Features of prescription drug monitoring programs associated with reduced rates of prescription opioid-related poisonings

Efficacy of interventions targeted at physician prescribers of opioids for chronic non-cancer pain: an overview of systematic reviews

BACKGROUND

To combat the opioid crisis, interventions targeting the opioid prescribing behaviour of physicians involved in the management of patients with chronic non-cancer pain (CNCP) have been introduced in clinical settings. An integrative synthesis of systematic review evidence is required to better understand the effects of these interventions. Our objective was to synthesize the systematic review evidence on the effect of interventions targeting the behaviours of physician opioid prescribers for CNCP among adults on patient and population health and prescriber behaviour.

METHODS

We searched MEDLINE, Embase, and PsycInfo via Ovid; the Cochrane Database of Systematic Reviews; and Epistemonikos. We included systematic reviews that evaluate any type of intervention aimed at impacting opioid prescriber behaviour for adult CNCP in an outpatient setting.

RESULTS

We identified three full texts for our review that contained 68 unique primary studies. The main interventions we evaluated were structured prescriber education (one review) and prescription drug monitoring programmes (PDMPs) (two reviews). Due to the paucity of data available, we could not determine with certainty that education interventions improved outcomes in deprescribing. There is some evidence that PDMPs decrease the number of adverse opioid-related events, increase communication among healthcare workers and patients, modify healthcare practitioners' approach towards their opioid prescribed patients, and offer more chances for education and counselling.

CONCLUSIONS

Our overview explores the possibility of PDMPs as an opioid deprescribing intervention and highlights the need for more high-quality primary research on this topic.

Association between prescription drug monitoring programs use mandates and prescription stimulants received by Medicaid enrollees

INTRODUCTION

Prescription drug monitoring program (PDMP) use mandates are an important policy tool to curb nonmedical opioid use. However, data are scarce about their efficacy on other commonly used prescription drugs such as stimulants.

METHODS

We used 2010-2020 state-level secondary data from Medicaid State Drug Utilisation Data and quasi-experimental difference-in-differences research design to estimate the association between PDMP use mandates and population-adjusted stimulants (amphetamines and methylphenidate) prescribing outcomes: (i) number of prescriptions filled; and (ii) total amount reimbursed in US dollars. To account for heterogeneity in mandates across US states, two policy variables were considered: limited and expansive. Limited PDMP use mandates require prescribers or dispensers to check the PDMP only when prescribing/dispensing opioids or benzodiazepines, while expansive PDMP use mandates are non-specific to opioids/benzodiazepines and require prescribers or dispensers to check the PDMP when prescribing/dispensing targeted controlled substances in Drug Enforcement Agency Schedule II-V. The sample included 49 US states and the District of Columbia. Nevada was excluded since it implemented the PDMP mandate before the period of analysis.

RESULTS

The state-wide implementation of the PDMP use mandate, either limited or expansive, was not associated with the number of prescriptions filled or the total amount reimbursed in US dollars for stimulants among Medicaid enrollees.

DISCUSSION AND CONCLUSION

There was no evidence for the associations between PDMP use mandates and stimulant prescribing among Medicaid enrollees. Future works are encouraged to replicate the study in other populations and with longer post-period analysis when the impact of the mandates might be more successfully materialised.

Prescription drug monitoring programs use mandates and prescription stimulant and depressant quantities

BACKGROUND

While the mandate to check patients' prescription history in Prescription Drug Monitoring Program (PDMP) database before prescribing/dispensing controlled drugs has been shown to be an important tool to curb opioid abuse, less is known about whether the mandate can reduce the misuse of other commonly abused prescription drugs. We examined whether PDMP use mandates were associated with changes in prescription stimulant and depressant quantities.

METHODS

Using data from Automated Reports and Consolidate Ordering System (ARCOS), we employed difference-in-differences design to estimate the association between PDMP use mandates and prescription stimulant and depressant quantities in 50 U.S. states and the District of Columbia from 2006 to 2020. Limited PDMP use mandate was specific only to opioids or benzodiazepines. Expansive PDMP use mandate was non-specific to opioid or benzodiazepine and required prescribers/dispensers to check PDMP when prescribing/dispensing targeted controlled substances in Schedule II-V. The main outcomes were population-adjusted prescription stimulant (amphetamine, methylphenidate, lisdexamfetamine) and depressant (amobarbital, butalbital, pentobarbital, secobarbital) quantities in grams.

