Reduction of ‘non-medical’ use of prescribed opioid analgesics, including personal misuse or abuse and diversion to others, has been targeted by the Centers for Disease Control and Prevention (CDC) and other federal agencies as public health priority.
An estimated 11 million persons in the U.S. engaged in nonmedical use of opioids in 2002-2003 based on an analysis of several public and private databases.
From 2002-2003 to 2009-2010, there was an interval increase of 75% in the number of persons using opioids for non-medical purposes for longer than 200 days in the past year. The public health impact of non-medical use of opioids is clear, contributing to three-quarters of nearly 23,000 deaths from pharmaceutical overdose and over 400,000 emergency department visits in 2011 alone.
Diverse strategies have been developed to deal with non-medical use of opioids but few have been demonstrated to be effective. The first strategy involves state legislation with apparent success in Florida where the problem of drug overdose has been particularly severe.
From 2003 to 2009, deaths caused by drug overdose in Florida increased by 61.0%, prompting State officials to shut down pill mills and office-based dispensing opioids without registration with the State in 2010. Florida also instituted mandatory dispenser reporting to the newly established prescription drug monitoring program.
Gratifyingly, overdose death rates from opioid analgesics declined from 2010 to 2012 by 27% and overdose deaths from benzodiazepines by 28%. Although this decline cannot be directly attributed to these measures, these regulations likely played a significant role. Of concern, overdose deaths increased, possibly due to prescription opioid misuse substituted by illicit narcotics usage.
State-based prescription drug monitoring programs (PDMP)s are databases of dispensed controlled substances and represent a second strategy which has been increasingly adopted across the nation. However, recent analyses by Brady and colleagues reported that no state’s PDMP significantly reduced per-capita dispensed opioids as of 2008.
One possible explanation was the severely limited utilization of PDMPs by healthcare providers. The authors offered several suggestions to improve PDMPs including: to increase PDMP usability; to institute data sharing among neighboring states; and to implement requirements for oversight of the PDMP.
Others have recommended a more proactive role for PDMP administrators such as surveying prescription data for suspicious purchasing patterns and alerting physicians and pharmacists. But, in an analysis of 146 million opioid prescriptions filled by 76% of US retail pharmacies in 2008, only 0.7% of patients were identified as likely doctor shoppers with at least 10 prescribers. Systems to take action against such patients are also still relatively rudimentary.
A third strategy relies on pharmacies to address clinician overprescribing and patient misuse of opioids. One pharmacy chain recently benchmarked opioid prescribers and sent letters to outliers asking them to justify their apparent over-prescribing.
Unfortunately, most high prescribers failed to respond and did not complain when the chain refused to fill their prescriptions. In this fragmented health care system, such sanctions are less effective. Nevertheless, pharmacies can also serve as valuable partners for well-intentioned physicians by alerting them to problematic patients such as those fill prescriptions too frequently or travel long distances to fill prescriptions.
A fourth strategy directly targets all clinicians and their practices. Urine drug testing and opioid use agreements which may have clinical rationale but a systematic review found no evidence that such opioid monitoring practices reduced adverse outcomes. Voluntary clinician education about the risks of opioids and safer prescribing practices such as the Risk Evaluation and Mitigation Strategy (REMS) developed by the FDA regarding extended-release (ER) and long-acting (LA) opioids is available.
Current REMS do not address prescribing immediate release (IR) opioids that are the most frequently acquired formulations in the dental and emergency room setting. Yet REMS does not target high dose opioid prescribing which does not correlate well with prescribing of ER/opioids.
Furthermore, an overemphasis on the risks of opioids has prompted some physicians to implement a blanket refusal to prescribe these drugs. This approach has been criticized as patient abandonment and neglects the Institute of Medicine’s original call to improve management of pain nearly two decades ago.
The limitations of current strategies mandate sweeping changes in pain management. The ultimate goal is to reduce the supply of opioids arising from inappropriate opioid usage as a primary approach to treat pain. Clinicians and patients need to learn that opioids do not treat the underlying pathology and can, over time, cause significant adverse side effects including increased pain via opioid-induced hyperalgesia.
Given the lack of evidence for long term and high dose opioid CNCP therapy, it is critical that all providers – physicians, other prescribers, pharmacies, insurers – as well as policymakers collaborate to develop systems of care that promote and support evidence-based non-pharmacologic therapies for pain such as cognitive behavior therapy and exercise.
Barbara J Turner, MD, MSED