Reduce Over-Prescription of Prescription Drugs

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Reducing prescription of opioids contributes to reducing risk in multiple 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.

Background

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. In other cases, 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

OxyContin
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. At the same time, the number of deaths due to prescription opioid overdoses has quadrupled. 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 then 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. Individuals discovered 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." 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.
 

Useful Statistics

• Surgery-related overprescribing results in 3.3 billion unused pills available for misuse
• Middle age women consume the most opioids
• Surgery is a gateway to persistent opioid use and potential misuse
• 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
• Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)
• Enough opioids were prescribed in 2016 to provide every American with 36 pills
• Immediate-release opioids are easiest to misuse
• 38 percent of U.S. adults were prescribed an opioid in 2015
• An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.
• 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 shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.
• The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.
• The Johns Hopkins’ Bloomberg School of Public Health released The Prescription Opioid Epidemic: An Evidence-Based Approach - 2015 (PDF | 547 KB).
  This 42-page report calls for stricter guidelines on the prescribing and dispensing of powerful pain medications

Individuals are being prescribed opioids through worker's comp claims:
 

Wokers' comp.PNG

Prescription Rates

A detailed analysis of opioid prescribing rates show various trends across the country.

 

• Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
• Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
• The MME prescribed per person in 2015 was about 3 times as high as in 1999.

Characteristics of counties with higher opioid prescribing:

• 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

In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council (nsc.org) 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.
  When digging into whether or not a pain killer is effective or not, doctors look at the Number Needed to Treat. NNT is 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 (Cochrane. org, 2014). 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. This can be seen in the diagram below.
Screen Shot 2017-05-31 at 3.10.06 PM.png

 Evidence for the Efficacy of Pain Medications
 

 

Promising Programs

Express Scripts

Express Scripts is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients.

Tool:
Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.
This program is uniquely positioned to reach across three critical touchpoints:

• the pharmacy
• physicians
• patients

Methods:

1. Limit first-time users of short-acting opioids to an initial fill of seven days.
2. Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.
3. Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.
4. Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
5. Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.
6. Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
7. Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
8. Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
9. Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.

Results:
A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

• 38% reduction in hospitalizations
• 40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
• A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up

Prescription Drug Monitoring Programs (PDMPs) - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program 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.

Prescriber Report Card Programs

• 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.
• 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.
• 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

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. 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. [citation needed]
Contact: John Cribbs (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.

Pharmacogenetics Test -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 (john@nodrugsneeded.com)

Prescriber Education - 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.

General Best Practices

Possible interventions by Healthcare Providers include:

 

Limiting the Supply of Prescription Opioids in Circulation

• 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.

Identifying & Treating Opioid-Dependent Individuals

• Learn to recognize the signs of Opioid Use Disorder, which can be found on the wiki page Improve Treatment & Enable Recovery for People with SUDs
• Actively manage and taper opioid use among individuals who are not benefiting from continued opioid therapy and who may be exhibiting concerning behaviors. More information regarding this can be found on the wiki page Improve & Expand Screening & Testing for Misuse
• Educate patients about treatments that help address chronic pain management.
• Provide ongoing, comprehensive addiction treatment, including Medication-Assisted-Treatment and behavioral support (With regulatory changes and increased funding options, more providers can be trained to treat this chronic condition just as they have been trained to treat other chronic conditions).

 

Tools & Resources

TR - Reduce Prescription of Opioids
 

Scorecard Building

Potential Objective Details
Potential Measures and Data Sources
Potential Actions and Partners

Resources to Investigate

More RTI on Reducing Prescription of Opioids

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Sources

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2. U.S. Department of Health and Human Services, “Press Release: Prescription painkiller overdoses at epidemic levels,” November 1, 2011, www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html.
3. Nora D. Volkow, “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,” National Institute on Drug Abuse, May 14, 2014, www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse.
4. Pokrovnichka, Anjelina. "History of Oxycontin: Labeling and Risk Management Program."
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15. National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
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