RESULTS

There was no evidence that limited PDMP use mandate was associated with a reduction in the prescription stimulant and depressant quantities. However, expansive PDMP use mandate that was non-specific to opioid or benzodiazepine and required prescribers/dispensers to check PDMP when prescribing/dispensing targeted controlled substances in Schedule II-V was associated with 6.2% (95% CI: -10.06%, -2.08%) decline in prescription amphetamine quantity.

CONCLUSION

Expansive PDMP use mandate was associated with a decline in prescription amphetamine quantity. Limited PDMP use mandate did not appear to change prescription stimulant and depressant quantities.

Association of Prescription Drug Monitoring Programs With Opioid Prescribing and Overdose in Adolescents and Young Adults

STUDY OBJECTIVE

Prescription opioid use is associated with substance-related adverse outcomes among adolescents and young adults through a pathway of prescribing, diversion and misuse, and addiction and overdose. Assessing the effect of current prescription drug monitoring programs (PDMPs) on opioid prescribing and overdoses will further inform strategies to reduce opioid-related harms.

METHODS

We performed interrupted time series analyses to measure the association between state-level implementation of PDMPs with annual opioid prescribing and opioid-related overdoses in adolescents (13 to 18 years) and young adults (19 to 25 years) between 2008 and 2019. We focused on PDMPs that included mandatory reviews by providers. Data were obtained from a commercial insurance company.

RESULTS

Among 9,344,504 adolescents and young adults, 1,405,382 (15.0%) had a dispensed opioid prescription, and 6,262 (0.1%) received treatment for an opioid-related overdose. Mandated PDMP review was associated with a 4.2% (95% CI, 1.9% to 6.4%) reduction in annual opioid dispensations among adolescents and a 7.8% (95% CI, 4.7% to 10.9%) annual reduction among young adults. For opioid-related overdoses, mandated PDMP review was associated with a 16.1% (95% CI, 3.8 to 26.7) and 15.9% (95% CI, 7.6 to 23.4) reduction in annual opioid overdoses for adolescents and young adults, respectively.

CONCLUSION

PDMPs were associated with sustained reductions in opioid prescribing and overdoses in adolescents and young adults. Although these findings support the value of mandated PDMPs as part of ongoing strategies to reduce opioid overdoses, further studies with prospective study designs are needed to characterize the effect of these programs fully.

Surveillance, Self-Governance, and Mortality: The Impact of Prescription Drug Monitoring Programs on U.S. Overdose Mortality, 2000-2016

Policy mechanisms shaping population health take numerous forms, from behavioral prohibitions to mandates for action to surveillance. Rising drug overdoses undermined the state's ability to promote population-level health. Using the case of prescription drug monitoring programs (PDMPs), we contend that PDMP implementation highlights state biopower operating via mechanisms of surveillance, whereby prescribers, pharmacists, and patients perceive agency despite choices being constrained. We consider whether such surveillance mechanisms are sufficient or if prescriber/dispenser access or requirements for use are necessary for population health impact. We test whether PDMPs reduced overdose mortality while considering that surveillance may require time to reach effectiveness. PDMPs reduced opioid overdose mortality 2 years postimplementation and sustained effects, with similar effects for prescription opioids, benzodiazepines, and psychostimulants. Access or mandates for action do not reduce mortality beyond surveillance. Overall, PDMP effects on overdose mortality are likely due to self-regulation under surveillance rather than mandated action.

Trends in Opioid Prescribing Following Pennsylvania Statewide Implementation of a Prescription Drug Monitoring Program

Background: The opioid epidemic is a major public health crisis in the United States. Legislators have enacted various strategies to combat this crisis, including the implementation of statewide prescription drug monitoring programs (PDMP). These PDMPs are electronic databases that collect and analyze patient prescription data on controlled substances, allowing physicians to review prior prescriptions before prescribing. The objective of this study was to determine opioid prescribing patterns after the implementation of a statewide PDMP in Pennsylvania.

