Opioid Monitoring Moving Crisis to Black Market

Ingrid Hein

November 25, 2019

"We're going to look back in a few years and say the biggest mistake we made was to cut back opioid prescriptions without addressing patients with opioid use disorder," predicted Scott Weiner, MD, from Brigham and Women's Hospital and Harvard Medical School in Boston.

The Prescription Drug Monitoring Program became mandatory in 16 states in 2013, and is now in effect in about half of all states. In Massachusetts, physicians, dentists, and podiatrists have been automatically enrolled in the program since its inception in 2013.

However, it can be extremely cumbersome and time-consuming to look up every patient in the database, Weiner pointed out.

The physician has to open a web browser outside the patient's electronic health record, type in the name and birth date, and wait. Many doctors are just not doing it. "So we wanted to make it easier," said Weiner.

His team integrated the program into a large electronic medical records system. "We wanted to see how this would affect the number of database queries and if it would decrease opioid prescriptions," Weiner told Medscape Medical News.

For their study, the researchers assessed database searches and opioid prescriptions in the 6 months before and the 6 months after implementation of one-click access to the prescription history of patients. He presented those data at the American College of Emergency Physicians 2019 Scientific Assembly in Denver.

For all specialties combined, database searches increased 36.6%, from 265,431 before the implementation of one-click access to 362,627 after.

In the nine emergency departments that used the electronic medical records system — two at large academic centers and seven at community hospitals — searches jumped 119.0%, from 6,473 before one-click access to 24,226 after.

There was a 5.2% reduction in opioid prescriptions for all specialties combined, and a 3.0% reduction for emergency medicine.

For prescriptions originating in the emergency department, the average morphine milligram equivalent per patient dropped from 137 mg before implementation to 113 mg after — a 17.4% decrease.

"The one-click integration is really transformative. Since the state mandates that I use it, it needs to be easier to use. Entering the patient name and date of birth is time-consuming and ridiculous," Weiner said. "The technology is not difficult; it just requires making sure security protocols are in place."

However, the effect of the program on the number of schedule II and schedule III opioid prescriptions that were filled was negligible, Weiner pointed out. "Three percent is not much of an effect on opioid prescribing."

Negligible Effect

There is now a "fourth wave of the opioid crisis" in the United States, which means that new solutions are needed to curb opioid use and overdose. It's not good enough to just look at prescriptions, said Weiner.

The evolution of the epidemic was illustrated in findings from a National Survey conducted in 2016, as reported by Medscape Medical News.

"Phase one was mostly opioid prescriptions, phase two was heroin, and phase three is fentanyl. Now there appears to be a fourth wave; we're seeing methamphetamine stimulants," he reported. "These are overtaking the death toll in several places now."

In phase one, physicians had to check the database because patients were going from hospital to hospital to fill multiple prescriptions. "It used to be more common to misuse prescription opioids, and now that it's becoming more difficult, we don't see that as much as we used to," Weiner explained. The database did a good job of making that difficult for patients.

Since the Prescription Drug Monitoring, overdose deaths have paradoxically increased.

"But patients with opioid use disorder are turning to an alternative: illicit fentanyl on the streets," he said. The illicit market is the easiest path to drugs. "That's why we're seeing continued death from overdose." In fact, he noted, "since the Prescription Drug Monitoring Program, overdose deaths have paradoxically increased."

"We are seeing that about 90% of patients have fentanyl in their bloodstream when they die from illicit drugs," said Weiner, citing a 2017 report.

The supply of illicit drugs has yet to be addressed.

The Prescription Drug Monitoring Program is not part of the solution, said Jane Orient, MD, executive director of the Association of American Physicians and Surgeons.

Treating Addiction

"If anything, it might make things worse if patients in pain resort to street drugs," Orient said. "I think we are putting bars on a small upstairs window while leaving the front door open."

Opioid prescribing is affected by many factors, Orient explained, including "enormous pressure on physicians who fear actions by hospitals, insurers, medical boards, and prosecutors for prescribing 'too much,' and the regulatory hassles."

We need different treatments for substance use disorder. "We now understand we need to take care of people even if they're still using," Weiner explained.

The good news is that more and more programs are treating opioid-dependent patients. And more hospitals are setting up rapid-access clinics, with a recovery coach and resources, and embracing a harm-reduction model, he added.

But before providers can prescribe buprenorphine to help get patients to the next step of their recovery, they have to complete an 8-hour training course. That needs to become easier, Weiner said.

Although making access to monitoring easier is not the solution, it could help, he added, as will easier access to drugs that help opioid-dependent patients recover.

American College of Emergency Physicians (ACEP) 2019 Scientific Assembly: Abstract 126. Presented October 28, 2019.

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