Drug Monitoring, 'Pill Mill' Laws Reduce Opioid Scrips

Megan Brooks

August 20, 2015

Florida's efforts to reduce abuse and diversion of prescription opioids through prescription drug monitoring programs (PDMPs) and "pill mill" laws have led to modest declines in opioid prescribing and use, according to a new study.

"PDMPs and pill mill laws offer viable policy options to address the prescription drug abuse epidemic," lead investigator Lainie Rutkow, JD, PhD, MPH, associate professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, told Medscape Medical News.

"While nearly every state now has a PDMP, a much smaller number of states have enacted pill mill laws. In states without pill mill laws, policy makers may want to consider introducing these types of laws, as they complement the goals of PDMPs," Dr Rutkow said.

The study was published online August 17 in JAMA Internal Medicine.

Impact in High Prescribers

Rates of opioid diversion, addiction, and overdose deaths have soared since the mid-2000s, and Florida has been at the epicenter of the problem, the authors write. In 2010, to combat pill mills, or rogue pain management clinics (where prescription opioids were inappropriately prescribed and dispensed), Florida lawmakers passed a law requiring clinics to register with the state and have a physician owner and established prescribing and dispensing requirements. In 2011, the state's PDMP became operational.

Dr Rutkow and colleagues measured the effect of Florida's PDMP and pill mill laws by analyzing prescription claims data and comparing them to data from Georgia, a neighboring state that has not implemented these measures.

Their analysis was based on 2.6 million patients, 431,890 prescribers, and 2829 pharmacies associated with roughly 480 million prescriptions in Florida and Georgia (7.7% for opioids) from July 2010 through September 2012.

A year after Florida's policies took effect, opioid prescriptions decreased by about 1.4%, opioid volume by 2.5%, and average morphine milligram equivalent per transaction by 5.6%, the investigators report.

These estimates are based on differences between actual and predicted outcomes had the policies not been implemented. However, the reductions were limited to prescribers and patients with the highest baseline opioid prescribing and use.

"Our results are important given soaring rates of prescription opioid abuse, as well as the prominent role that laws have in shaping states' responses to the epidemic," the authors note.

They say longer-term studies are needed to confirm a sustained effect of these policies on opioid prescribing and use. It would also be worthwhile to study the individual effect of Florida's PDMP and pill mill laws separately.

"While some states are considering mandatory PDMP registration and use provisions, other options include outreach, education, and training to help prescribers better understand the utility of their state's PDMP," Dr Rutkow commented.

In an interview with Medscape Medical News, David Craig, PharmD, a pain specialist at the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida, who wasn't involved in the study, noted that while pill mill laws and drug monitoring programs do seem to be having an effect based on recent declines in overdose deaths related to oxycodone, "more concerning now is the rise in heroin overdoses, which is kind of predictable; as there is more emphasis and scrutiny on a population forces people to look other places. It's like whack-a-mole."

There is also the "very real risk" for undertreatment for people who need opioid pain medications, Dr Craig said. "Now that we have overscrutinized opioids in management of pain in general, people are just afraid of prescribing and pharmacies are afraid of dispensing these kinds of medications nowadays. I think there is an unintended consequence here with trying to target the bad guys who are trying to get around the system and get these medications either for distribution or themselves personally and I think that unfortunately people who are left to feel the ramifications are chronic pain patients," he explained.

Dr Craig also noted that pain management is "an area of practice that does not pay very well and now you add these additional regulatory burdens, I think unfortunately a lot of people have been caught in the crosshairs of a lot of these initiatives. I work at a cancer center and we see it even for our cancer patients, which I think is a really bad outcome."

The study was funded by the Robert Wood Johnson Foundation Public Health Law Research program and by the Centers for Disease Control and Prevention. One author disclosed serving as the chair of the US Food and Drug Administration's peripheral and central nervous system advisory committee, serving as a paid consultant to a mobile start-up (PainNavigator) and to IMS Health Incorporated, and being a member of an IMS Health scientific advisory board.

JAMA Intern Med. Published online August 17, 2015. Abstract

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