Methods: After IRB approval, PDMP data were obtained from the Pennsylvania Department of Health. Data obtained included: drug name, days supplied, refill count, and partially filled prescriptions. The study timeline was three years, from first quarter 2017 through first quarter 2020.

Results: Over the three years post-implementation of a PDMP, Pennsylvania saw a 33% decrease in the overall quantity of opioid pills prescribed (677,194 absolute reduction), a 9% decrease in partially filled prescriptions (5,821 absolute reduction), and an 18% decrease in authorized refills (525 absolute reduction). Opioid prescriptions for greater than seven days of supply decreased by a larger amount than prescriptions for less than seven days of supply (43% vs 27%). Similarly, prescriptions for more than 22 pills saw a greater decrease than prescriptions for less than 21 days (37% vs 21%). However, the rate of decrease in opioid pills prescribed lessened from 14% in the first two years post implementation, to 10% in the third year. The decrease in partially filled opioid prescriptions for the first two years averaged 14% per year, while it increased by 23% in the third year. An 8% average decrease occurred in the rate of refills for opioid prescriptions for the first two years post implementation, followed by a 3% reduction in the third year.

Conclusion: There was a 33% decrease in the overall quantity of opioid pills prescribed in the three years after the implementation of the PDMP. The first two years after implementation saw the largest decreases in prescribing habits, which slowed in the third year. More data are needed to show the long-term effects of implementing a statewide PDMP.

Methodological considerations for estimating policy effects in the context of co-occurring policies

Understanding how best to estimate state-level policy effects is important, and several unanswered questions remain, particularly about the ability of statistical models to disentangle the effects of concurrently enacted policies. In practice, many policy evaluation studies do not attempt to control for effects of co-occurring policies, and this issue has not received extensive attention in the methodological literature to date. In this study, we utilized Monte Carlo simulations to assess the impact of co-occurring policies on the performance of commonly-used statistical models in state policy evaluations. Simulation conditions varied effect sizes of the co-occurring policies and length of time between policy enactment dates, among other factors. Outcome data (annual state-specific opioid mortality rate per 100,000) were obtained from 1999 to 2016 National Vital Statistics System (NVSS) Multiple Cause of Death mortality files, thus yielding longitudinal annual state-level data over 18 years from 50 states. When co-occurring policies are ignored (i.e., omitted from the analytic model), our results demonstrated that high relative bias (> 82%) arises, particularly when policies are enacted in rapid succession. Moreover, as expected, controlling for all co-occurring policies will effectively mitigate the threat of confounding bias; however, effect estimates may be relatively imprecise (i.e., larger variance) when policies are enacted in near succession. Our findings highlight several key methodological issues regarding co-occurring policies in the context of opioid-policy research yet also generalize more broadly to evaluation of other state-level policies, such as policies related to firearms or COVID-19, showcasing the need to think critically about co-occurring policies that are likely to influence the outcome when specifying analytic models.

The effect of state policies on rates of high-risk prescribing of an initial opioid analgesic

BACKGROUND

Multiple state policies, such as prescription drug monitoring programs (PDMPs) and duration limits, have been implemented to decrease high-risk opioid prescribing. Studies demonstrate that many policies decrease certain opioid prescribing behaviors, but few examine their intended effects on the targeted high-risk prescribing practices, nor disentangle the effects of concurrent state or federal policies likely to influence those practices.

METHODS

Forty-one million initial prescriptions for new opioid episodes from 2007 to 2018 were identified using national pharmacy claims. We identified high-risk initial prescriptions, defined as >7 days' supply, average daily MME >90, or concurrent with benzodiazepines and estimated three multivariable logistic regression models to assess the association between policies and outcomes controlling for patient, prescriber, and county characteristics.

RESULTS

Initial prescriptions for >7 days declined from 23.8% in 2007 to 14.9% in 2018, associated with mandatory and interoperable PDMPs and prescription duration limits but not other policies examined. Initial prescriptions with daily MME > 90 declined from 13.2% to 1.9%, associated with pain management clinic laws but not consistently with other policies. Initial prescriptions concurrent with benzodiazepines declined only modestly from 6.9% to 6.5%, associated with pain management clinic laws but not other policies examined.

