania emergency department. In related work, he found that the databases often prompt conversations about opioids between provider and patient. In other cases, he said, prescription drug monitoring programs “help dispel a suspicion that a patient is seeking additional opioids.”
Monitoring programs are mitigating the opioid epidemic. One study, published in Health Affairs, found they’re associated with a decline in the chance a patient with pain will receive a Schedule II opioid prescription, to 3.7 percent from 5.5 percent. The study was based on a sample of 26,275 doctor’s office visits in the 24 states that started drug monitoring operations during 2001-2010. The results of another study— of Medicare beneficiaries over 2007-12 in 10 states — suggest that such programs are associated with reductions in the strength of opioid medications dispensed and the duration of opioid prescriptions. Deaths related to oxycodone use fell 25 percent in 2012, after Florida created a monitoring program.
But other work shows that having access to a prescription drug monitoring program is not enough. States can make the programs much more effective by mandating prescribers to engage with it. Twenty-five states require prescribers — physicians and dentists — to register with their state database. This forces prescribers to push through the first barrier to use — just signing up — and seems to make a difference.
One study, published this year in Health Affairs, found that states that required prescriber registration saw a 10-percentage-point reduction in use of Schedule II opioids among Medicaid enrollees, relative to states that did not require registration.
Most, but not all, states with mandatory registration also require prescribers to consult their state databases before prescribing an opioid. A study published in Health Services Research this year found that states requiring this experienced a reduction in the duration of opioid prescriptions in the Medicare population. Another study, also of the Medicare population, found that mandatory use was associated with fewer patients getting opioids from multiple doctors — so-called doctor shopping — and with patients holding a smaller supply of the drugs.
Studies expanding beyond the Medicare population to include younger Americans find that use mandatesreduce admissions to treatment facilities for opioid use disorder. A New York study of prescriptions by dentists in an urgent care center found that when its mandatory program went into effect, opioid pills prescribed went down 78 percent.
When states roll out monitoring programs, opioid-related overdose deaths fall, according to one study. And they decline more in states that mandate their use. Though some studies have not found that such programs reduce opioid use or opioid-related mortality, it could be because they do not distinguish between programs with such mandates and those without.
Nevertheless, prescription drug monitoring programs have limitations. They can track only dispensed drugs, not black-market drugs (like heroin and fentanyl). And though they can be used to tell how many and what kinds of opioids are dispensed, they can’t tell who takes them or if they’re diverted to the black market. The programs could also be more effective if more prescribers used them. One study found that only about half of primary care physicians use the database. Among those who use them, many do not do so routinely.
The data monitoring programs could be more useful if integrated with other health data and shared across states, as recommended by the opioid commission. Doing so could make it easier to combine prescription data with other data that could indicate problems — like a history of mental health or substance use disorders. These data, together, can help predict who is most likely to suffer adverse outcomes from prescribed opioids. This is an approach being adopted by the Department of Veterans Affairs, with an evaluation underway. [Disclosure: I am involved in that evaluation.]
Prescription drug monitoring programs are not the only tool to combat the opioid crisis. Other state laws that tighten regulations of pain clinics and combat doctor shopping can help, too, reducing overdose deaths and admissions to treatment facilities. Wider distribution of naloxone, which can reverse an opioid overdose, and public education on its delivery can also help, as can greater access to safe means of disposing of unused pills.
Prescription drug monitoring programs have shown promise, but so long as relatively inexpensive heroin and fentanyl are available on the street, they will never be a full solution on their own.