CDC Grand Rounds: Prescription Drug Overdoses

A U.S. Epidemic

Leonard Paulozzi, MD; Grant Baldwin, PhD; Gary Franklin, MD; R. Gil Kerlikowske, MA; Christopher M. Jones, Pharm D; Neelam Ghiya, MPH; Tanja Popovic, MD, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2012;61(1):10-13. 

In This Article

Prevention Strategies

Some promising strategies exist for addressing these two high-risk groups. The first is use of prescription data combined with insurance restrictions to prevent "doctor shopping" and reduce inappropriate use of opioids. Users of multiple providers for the same drug, people routinely obtaining early refills, and persons engaged in other inappropriate behaviors can be tracked with state prescription drug monitoring programs or insurance claim information. Public and private insurers can limit the reimbursement of claims for opioid prescriptions to a designated doctor and a designated pharmacy. This action is especially important for public insurers because Medicaid recipients and other low-income populations are at high risk for prescription drug overdose. Insurers also can identify inappropriate use of certain opioids for certain diagnoses (e.g., the use of extended-release or long-acting opioids like transdermal fentanyl or methadone for short-term pain).

A second strategy is improving legislation and enforcement of existing laws. Most states now have laws against doctor shopping, but they are not enforced uniformly. In contrast, only a few states have laws regulating for-profit clinics that distribute controlled prescription drugs with minimal medical evaluation. Laws against such "pill mills" as well as laws that require physical examinations before prescribing might help reduce the diversion of these drugs for nonmedical use. In addition, a variety of other state controls on prescription fraud are being employed. For example, according to the National Alliance for Model State Drug Laws, 15 states required or permitted pharmacists to request identification from persons obtaining controlled substances as of March 2009.*

A third strategy is to improve medical practice in prescribing opioids. Care for patients with complex chronic pain problems is challenging, and many prescribers receive little education on this topic. As a result, prescribers too often start patients on opioids and expect unreasonable benefits from the treatment. In a prospective, population-based study of injured workers with compensable low back pain, 38% of the workers received an opioid early in their care, most at the first doctor visit.[14] Among the 6% who went on to receive opioids for chronic pain for 1 year, most did not report clinically meaningful improvement in pain and function, even though their opioid dose rose significantly over the year.

Evidence-based guidelines can educate prescribers regarding the under-appreciated risks and frequently exaggerated benefits of high-dose opioid therapy. Such guidelines especially are needed for emergency departments because persons at greater risk for overdose frequently visit emergency departments seeking drugs. Guidelines will be more effective if health system or payer reviews hold prescribers accountable for their behaviors.

A public health approach to the problem of prescription drug overdose also should include secondary and tertiary prevention measures to improve emergency and long-term treatment. Overdose "harm reduction" programs emphasize broader distribution (to nonmedical users) of an opioid antidote, naloxone, that can be used in an emergency by anyone witnessing an overdose. Efforts also are under way to increase the ability of professionals responding to emergencies to administer optimum treatment for overdoses. Substance abuse treatment programs also reduce the risk for overdose death.[15] Continued efforts are needed to remove barriers to shifting such programs from methadone clinics to office-based care using buprenorphine. Office-based care can be less stigmatizing and more accessible to all patients, especially those residing in rural areas.

Washington is an example of a state that has moved aggressively to improve medical practice in opioid prescribing by developing interagency opioid-dosing guidelines. The guidelines emphasize a dosing "yellow flag" at 120 mg/day morphine equivalent dose for new patients with chronic pain. The guidelines were introduced in April 2007 as a web-based tool, including 2 hours of free continuing medical education and specific "best practice" guidance, use of a patient-prescriber agreement, and judicious use of random urine drug screening. Eighteen months after introduction of the guidelines, a survey was conducted of primary-care physicians to assess overall concerns and acceptance of dosing guidance and to identify gaps in knowledge that might be addressed by new guideline tools. A majority of prescribers surveyed were not using all the best practices, likely because they did not have brief, usable tools. For example, only 38% were using random urine screens often or always, and 69% never or almost never tracked physical function. As a result, brief, open source tools such as patient questionnaires were added for ease of incorporation into routine practice. Additionally, Washington has focused on improving practitioner access to pain specialists. Specific methods are under development to offer "pain proficiency" training to primary-care prescribers, who can then become mentors/consultants to their colleagues, particularly in rural areas. In addition, the University of Washington has made twice-weekly pain consultations with a panel of specialists available. In March 2010, the Washington state legislature passed legislation that repealed permissive prescribing rules for opioids and instituted new rules largely reflective of the dosing guidance and other best practices emphasized in the guidelines.

*Additional information available at http://www.namsdl.org/presdrug.htm.
Additional information available at http://www.agencymeddirectors.wa.gov.

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