CONCLUSIONS

The opioid policy environment has changed rapidly with a range of different policies being implemented addressing high-risk prescribing. PDMP laws mandating prescriber use and pain clinic laws both appear efficacious but decrease different types of high-risk opioid prescribing. New policies should be considered in light of the prevalence of the problem being addressed.

Mapping the research addressing prescription drug monitoring programs: A scoping review

ISSUES

Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice.

APPROACH

A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021.

KEY FINDINGS

A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use.

IMPLICATIONS

Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement.

CONCLUSION

Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.

Impacts of prescription drug monitoring program policy changes and county opioid safety coalitions on prescribing and overdose outcomes in California, 2015-2018

In 2015, California received funding to implement the Prescription Drug Overdose Prevention Initiative, a 4-year program to reduce deaths involving prescription opioids by 1) leveraging improvements to California's prescription drug monitoring program (PDMP) (i.e., mandatory PDMP registration for prescribers and pharmacists), and 2) supporting county opioid safety coalitions. We used statewide data from 2011 to 2018 to evaluate the Initiative's impact on opioid prescribing and overdose rates. Prescribing data were obtained from California's PDMP; fatal and non-fatal overdose data were obtained from the California Department of Public Health. Outcomes were monthly opioid prescribing rates and opioid overdose rates, modeled using generalized linear mixed models. Exposures were mandatory PDMP registration, presence of county coalitions, and Initiative support for county coalitions. Mandatory PDMP registration was associated with a 25% decrease (95%CI, 0.71-0.79) in opioid prescribing rates after 24 months. Having a county coalition was associated with a 2% decrease (95%CI, 0.96-0.99) in the opioid prescribing rate; receiving Initiative support was associated with an additional 2% decrease (95%CI, 0.97-0.98). Mandatory PDMP registration and county coalitions were associated with a 35% decrease (95%CI, 0.43-0.97) and a 21% decrease (95% CI, 0.70-0.90), respectively in prescription opioid overdose deaths. Both interventions were also associated with significantly fewer deaths involving any opioid but had no significant association with non-fatal overdose rates. Findings add to the knowledge available to guide policy to prevent high-risk prescribing and opioid overdoses. While further study is needed, coalitions and mandatory PDMP registration may be important components in such efforts.

Query mandates in prescription drug monitoring programs reduce opioid use among commercially insured patients with cancer

BACKGROUND

Prescription drug monitoring programs (PDMPs) have been shown to reduce opioid use in the general and noncancer populations. However, evidence of PDMP impacts on patients with cancer remains limited.

OBJECTIVE

The aim of the study was to examine the impact of PDMP mandates on individual-level opioid use among patients with cancer.

METHODS

This is a retrospective cohort study of patients with newly diagnosed cancer aged 18-65 years in the IQVIA PharMetrics Plus database (IQVIA Inc; nationally representative data of the U.S. commercially insured population in 49 states) between 2013 and 2015. The primary exposure was PDMP rigor (ranked from highest to lowest rigor): provider query + registration, query only, registration only, and unexposed. The study outcomes included (1) prevalent use among all individuals; and among opioid users (2) total days supplied, (3) daily morphine equivalent dose (MED), and (4) cumulative MED.

RESULTS

Of the eligible cohort (n=28,353), 37.5% (10,656) received opioids after a cancer diagnosis. The individuals exposed to these mandates were as follows: query + registration: 3899 (13.8%); query only: 3459 (12.2%); registration only: 2764 (9.7%); and no mandates: 18,231 (64.3%). The PDMP mandates had no effect on prevalent opioid use. Compared with unexposed patients, those subject to query mandates-alone or with registration mandates-experienced 12 fewer opioid days supplied and a lower mean cumulative MED (-662 mg and -702 mg, respectively), P < 0.01. Registration-only mandates were associated with 21 days more (P < 0.01) total days supplied and lower daily MED (1.1 mg; P < 0.05) but had no statistically significant effect on cumulative MED (-46 mg, P > 0.05).

CONCLUSION

Query mandates are a stronger PDMP tool than registration mandates in reducing opioid days supplied and cumulative MED. Initiatives should target PDMP mandates toward intended patient groups to reduce high-risk opioid use without compromising adequate pain treatment.

