To address the opioid overdose epidemic in this country, states have implemented policies to reduce inappropriate opioid prescribing.
A growing body of recent scientific evidence suggests that mandatory provider use of prescription drug monitoring programs (PDMPs) will change prescribing practices that increase overdose risk.1
PDMPs are state-based electronic databases that collect data on controlled prescription drugs dispensed by pharmacies and, in some states, by dispensing physicians. They contain information about patients’ controlled substance prescription history that doctors can review prior to writing a prescription to help them identify risk factors for opioid-related fatal overdose, such as dangerous combinations of medications, receipt of opioids from multiple sources and total prescribed opioid dosage. According to the CDC, PDMPs are among the most important state-level interventions to improve painkiller prescribing, inform clinical practice, and protect patients at risk.
The dangerous combination of opioids and benzodiazepines
The dangers of opioids are well known. So of course, Shatterproof advocates for legislating that prescribers check a patient’s prescription history before considering prescribing an opioid. But if most opioids are listed in Schedule’s II and III of the Federal Controlled Substance Act, why do the Shatterproof recommendations include a prescriber checking a patient’s history before considering prescribing drugs listed in Schedules II, III and IV?
The reason is that Schedule IV includes benzodiazepines, which, if taken concurrently with an opioid, can be extremely dangerous. In fact, Guideline #11 in the recently released CDC Guideline for Prescribing Opioids for Chronic Pain states: “Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.”
Benzodiazepines and opioids both cause central nervous system depression and can decrease respiratory drive. Concurrent use is likely to put patients at greater risk for potentially fatal overdose. One case-cohort study found concurrent benzodiazepine prescription with opioid prescription to be associated with a near quadrupling of risk for overdose death, compared with opioid prescription alone. Clinicians should check the PDMP for concurrent controlled medications prescribed by other clinicians and should consider involving pharmacists and pain specialists as part of the management team when opioids are co-prescribed with other central nervous system depressants.
Recent data confirms that both overdoses and deaths involving combinations of opioid analgesics and benzodiazepines are rising:
- A 2016 study published in the American Journal of Public Health found that in 2013, 22,767 people died of an overdose involving prescription drugs in the United States. Benzodiazepines were involved in 31% of these fatal overdoses.2
- A 2015 study published in the British Medical Journal found approximately 50% of the veterans who died from drug overdose between 2004 and 2009 were prescribed opioids and benzodiazepines at the same time. Those at highest risk of death were those receiving the larger quantities of benzodiazepines.3
Beyond benzodiazepines, Schedules II, III and IV controlled substances contain sedatives/tranquilizers, and stimulants which are subject to misuse, addiction and death. For further information on drugs that are contained in each of Schedules II, III and IV, see page 25 of our PDMP report.
There’s lots of evidence that PDMPs work
New York mandated the use of PDMPs in 2013, and in that first year, doctor shopping decreased by 75%, the number of opioid doses dispensed decreased by 10%, and the number of prescriptions for buprenorphine, a drug used to treat opioid addiction, increased by 15%.4
What’s more, a recent report from CDC’s Injury Center5 found that the combined implementation of mandatory review of state PMDPs and pain clinic laws had the following results:
- Opioids prescriptions were reduced by 8%
- Prescription opioid overdose death rates fell by 12%
- No associated increase in heroin overdose deaths was found
But in the vast majority of states, PMDP participation is extremely low
Although 49 states and the District of Columbia have legislation authorizing the creation and operation of PDMPs, most states underutilize this life saving clinical tool. In 2014, in a sample of states without legislation that mandates their use, PMDPs were checked by doctors just 14% of the time. That means that 86% of opioid prescriptions were written without a doctor ever checking the patient’s prescribing history.
We must advocate for proven, effective policies so that every doctor in America is consulting a PDMP before making the decision to prescribe dangerous opioids or benzodiazepines. Doctors who are committed to “doing no harm” should know whether it’s safe to give these drugs to their patients. They should know how often they’ve been prescribed before, know about other medications being prescribed that could have contraindications, and be on the lookout for potential risks.
Critical elements of effective state legislation
Shatterproof has analyzed PDMP best practices to identify specific policies that states should adopt to reduce the loss of life. In March, 2016, we published twelve recommendations in our groundbreaking report, “Critical Elements of Effective State Legislation”. Here’s a summary of our recommendations:
- Dispensers report specified information expeditiously. This will allow health care providers to have the most up-to-date and accurate prescription information, which helps them make better-informed prescribing decisions.
- Prescribers query PDMP before prescribing drugs in Schedules II, III and IV, obtaining vital, sometimes life-saving, background information before they write a script.
- Licensed prescribers register with PDMP, ensuring the across-the-board compliance that will make the system most effective.
- Enable delegation of PDMP data queries, which saves doctors valuable time.
- Authorize specified recipients of PDMP data, allowing insurers and other stakeholders to become strategic partners in preventing and identifying drug abuse.
- Proactively analyze and distribute PDMP data, identifying any inappropriate prescribing and misuse patterns early.
- Require interstate sharing of PDMP data to provide doctors with complete information.
- Provide de-identified information, so providers can identify patterns and trends that could aid in the effort to end addiction (while protecting patient confidentiality).
- Take a community-based approach to PDMP data so communities can work together to monitor, treat and prevent substance use disorders.
- Link PDMP data to pain and addiction treatment, so that interventions can be arranged before lives are lost.
- Institute confidentiality protections to keep patients’ privacy safe.
- Track and report evaluation measures so that every PDMP can continue to get better and better.
Current status of PDMP legislation in the United States
In 2012, Kentucky became the first state in the nation to pass legislation mandating comprehensive PDMP use. That legislation led to a 13% decline in opioids dispensed, a 25% decline in prescription opioid deaths, and an almost 90% increase in prescriptions for buprenorphine, a medication to treat opioid addiction.6
There are currently only eight states that mandate that prescribers query their PDMP before prescribing drugs in Schedules II, III and IV—however, Shatterproof will be leading legislative efforts in several states in 2017. Furthermore, in the first quarter of 2017, Shatterproof will be publishing a detailed listing of legislation in each of the 50 states, for each of the above listed recommendations.