On January 13, 2015, in an unparalleled broadcast effort, Arizona’s 33 TV stations and over 93 radio stations across the state simulcast an Arizona State University produced documentary on the steadily increasing rates of opioid and heroin use. The investigative report followed the journey of several young adults as they struggled with addiction to heroin and other prescription opioids.
Many of the roads to addiction depicted in the documentary began innocently, with a doctor’s prescription or a family medicine cabinet. One subject, a 21-year-old man described his devastating path to heroin, when after a football injury in high school he was prescribed Percocet, which he continued to obtain after his prescriptions ran out through illegal avenues. When the student’s money ran short, his dealer recommended a cheaper option, heroin. Unfortunately, this sequence seems to be a common path to heroin abuse. In fact, studies have found that three out of four new heroin users previously abused prescription opioids.
During the 2000s, prescription opioid sales increased four-fold, in parallel with increasing overdose rates, which account for over 35 percent of all drug overdoses in the U.S. In 2012, 259 million prescriptions for painkillers were written, enough for every adult to have their own bottle of pills. These pharmaceuticals are regulated in many ways, so why can’t we curb the high rates of misuse?
Prescription Drug Monitoring Programs (PDMPs) are state run databases used to prevent and uncover prescription drug abuse. Ideally, PDMPs allow prescribers to identify patterns of “doctor shopping,” and can also assist licensing boards and law enforcement in recognizing inappropriate prescribing and dispensing of controlled substances. Currently 49 states and the District of Columbia operate PDMPs. Despite the widespread adoption of these monitoring systems, prescribers use them quite rarely. A 2009-2012 study found that the median registration rate for prescribers across the country was 35 percent. The rate at which prescribers actually use the database to check on specific patients before prescribing controlled substances is much lower.
Much of the problem is in the statutes and regulations governing these databases. Only 26 states require or recommend prescribers access the state’s PDMP database, with the majority only recommending it be accessed. For example, Arizona recommends prescribers in the state access the database prior to prescribing certain controlled substances. However, only 30 percent of prescribers are even signed up to use it, making it largely ineffective. Fortunately, evidence shows that initiatives can effectively increase the number of prescribers who sign up for the database and more importantly, the number who actually use it.
Beginning in 2012, Arizona instituted a Prescription Drug Reduction Initiative, which incorporates a multi-agency approach to prescription drug abuse. The initiative focuses on education regarding the PDMP, increasing sign up, monitoring prescribing practices, as well as other initiatives focused on decreasing access, like drop boxes for unused prescription opioids. Measures in the Prescription Drug Reduction Initiative include sending report cards to physicians on their prescriptions compared to other physicians in the area and in like practices. As a result, pilot counties have seen PDMP sign up increase by over 50 percent, the number of prescribers actually using the system increase by 30 percent, and the number of controlled substances prescribed in these counties from 2012-2013 decrease by over six percent.
As shown in certain Arizona counties, when PDMPs are promoted and used by prescribers, they can effectively decrease the number of dispensed controlled substances, particularly opioids. So why aren’t these incredibly useful tools utilized to their full potential?
The majority of states do not require prescribers to sign up or access the PDMP database, greatly limiting their utilization. Physicians are understandably concerned about treating real pain, being identified as an over prescriber, privacy issues, and demands on their time. Physicians groups and a number of patients went so far as to challenge this type of data collection, alleging that it violated their privacy rights, in Whalen v. Roe. The Supreme Court upheld the collection and use of prescriber data, noting its laudable public health objective, so long as adequate security measures are in place to protect the data collected.
Given physician and patient concerns, amending legislation to strengthen PDMPs is difficult, and perhaps not the most efficient method to increase their impact. Arizona was able to quickly increase rates of use and reduce controlled substance prescriptions through education and monitoring allowed under the existing framework. While there is much more that can and should be done to combat prescription drug abuse, leveraging existing tools is a necessary step forward. States must use and strengthen these programs to combat prescription drug abuse to protect the public’s health and reverse the steadily increasing rates of prescription drug and heroin use.
This blog post was prepared by Kim Weidenaar, J.D., Deputy Director for the Network for Public Health Law – Western Region at the Sandra Day O’Connor College of Law, Arizona State University.
The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.
Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not necessarily represent the views of, and should not be attributed to, RWJF