When an obscurity becomes trend: social-media descriptions of tianeptine use and associated atypical drug use

Background: Originally believed to be an atypical antidepressant acting at serotonin transporters, tianeptine is now known to also be an atypical agonist at mu-opioid receptors. Its nonmedical use may be increasing amidst the broader context of novel drug and supplement use.Objectives: To analyze social-media text from current, former, and prospective tianeptine users for better understanding of their conceptualizations of tianeptine, motives for and patterns of use, and reported benefits and harms.Methods: Reddit posts were obtained and thematically coded; additional quantitative analyses were conducted.Results: A total of 210 posts mentioning tianeptine were made between 2012 and 2020. Eighteen thematic categories were identified, 10 of which were consistent with expected themes. Two independent raters coded all text, generating 1,382 unique codes, of which 1,090 were concordant (78.9% interrater agreement). Tianeptine use was frequently associated with use of other drugs, particularly kratom, phenibut, and racetams. People conceptualized and variously used tianeptine as an opioid, antidepressant, and "nootropic" (cognitive enhancer). Between 2014 and 2020, mentions of positive effects decreased, while mentions of adverse effects and withdrawal increased. Motivations for use included substitution or withdrawal mitigation for other drugs (especially opioids) and for kratom itself; self-treatment for psychiatric symptoms; and improvement of quality of life, mood, or performance. Descriptions of tolerance, withdrawal, and addiction were evident. Intravenous use was rare and strongly discouraged, with detrimental effects described.Conclusion: Tianeptine is recognized as an opioid (though not only an opioid) in online communities. Posts describe benefits, acute risks, and patterns of co-use that warrant greater clinical attention.

Prescription Drug Monitoring Program: Access in the First Year

BACKGROUND AND OBJECTIVES

Prescription Drug Monitoring Programs (PDMP) detect high-risk prescribing and patient behaviors. This study describes the characteristics associated with documented PDMP access when prescribing opioids.

METHODS

Retrospective chart review of 695 opioid prescriptions written from inpatient and outpatient medical and psychiatric settings. Data were abstracted and analyzed to identify characteristics associated with documented PDMP access.

RESULTS

One-third of the charts had PDMP access documented within the week of opioid prescription; 12% showed PDMP consultation on the same day. Services varied greatly from 10.5% (inpatient medicine) to 57% (inpatient psychiatry) with regard to same-day PDMP access (P < .0001). Patient characteristics associated with PDMP access include having acute pain, current mental health treatment, and current and past substance use disorders (all P < .05). Logistic regression modeling identified three variables associated with the odds of PDMP access (c-statistic = 0.66): if the prescription originated from the inpatient medicine unit (odds ratio [OR] = 0.47, 95% confidence interval [CI] = 0.32, 0.68), or if the patient received a prescription for an opioid in the past 30 days (OR = 0.30, 95% CI = 0.10, 0.90) or had a urine toxicology screen in the past year (OR = 2.00, 95% CI = 1.40, 2.90).

DISCUSSION AND CONCLUSIONS

Utilization of the PDMP varied by specialty and setting.

SCIENTIFIC SIGNIFICANCE

This study is among the first to compare rates of PDMP access in a large sample by specialty and practice setting in a healthcare system with a policy requiring its access and appropriate documentation. With less than one-third adherence to the policy, additional steps to increase consistent PDMP access are warranted. (Am J Addict 2021;00:00-00).

Measuring Relationships Between Proactive Reporting State-level Prescription Drug Monitoring Programs and County-level Fatal Prescription Opioid Overdoses

BACKGROUND

Prescription drug monitoring programs (PDMPs) that collect and distribute information on dispensed controlled substances have been adopted by nearly all US states. We know little about program characteristics that modify PDMP impact on prescription opioid (PO) overdose deaths.

METHODS

We measured associations between adoption of any PDMP and changes in fatal PO overdoses in 2002-2016 across 3109 counties in 49 states and D.C. We then measured changes related to the adoption of "proactive PDMPs," which report outlying prescribing/dispensing patterns and provide broader access to PDMP data by law enforcement. Comparisons were made within 3 time intervals that broadly represent the evolution of PDMPs (2002-2004, 2005-2009, and 2010-2016). We modeled overdoses using Bayesian space-time models.

