Study: Did prescription monitoring


Image: Dr. Tongil “TI” Kim
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Credit: UT Dallas

Mandates designed to reduce opioid prescriptions in the United States have worked, but they also had an unintended and undesirable public health outcome, according to a recent study by a researcher at the University of Texas at Dallas.

The study, published online July 2 in Production and operations management, focused on the mandatory use of Prescription Drug Monitoring Programs (PDMP). Many states have policies in place that require prescribers to check a patient’s prescription history before initiating or renewing prescriptions for controlled substances.

Dr. Tongil “TI” Kim, an assistant professor of marketing at Naveen Jindal School of Management, and study co-authors found that in states that mandated PDMP use, opioid prescriptions declined as intended. The warrants, however, have had the unintended effect of pushing existing opioid users toward more lethal illicit substitutes, such as heroin.

“There are currently more than 2 million people with opioid use disorder, characterized by chronic abuse of prescription opiates,” Kim said. “With more than 130 people dying every day from opioid overdoses, it has become a serious social problem in America.”

Facing the epidemic

The overprescription of opioids by physicians is considered a major driver of the epidemic nationwide, Kim said. Many patients who are introduced to prescription opioids, usually for pain management, continue to show a pattern of escalating use or begin using more dangerous medications instead.

Additionally, Kim said there is ample evidence of physician shopping, in which a patient requests opioid prescriptions from multiple physicians who may not be aware of the duplicates.

“Easy access to prescription opioids can further exacerbate opioid addiction and abuse,” he said. “Mandatory use of the PDMP may curb such buying behavior by physicians.”

Prescription Drug Monitoring System provides better data visibility of these practices by enabling statewide sharing of patient-level prescribing information on controlled substances between providers, pharmacies, and managers of law enforcement.

The study focused on the period during the early rollout of mandatory PDMP use, when 19 states legally required prescribers to check the system before prescribing controlled substances.

Currently, all states except South Dakota and Kansas require PDMPs. Texas began its term in 2020.

Decreasing prescriptions, increasing deaths

The researchers constructed a national dataset that included detailed information on opioid prescribing and the incidence of prescription opioid and heroin-related deaths in all US states between 2006 and 2015.

The analysis found that implementing the PDMP reduced opioid prescriptions by 6.1%.

Despite the reduction, however, the researchers determined that the policy did not reduce deaths from prescription opioids. Additionally, heroin-related deaths increased by 50.1% under PDMP mandates.

Kim speculates that imposing supply restrictions on prescription opioids could have caused patients to seek out dangerous and illegal alternatives.

“Previous research has shown that when faced with restricted access to addictive substances, individuals simply seek out alternatives rather than limiting their intake,” Kim said. “Therefore, it is essential to assess whether any restriction in the supply of prescription opioids leads to an overall reduction in opioid consumption or whether patients simply seek out illicit alternatives, such as heroin.

“In our case, we measured overdose deaths as a proxy and found a substantial increase, suggesting that the policy unintentionally stimulated greater substitution.”

To identify the causal effects of mandatory PDMP on opioid prescriptions and overdose deaths, the researchers used a differences-in-differences approach to assess policy implementation in different states at different times.

They also performed an analysis of Google Trends and found additional corroborating evidence. Keyword searches for prescription opioids such as OxyContin and Vicodin declined after the policy was put in place, while searches for heroin increased significantly.

The study also showed that the degree of substitution varied. States with more restrictive PDMP mandates saw a more dramatic reduction in the rate of prescribing, but a larger increase in heroin overdose deaths.

Consequences

Researchers have found evidence that unintended substitution effects can be mitigated in several ways.

For example, they found that areas with low heroin availability and high capacity for opioid use disorder treatment facilities did not experience significant heroin substitution in treatment settings. Mandated PDMPs.

“This suggests that restricting the availability of illicit substances through increased policing, for example, and investing in treatment capacity can mitigate the unintended consequences of PDMP mandates,” Kim said.

Co-authors of the study are corresponding author Dr. Diwas KC of Emory University and Dr. Jiayi Liu of Virginia Tech.


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