Prescription Fixes: Drug databases work, but only if they are queried

People are in a lot of pain in the United States and around the world.

Lower back and neck pain alone — not to mention all the other body parts that cause discomfort — rose from the 12th most significant cause of health loss worldwide to the 4th between 1990 and 2015, higher than diabetes, lung cancer, and AIDS.

In theory, the development and wider availability of prescription painkillers — mostly opioids such as Vicodin and OxyContin — as a treatment for pain — acute or chronic — should be pushing pain down in the rankings. But, as anyone who has even a vague awareness of national news knows, that’s not the case. In fact, opioid use is through the roof, opioid addiction is widespread, and opioid-related deaths are setting records. Along with this trend, there has been a rise in heroin use, the thought being that people who like the feeling they get from prescription opioids are more likely to start using heroin, either because they like the high even more or because their prescriptions for legally available drugs  are no longer available.

Because the entry point to this epidemic is prescriptions from doctors, it makes sense that there are many efforts afoot to figure out better ways for people to get the help they need. The Pew Charitable Trusts have made an enormous contribution to these efforts recently with a new report, “Prescription Drug Monitoring Programs: Evidence-based practices to optimize prescriber use.”

This fact-filled, purposeful, and dispassionate report provides myriad jumping off points for federal, state, and local decision-makers looking for ways to fix the prescription drug problems in their communities. It’s a manageable 84 pages, plus end notes, but I’ve done you all a favor by reading it and will be using it as inspiration for a series of posts about possible solutions to the ongoing crisis.  

The title of this series is a nod to Tina Rosenberg and David Bornstein’s column Fixes in The New York Times, which paved the way for the solutions journalism movement. My aim with these posts is to look for areas where things that are already working can be more broadly implemented, which is clearly the aim of the Pew Charitable Trusts, too.

Let’s start with a solution that seems so basic it’s hard to believe it’s not universally applied already: Use prescription drug monitoring programs (PDMPs) to track prescription drugs. These programs track who is receiving such drugs, who is prescribing them, and for what purpose. They also require prescribers to check past histories of prescriptions before they write a new prescription for an addicted drug. As the Pew report states:

Prescriber use mandates can rapidly increase PDMP utilization, which can have an immediate impact on prescriber behavior, helping to reduce inappropriate prescribing of opioids and benzodiazepines and also multiple-provider episodes (when patients visit numerous prescribers and/or pharmacies to obtain the same or similar drugs in a short time span). Kentucky, New York, and Ohio are potential models for states looking to mandate PDMP use.

Most states have a prescription drug monitoring program. Missouri is the sole laggard. But programs can be fig leaves, too. Most states do not require prescribers to check their drug databases.

For example, California’s program languished for years without adequate funding and no requirement that prescribers actually check it.

As the Pew report notes, the very first prescription monitoring programs started in California started back in 1939. And yet 77 years later, the state did not require prescribers to make use of the information. It was as if there were cameras recording shoplifting, armed robbery, even murders, and the police were refusing to use them as evidence.

It took repeated attempts in the state legislature and at the ballot box to finally pass a law in California last year that made it a requirement for all prescribers to check the state’s prescription drug database before writing new prescriptions.

This still is not the norm.

It wasn’t until 2009 that any state had a prescriber mandate. Nevada was the first. And it wasn’t until 2012 that Kentucky became the first state to enact what is known as a comprehensive mandate, meaning that all prescribers in the state now have to check the state’s prescription database before any initial opioid prescription. To date, just 13 states have such a mandate.

Do these programs work?

After a prescription drug monitoring program went into effect in Virginia, the Survey and Evaluation Research Laboratory (SERL) at the Virginia Commonwealth University surveyed prescribers in that state and found that it seemed to be encourage prescribers to be cautious when prescribing addictive drugs but did not prevent them from giving the patients the care they needed. A review by the University of Kentucky, part of an effort to improve its own drug program, described the Virginia findings this way:

Survey data also revealed that approximately one-third (36%) of physicians reported that over the past three years they had prescribed fewer Schedule II prescription drugs, citing increased media coverage and law enforcement activity as the main reasons. Of those physicians reporting decreased Scheduled II prescribing, over half (60%) indicated this change in prescribing had not impacted their ability to manage their patients’ pain while 31% percent indicated a negative impact on their ability to manage their patients’ pain.

Still, there was no requirement that prescribers check the database in Virginia at the time.

Look at what happened in Kentucky when it passed a law in April 2012 that required prescribers to enroll in and use its drug monitoring system, known as KASPER or Kentucky All Schedule Prescription Electronic Reporting. A review by the PDMP Center of Excellence at Brandeis University found that the law made a difference.

The new law mandated that prescribers check KASPER before prescribing any Schedule II drugs or for any hydrocodone products in Schedule III. Enrollment by prescribers shot up, from 7,911 registered users before the law to 25,409 by the end of July 2013. Those users really did use the system, too. The total number of KASPER prescription histories requested by users went up from 811,000 before the law to 4.6 million by 2013.

Addictive drug prescriptions went down, too. From August 2011 to July 2012, there were 7.4 million doses prescribed. And from August 2012 to July 2013, there were 6.9 million doses prescribed, a drop of 8.5 percent. That included a 10.3 percent decline in hydrocodone prescriptions and an 11.6 percent decline in oxycodone prescriptions.

The mandates are just one of many ways to make drug prescriptions safer, according to the Pew report. I’ll explore more possible solutions in future posts.

[Photo by frankieleon via Flickr.]