America continues to be in the throes of an opioid addiction crisis, including an epidemic of overdose deaths, with no end in sight. It’s a problem that obliterates every preconceived notion of what a person with addiction looks like. Those of us working every day to help people struggling with addiction are desperate for tools to help stem the tide.
The number of overdose deaths in the U.S. due to opioids, which include heroin and prescription pain relievers such as morphine, oxycodone, and hydrocodone, quadrupled between 1999 and 2011. This stark increase in opioid overdose deaths, most of which were accidental, closely parallels the rapid increase in prescribing of opioids during the same time period. It also parallels other markers of addiction to opioids, such as rates of admission to treatment facilities for opioid detoxification.
And, as the number of individuals dependent on opioids increases, so does the demand for heroin, because once a person has developed physical dependence on opioids, cessation of use inevitably results in extremely uncomfortable withdrawal, which then leads many to switch over to the less expensive and increasingly more available heroin.
Prior to the 1980s, opioid pain relievers were typically prescribed either for short-term post-operative pain, in small amounts, or for pain associated with terminal cancer. Since then, prescriptions for opioid pain relievers have increased dramatically as a result of several factors: the efforts of a small group of specialized pain physicians, who argued that individuals with chronic pain deserved more access to the powerful analgesia provided by opioids (despite a lack of evidence that opioids provide good analgesia for chronic non-cancer pain), the argument , now discredited, that opioids almost never produce addiction when used to treat pain, the transformation of American medicine into a volume business with shorter and shorter doctor-patient visits that typically lead to a prescription rather than a longer discussion about alternative ways to manage pain, and the efforts of pharmaceutical companies to encourage opioid prescribing while producing long-acting medication formulations with higher quantities of medication in each pill or tablet.
The end result has been that the U.S., with less than 5 percent of the world population, has been consuming 80 percent of the world’s supply of opioids, including more than 99 percent of the global supply of hydrocodone (Vicodin). This prescribing anomaly has not clearly produced better pain relief for the majority of chronic pain sufferers, nor has it allowed millions managed chronically with opioid pain relievers to return to work or function better in their homes or communities.
There are numerous ways to address the problems associated with what has been called a U.S. epidemic of opioid prescribing. One approach to reduce unnecessary or inappropriate opioid prescribing is through the use of prescription drug monitoring programs (PDMPs). PDMPs are electronic state-managed databases, which track prescriptions for controlled substance medications. The most robust PDMPs keep track of this data in real time (up to the minute) and allow physicians to check what other controlled substance prescriptions patients have obtained in their state. This helps prevent patients from “doctor shopping,” in which individuals seek out multiple physicians in order to obtain extra medications to support their own or others’ addictions. PDMPs can also alert physicians to the possibility that patients may have been prescribed other medications, such as benzodiazepines, a class of addicting sedatives that increase the risk of accidental overdose and were present in 31 percent of opioid analgesic poisoning deaths in 2011.
PDMPs have been established in 49 states, but they differ significantly from one state to another, and there are marked differences in how states set up agreements with other states to share the data. The value of PDMPs is hampered by lack of physician access to information about what prescriptions patients have filled in other states. In New York, for example, while physicians are required to check the state PDMP prior to prescribing a controlled substance (this is not required in most states), there is no information available to New York physicians about prescriptions obtained in any other state. Some states, like Connecticut, have established sharing of PDMP data, giving physicians much more information, but even Connecticut physicians can obtain prescription information from fewer than a third of the states (and New York isn’t one of them).
The extremely valuable, potentially life-saving information available in PDMPs should be readily shared among the states. Each state has its own PDMP database, with various software systems used to store and share the information. While some progress has been made to allow interoperability of these state-based systems, we appear to be a long way from easy access to national controlled substance prescription information on our patients, without which well meaning and caring physicians will continue to prescribe some opioids and other controlled substances to individuals who need addiction treatment rather than more medications.
To be sure, PDMPs face a host of questions and issues that remain to be addressed fully, including how to keep the information in them safe from hackers. Nevertheless, establishing a national PDMP—or its equivalent through easy interoperability among state-based systems—would be a public good that will save lives and improve the care of millions of Americans battling addiction. If we are serious about confronting our national opioid addiction problem, federal support for the establishment of a national PDMP should now be given the highest priority.
Collins, an addiction psychiatrist, is physician-in-chief at Silver Hill Hospital in New Canaan, Connecticut, and president-elect of the New York Society of Addiction Medicine (NYSAM).