This post was co-authored by Michael Gilbert.
When it comes to drug overdose, we may be winning one battle, but losing the war. As deaths involving prescription painkillers are leveling off, the latest stats on heroin fatalities could not be more dire. These deaths have quadrupled between 2000 and 2013, doubling just between 2010 and 2012. What's often lost behind the headlines is that the trends in prescription painkiller and heroin abuse are linked.
There is evidence to suggest that the raging heroin problem is being fueled by the crackdown on painkillers like OxyContin and Vicodin. Shuttering pill-mills, tightening restrictions on certain analgesics, and making products harder to snort and inject all seem to be curbing prescription drug abuse. But addiction does not simply go away when the pills do, which is why people dependent on prescription opioids have been switching to heroin in record numbers. From a chemical standpoint, heroin is very similar to its prescription drug cousins. Its uncontained black market availability and association with injection drug use make heroin a much more dangerous habit.
So what are we doing about this morphing crisis? One of the go-to answers is the prescription monitoring program (PDMPs, or PMPs for short). These state-run databases (all states except MO now have one) are designed to identify possible prescription drug abuse and diversion by "problem" patients and providers. For example, if a patient with severe lower back pain receives prescriptions for powerful painkillers from five different doctors all in one week, the PDMP can flag the individual as a possible abuser and/or dealer. Without the database, each prescriber -- and pharmacist -- may not be aware of the patient's previous visits.
PDMPs are prominently featured by government agencies on all levels as a key weapon in the fight against the raging overdose problem. If only we could get more prescribers and pharmacists to use these databases -- the accepted wisdom goes -- the overdose crisis could subside, if not go away completely.
But are PDMPs really the right tool for the job? When it comes to tracking diversion of medications, curbing their misuse, and reducing "doctor shopping," the evidence on PDMPs is "mixed." It is plausible that, as they continue to gain popularity, PMDPs may curb the flow of prescription opioids into the hands of patients who might abuse or re-sell them. But if the ultimate goal is to curb overdose, then PDMPs' utility is far from clear. In 2011, the CDC reviewed the evidence on links between PDMPs and overdose, finding no evidence of impact. Although some states have experienced drops in prescription drug overdoses after implementing PDMPs, these declines have not been sustained and -- what is more worrisome -- are usually accompanied by rising heroin-related deaths.
Why the mismatch between the intent of PDMPs and their real-world impact? The problem isn't just that many health care providers are reluctant to use these (sometimes clunky) databases, that states fail to share data, or that mandates requiring their use are insufficiently strict. The problem isn't even that over-reliance on PDMPs may, at times, paradoxically increase prescription of painkillers. The key issue is that PDMPs are designed only to generate information about possible problems. What we do with that information is where the rubber hits the road.
Suppose I am a health care provider and I check the PDMP, only to find that my patient has several prescriptions for a certain painkiller. What are my options? Withholding prescriptions, "firing" the patient, or alerting the police are all standard actions in the PDMP playbook; all effectively push patients out of the health care system. Law enforcement involvement is certainly appropriate to stop major prescription drug diversion, but investigators do not -- and should not -- rely on health care providers to turn in their patients, except in the most egregious cases. If "problem" patients are simply turned away, they will likely seek out black-market alternatives -- typically heroin. Even when practitioners do refer patients to treatment, many of the affordable, evidence-based programs have waitlists that are weeks -- or months -- long, leaving patients with few options in the meantime. In other words, without understanding how to use information gleaned from PDMPs to simultaneously reduce prescription drug abuse and prevent patients from turning to the black market for a fix, the increased use of PDMPs can cause more harm than good.
We have already seen that abuse deterrent formulations of painkillers -- touted as a quick fix to the overdose crisis -- may in fact be driving heroin abuse. This experience should prompt us to think critically about PDMPs and proceed with caution. Having already spent hundreds of millions state and federal dollars on these programs, we must do more to make sure that PDMPs are part of the solution, not part of the problem. How do we do that? On a practical level, PDMPs must integrate with tools like electronic medical records already being used by health care providers and pharmacists. More fundamentally, information gleaned from the PDMP must spur medical professionals to take actions that are designed and proven to help, not hurt the patient. Engaging patients in safe and effective treatment -- and doing so without delay -- should be fundamental to any prescription drug monitoring system. For this, we need more resources, training, and technological innovation; the Affordable Care Act holds promise to meet some of these challenges.
Another important opportunity is to use PDMPs to better target distribution of naloxone -- the opioid antagonist. Health care providers and (in an increasing number of jurisdictions, pharmacists) can prescribe this life-saving medication. Putting naloxone in the hands of at-risk individuals, their friends and family, and other possible bystanders has already helped save tens of thousands of lives, but the practice is just now catching on.
As things stand, there is little reason to believe that PDMPs increase the use of proven overdose prevention measures; there is even some evidence that PDMPs may drive patients away from enrolling in drug treatment. To put it bluntly, cutting patients off from access to prescription drugs, firing them, and referring cases to law enforcement without doing the hard work to actually help those who need it -- and when they need it most -- seems like the surest way to keep fueling America's heroin crisis.
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