RESULTS

Adoption of electronic PDMP access was associated with 9% lower rates of fatal PO overdoses after three years (rate ratio [RR] = 0.91, 95% credible interval [CI]: 0.88-0.93) with well-supported effects for methadone (RR = 0.86,95% CI: 0.82-0.90) and other synthetic opioids (RR = 0.82, 95% CI: 0.77-0.86). Compared with states with no/weak PDMPs, proactive PDMPs were associated with fewer deaths attributed to natural/semi-synthetic opioids (2002-2004: RR = 0.72 [0.66-0.78]; 2005-2009: RR = 0.93 [0.90-0.97]; 2010-2016: 0.89 [0.86-0.92]) and methadone (2002-2004: RR = 0.77 [0.69-0.85]; 2010-2016: RR = 0.90 [0.86-0.94]). Unintended effects were observed for synthetic opioids other than methadone (2005-2009: RR = 1.29 [1.21-1.38]; 2010-2016: RR = 1.22 [1.16-1.29]).

CONCLUSIONS

State adoption of PDMPs was associated with fewer PO deaths overall while proactive PDMPs alone were associated with fewer deaths related to natural/semisynthetic opioids and methadone, the specific targets of these programs. See video abstract at, http://links.lww.com/EDE/B619.

Association Between State Policies on Improving Opioid Prescribing in 2 States and Opioid Overdose Rates Among Reproductive-aged Women

BACKGROUND

The opioid overdose epidemic has been declared a public health emergency. Women are more likely than men to be prescribed opioid medications. Some states have adopted policies to improve opioid prescribing, including prescription drug monitoring programs (PDMPs) and pain clinic laws.

OBJECTIVE

Among reproductive-aged women, we examined the association of mandatory use laws for PDMPs in Kentucky (concurrent with a pain clinic law) and New York with overdose involving prescription opioids or heroin and opioid use disorder (OUD).

STUDY DESIGN, SUBJECTS, AND OUTCOME MEASURES

We conducted interrupted time series analyses estimating outcome changes after policy implementation in Kentucky and New York, compared with geographically close states without these policies (comparison states), using 2010-2014 State Inpatient and State Emergency Department Databases. Outcomes included rates of inpatient discharges and emergency department visits for overdoses involving prescription opioids or heroin and OUD among reproductive-aged women.

RESULTS

Relative to comparison states, following Kentucky's policy change, we found an immediate postpolicy decrease and a decreasing trend in the rate of overdoses involving prescription opioids, an immediate postpolicy increase in the rate of overdoses involving heroin, and a decreasing trend in the OUD rate (P<0.01); New York's policy change was not associated with the assessed outcomes.

CONCLUSIONS

PDMPs and pain clinic laws, such as those implemented in Kentucky, may be promising strategies to reduce the adverse impacts of high-risk opioid prescribing among reproductive-aged women. As states continue efforts to improve inappropriate opioid prescribing, similar strategies as those adopted in Kentucky merit consideration.

Systematic Evaluation of State Policy Interventions Targeting the US Opioid Epidemic, 2007-2018

Importance

In response to the increase in opioid overdose deaths in the United States, many states recently have implemented supply-controlling and harm-reduction policy measures. To date, an updated policy evaluation that considers the full policy landscape has not been conducted.

Objective

To evaluate 6 US state-level drug policies to ascertain whether they are associated with a reduction in indicators of prescription opioid abuse, the prevalence of opioid use disorder and overdose, the prescription of medication-assisted treatment (MAT), and drug overdose deaths.

Design, Setting, and Participants

This cross-sectional study used drug overdose mortality data from 50 states obtained from the National Vital Statistics System and claims data from 23 million commercially insured patients in the US between 2007 and 2018. Difference-in-differences analysis using panel matching was conducted to evaluate the prevalence of indicators of prescription opioid abuse, opioid use disorder and overdose diagnosis, the prescription of MAT, and drug overdose deaths before and after implementation of 6 state-level policies targeting the opioid epidemic. A random-effects meta-analysis model was used to summarize associations over time for each policy and outcome pair. The data analysis was conducted July 12, 2020.

Exposures

State-level drug policy changes to address the increase of opioid-related overdose deaths included prescription drug monitoring program (PDMP) access, mandatory PDMPs, pain clinic laws, prescription limit laws, naloxone access laws, and Good Samaritan laws.

