Reduce Over-Prescription of Prescription Drugs

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 limit the number of excess pills that are often diverted for inappropriate use. Interventions which 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

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 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." 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 pleaded guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. According to Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing, "For years the sole focus was on reducing non-medical use, reducing abuse....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."

Physicians, dentists, and other healthcare professionals have a key role to play in preventing patients from developing an addiction to pain medication. Studies have shown that it is possible for people to become addicted to such medications in a matter of days. Reducing over-prescribing is a powerful tool needed to prevent dependence. Prescribing practices could be improved to reduce the prescription of opioids by:

• providing better education in US medical schools about pain management, opioid abuse, and addiction
• modifying regulations on direct advertisements by pharmaceutical companies
• limiting the ways companies influence doctors, such as restricting gifts, vacations, and other forms of compensation.

Insurance Company Practices Contribute to Over-Prescription of Opioids

The over-prescription of opioids is largely a result of the US health insurance structure. Unlike countries that provide universal health care funded by state taxes, the United States has a mostly privatized system of care. And experts say insurers are much more likely to pay for a pill than physical therapy or repeat treatments. According to Judith Feinberg of the West Virginia University School of Medicine: “Most insurance, especially for poor people (Medicaid), won't pay for anything but a pill. Say you have a patient that's 45 years old. They have lower back pain, you examine them, they have a muscle spasm. Really the best thing is physical therapy, but no one will pay for that. So, doctors get very ready to pull out the prescription pad. Even if the insurance covers physical therapy, you probably need prior authorization which is a lot of time and paperwork.”

The US health-care system is different from other countries in other ways, too. There is pressure to address pain, and a pervasive attitude that everything is fixable. As a result, doctors in the United States are much more likely to provide painkillers than doctors in other countries. One comparative study found that Japanese doctors treated acute pain with opioids about half the time. In the United States, the number was 97 percent of the time.

Useful Statistics

• In 2018, more than 1 in 5 Americans had an opioid prescription filled.

• The US has 5% of the world's population, but consumes 80% of the world's prescription opioids.

• Surgery-related overprescribing results in 3.3 billion unused pills available for misuse.

• Previously the majority of heroin users entering treatment began their misuse with heroin. National-level general population heroin data shows that now nearly 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.

• Middle-age women consume the most opioids.

• Surgery is a gateway to persistent opioid use and potential misuse.

Prescription Patterns

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). 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

Relevant Research

National Institute on Drug Abuse (NIDA). This research report, "How can prescription drug misuse be prevented?" highlights the different roles that physicians, their patients, and pharmacists can play in identifying and preventing non-medical use of prescription drugs.

The National Safety Council (NSC) 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. It does this through leadership, research, education, and advocacy. In this NSC paper, prescription opioids are shown to be less effective than they may seem to the public. When evaluating 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.

Impactful Federal, State, and Local Policies

DEA Diversion Control Program (DCP) is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs. DEA’s Diversion Control efforts are geared toward preventing the non-medical use of controlled prescription drugs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards.

The National Conference of State Legislatures (NCSL) is a nonpartisan public association that was established in 1975. Its membership includes sitting state legislators. NCSL published "Prescribing Policies: States Confront Opioid Overdose Epidemic." NCSL publishes regular legislative research updates. For example, a search on their online database using the keyword "opioids" revealed a national summary -- in the 2023 legislative session, 103 laws were enacted related to fentanyl.

Available Tools & Resources

SAFE Project. See the wiki titled "Expand and Enhance Prescription Drug Monitoring Programs (PDMPs)" for more detailed information on improving PDMPs which are among the most promising state-level interventions to improve opioid prescribing, inform clinical practice, and protect patients at risk.

The US Department of Health & Human Services provides a series of articles within its website for "Help & Resources for the National Opioid Crisis."

Grants.gov provides a searchable database of grant and funding opportunities.

Advanced Opioid Management is a program that was launched in 2017 by Express Scripts, a prescription benefit plan provider. They offer a comprehensive program that works across the care continuum to prevent opioid use and misuse by reach reaching three critical touch points -- the pharmacy, physicians, and patients. Some aspects of the program include:

• Limit first-time users of short-acting opioids to an initial fill of seven days.
• Require enhanced prior authorization for all long-acting opioids to block fills for new users.
• Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg MED per day.
• Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary, and unlikely to result in adverse medical consequences.
• 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.
• 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.
• Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
• Provides disposal bags to first-time opioid users whom 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.
• 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.

One pilot program with more than 100,000 members showed:

• 38% reduction in hospitalizations
• 40% drop in emergency room visits during six months of follow-up
• Follow-up counseling calls showed a 19% decrease in the day’s supply of opioid dispensing

Promising Practices

Prescription Drug Monitoring Programs (PDMPs) can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help identify patients at high-risk who would benefit from early interventions. The CDC recommends that state-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. While PDMPs are now available in all 50 states, requirements vary from state to state. See SAFE Solutions article on PDMPS for more information.

• Arizona - quarterly report cards are prepared and distributed by the state's PDMP. 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's PDMP created a "Practice Insight Report" providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: (a) top 25 patients by number of other prescribers visited in past 12 months, (b) top 25 patients by MME, (c) top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, and (d) a listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months. Ohio also developed the "safety checkpoints" approach to minimize inappropriate prescriptions but still allow people who need them to be able to get them--with some added precautions.

• West Virginia doctors are ranked based on how much they prescribe.