Reduce Over-Prescription of Prescription Drugs

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Introductory Paragraph

Reducing prescription of opioids contributes to reducing risk in two major ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use. Interventions that healthcare providers can implement to limit the supply of prescription opioids in circulation include:

  • Decrease supply by changing prescribing practices, reducing both dose and quantity.
  • Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
  • Be diligent in follow-up on diversion/prevention opportunities.
  • Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

Key Information

Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths. However, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

History

The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.[1] At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.[2]The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential than other narcotics. This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. It was soon discovered that snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." [3] Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.[4]

Useful Statistics

  • 38 percent of U.S. adults were prescribed an opioid in 2015.
  • Enough opioids were prescribed in 2016 to provide every American with 36 pills.
  • Surgery-related overprescribing results in 3.3 billion unused pills available for misuse. [5]
  • Previously the majority of heroin users entering treatment began their misuse with heroin. National-level general population heroin data shows now 80% of new heroin users start off using pain pills.
  • One study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.
  • An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.[6]
  • Middle age women consume the most opioids [7]
  • Surgery is a gateway to persistent opioid use and potential misuse[8]

Prescription Rates

One geographic analysis of opioid prescribing rates in 2015 revealed a high variability between counties across the country, with providers in some counties prescribing 6 times more opioids per person than the lowest prescribing counties. The characteristics of counties with higher opioid prescribing rates included:

  • Small cities or large towns
  • Higher percent of white residents
  • More dentists and primary care physicians
  • More people who are uninsured or unemployed
  • More people who have diabetes, arthritis, or disability

Effectiveness

The National Safety Council (NSC)[9] is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy. In one NSC paper, prescription opioids are shown to be less effective than they may seem to the public. When digging into whether or not a pain killer is effective or not, doctors look at the Number Needed to Treat (NNT) - the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life. So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. [10]

Relevant Research

How can prescription drug misuse be prevented?[11]Misuse of Prescription Drugs Research Report

Impactful Federal, State, and Local Policies

Prescribing Policies: States Confront Opioid Overdose Epidemic[12]

2016 State Legislation Limiting Opioid Prescriptions[13]

Tools & Resources

The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.[14]

Health & Human Services Help & Resources for National Opioid Crisis[15] Safe and Proper Use of Opioids and prescribing.[16]

Help & Resources for the National Opioid Crisis Grant and Funding opportunities.[17]

Promising Practices

PDMPsThe CDC recommends that state-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. [18] See SAFE Solutions article on PDMPS for more information. https://www.yoursafesolutions.us/wiki/Expand_and_Enhance_Prescription_Drug_Monitoring_Program_(PDMP)</ref> PDMPs are now available in 49 states and can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[19]

  • Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[20]
  • Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[21]
  • Ohio In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
  • West Virginia doctors are going to to be ranked based on how much they prescribe opioids[22]

Saliva Drug Screening For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[23]

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. Contact: John Cribbs at john@nodrugsneeded.com

DEA Diversion Control Program (DCP) - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [24] -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication. Contact: John Cribbs at john@nodrugsneeded.com. [25]- Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released CDC Guideline for Prescribing Opioids for Chronic Pain



Sources

  1. www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse
  2. http://www.nytimes.com/2007/05/10/business/11drug-web.html
  3. http://www.planagainstpain.com/resources/usnd/
  4. http://www.planagainstpain.com/resources/usnd/
  5. http://pediatrics.aappublications.org/content/136/5/e1169
  6. https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/
  7. https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/
  8. https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/
  9. http://www.nsc.org/pages/home.aspx nsc.org
  10. https://www.nsc.org/getmedia/8ecdc0e5-ae58-43e8-b98b-46c205e1c2b2/evidence-efficacy-pain-medications.pdf
  11. https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/how-can-prescription-drug-misuse-be-prevented
  12. https://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx
  13. https://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx
  14. https://www.cdc.gov/opioids/providers/prescribing/guideline.html
  15. https://www.hhs.gov/opioids/
  16. https://www.hhs.gov/opioids/prevention/safe-opioid-prescribing/index.html
  17. https://www.grants.gov/search-grants.html?cfda=93.430%2093.664%2093.378%2093.687%2093.732%2093.191%2093.732%2093.732%2093.162%2093.928%2093.527%2093.193%2093.933%2093.243%2093.276%2093.788%2093.959%2093.279%2093.273%2093.912%2093.136%2093.421%2093.772%2093.087
  18. https://www.cdc.gov/drugoverdose/pdmp/
  19. https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain
  20. https://forensicfluids.com/
  21. https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use
  22. https://www.medscape.com/viewarticle/842715_2
  23. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063
  24. https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test
  25. https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education