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The Divided States of Opioids

U.S. states vary widely in success of monitoring opioid prescriptions

by Elaine Meyer

Published April 9, 2014

As the rate of overdosing on prescription opioids like Oxycontin and Vicodin has risen dramatically across the U.S. since the early 1990s, states have struggled to reign in over-prescription of these popular painkillers. A new study suggests that some states may have made some major headway, while others seem to be having more difficulty.

Published in the March/April issue of Public Health Reports, the report examined the influence of state prescription drug monitoring programs, which exist in some form in all 50 states, on the rates of opioid analgesics dispensed. In such programs, an agency houses an electronic database of controlled substances dispensed throughout the state. This database is available to authorized individuals like doctors and pharmacists, who can consult the database to monitor to make sure patients are not “doctor shopping”—getting painkillers and other drugs from multiple doctors. Law enforcement can also seek access to these monitoring databases to track suspicious prescribing activity by medical providers.

Doctoral student Joanne Brady, and Drs. Guohua Li, Charles Dimaggio, and Hannah Wunsch of Columbia University Mailman School of Public Health’s Department of Epidemiology, with other colleagues from the Departments of Anesthesiology and Emergency Medicine at Columbia, examined quarterly data from the U.S. Drug Enforcement Administration on the seven most commonly prescribed opioid analgesics: fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, and oxycodone.

The annual number of prescriptions for these drugs nearly tripled between 1991 to 2010, from about 76 million to nearly 210 million, according to the National Institute on Drug Abuse. Sales of painkillers to pharmacies and health care providers increased more than 300 percent between 1999 and 2008, according to data from the Drug Enforcement Administration. During the same time sales spiked, drug overdose death rates more than tripled, according to the CDC.

A 2013 study from Johns Hopkins University Bloomberg School of Public Health found prescription of opioid analgesics like Oxycontin, Vicodin, and Percocet had significantly increased compared to other, less addictive painkillers, despite little evidence from clinical studies that opioids are safer or more effective.

The Columbia researchers found that the annual equivalent in milligrams of morphine per American increased fivefold from 1999 to 2008, from 163 to 837. That is a jump from less than two average daily doses of oxycodone per American per year to nearly eight doses.

When averaged together, state prescription drug monitoring programs were associated with a small 3 percent decrease in morphine milligram equivalents of opioids.

However, when the research team looked on a state-by-state basis, they found that nine states dispensed significantly fewer opioids after launching their drug monitoring programs, 14 reported no change, and eight states reported significant increases.

Over the 10-year period, Colorado had the greatest decrease in opioids dispensed associated with its prescription drug monitoring program—a 66 percent reduction in morphine milligram equivalents, followed by Texas at 54 percent and Wyoming at 48 percent. Connecticut had the largest increase, at 61 percent morphine milligram equivalents dispensed.

Prescription drug monitoring programs or PDMPs that are overseen by state health departments appeared to be more effective than those administered by other government agencies, such as a state bureau of narcotics or a board of pharmacy, according to the authors. Seven of the states with department of health-administered programs dispensed almost 18 percent fewer milligram morphine equivalents than states where the program is administered by another agency or bureau.

“It indicates a public health approach is more effective than alternatives, such as the law enforcement and criminal justice approaches,” says Dr. Li. “Maybe the department of health administered PDMPs are more receptive and accessible to healthcare providers,” he says, adding that this is speculation.

Although past studies found that the state drug monitoring programs had little effect on dispensing of opioids and overdose mortality, most of these studies looked at earlier time periods and did not factor in the variation in how these programs are administered.

“While data through 2008 show state prescription drug monitoring programs have greatly expanded and rates of opioids dispensed are stabilizing, there exists considerable room to improve the overall effectiveness of state PDMPs, such as increasing interstate data sharing and making prescription drug-dispensing information accessible by healthcare providers in real time,” said Ms. Brady.

Educating about prescription drug monitoring programs and integrating them into clinical and pharmacy routines may also improve their effectiveness, according to the authors.

For more on prescription opioids, read the2x2project’s series “When the prescription becomes the problem” and databyte “Are doctors overprescribing opioids?”

Edited by Dana March. 

2 Responses to “The Divided States of Opioids”

  1. April 09, 2014 at 6:11 pm, Elaine Meyer said:

    Yes, this is definitely an emerging trend, and there have been some studies that find that prescription opioid users transition to using heroin, or, like you say, that regulation of opioids–such as making OxyContin tamper-resistant so people can’t snort it–has led to a switch to heroin.

    Here are a couple:

    “Prescription opioid misuse was a key feature of trajectories into injection drug use and/or heroin use amongst this sample of young IDUs. A new pattern of drug use may be emerging whereby IDUs initiate prescription opioid misuse before using heroin.”

    http://www.sciencedirect.com/science/article/pii/S095539591100096X

    “Although 24% found a way to defeat the tamper-resistant properties of the abuse-deterrent formulation, 66% indicated a switch to another opioid, with “heroin” the most common response.”

    http://www.nejm.org/doi/full/10.1056/nejmc1204141

    Reply

  2. April 09, 2014 at 2:43 pm, Hank Swager said:

    In Cleveland Ohio the local papers and police departments have reported that the decreases in illegal pharmaceutical opioid has led to an increase in heroin addictions. Is there any data out there on the rises in heroin use or is it still mostly anecdotal?

    Reply

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