Main Outcomes and Measures

The outcomes of interests were quarterly state-level mortality from drug overdoses, known indicators for prescription opioid abuse and doctor shopping, MAT, and prevalence of drug overdose and opioid use disorder.

Results

This cross-sectional study of drug overdose mortality data and insurance claims data from 23 million commercially insured patients (12 582 378 female patients [55.1%]; mean [SD] age, 45.9 [19.9] years) in the US between 2007 and 2018 found that mandatory PDMPs were associated with decreases in the proportion of patients taking opioids (-0.729%; 95% CI, -1.011% to -0.447%), with overlapping opioid claims (-0.027%; 95% CI, -0.038% to -0.017%), with daily morphine milligram equivalent greater than 90 (-0.095%; 95% CI, -0.150% to -0.041%), and who engaged in drug seeking (-0.002%; 95% CI, -0.003% to -0.001%). The proportion of patients receiving MAT increased after the enactment of mandatory PDMPs (0.015%; 95% CI, 0.002% to 0.028%), pain clinic laws (0.013%, 95% CI, 0.005%-0.021%), and prescription limit laws (0.034%, 95% CI, 0.020% to 0.049%). Mandatory PDMPs were associated with a decrease in the number of overdose deaths due to natural opioids (-518.5 [95% CI, -728.5 to -308.5] per 300 million people) and methadone (-122.7 [95% CI, -207.5 to -37.8] per 300 million people). Prescription drug monitoring program access policies showed similar results, although these policies were also associated with increases in overdose deaths due to synthetic opioids (380.3 [95% CI, 149.6-610.8] per 300 million people) and cocaine (103.7 [95% CI, 28.0-179.5] per 300 million people). Except for the negative association between prescription limit laws and synthetic opioid deaths (-723.9 [95% CI, -1419.7 to -28.1] per 300 million people), other policies were associated with increasing overdose deaths, especially those attributed to non-prescription opioids such as synthetic opioids and heroin. This includes a positive association between naloxone access laws and the number of deaths attributed to synthetic opioids (1338.2 [95% CI, 662.5 to 2014.0] per 300 million people).

Conclusions and Relevance

Although this study found that existing state policies were associated with reduced misuse of prescription opioids, they may have the unintended consequence of motivating those with opioid use disorders to access the illicit drug market, potentially increasing overdose mortality. This finding suggests that there is no easy policy solution to reverse the epidemic of opioid dependence and mortality in the US.

Changes in opioid prescribing after implementation of mandatory registration and proactive reports within California's prescription drug monitoring program

BACKGROUND

In 2016, California updated its prescription drug monitoring program (PDMP), adding two key features: automated proactive reports to prescribers and mandatory registration for prescribers and pharmacists. The effects of these changes on prescribing patterns have not yet been examined. We aimed to evaluate the joint effect of these two PDMP features on county-level prescribing practices in California.

METHODS

Using county-level quarterly data from 2012 to 2017, we estimated the absolute change associated with the implementation of these two PDMP features in seven prescribing indicators in California versus a control group comprising counties in Florida and Washington: opioid prescription rate per 1000 residents; patients' mean daily opioid dosage in milligrams of morphine equivalents[MME]; prescribers' mean daily MME prescribed; prescribers' mean number of opioid prescriptions per day; percentage of patients getting >90 MME/day; percentage of days with overlapping prescriptions for opioids and benzodiazepines; multiple opioid provider episodes per 100,000 residents.

RESULTS

Proactive reports and mandatory registration were associated with a 7.7 MME decrease in patients' mean daily opioid dose (95 %CI: -11.4, -2.9); a 1.8 decrease in the percentage of patients prescribed high-dose opioids (95 %CI: -2.3, -0.9); and a 6.3 MME decrease in prescribers' mean daily dose prescribed (95 %CI: -10.0, -1.3).

CONCLUSIONS

California's implementation of these two PDMP features was associated with decreases in the total quantity of opioid MMEs prescribed, and indicators of patients prescribed high-dose opioids compared to states that had PDMP's without these features. Rates of opioid prescribing and other high-risk prescribing patterns remained unchanged.

The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): Evidence-based practices in the HEALing Communities Study

BACKGROUND

The number of opioid-involved overdose deaths in the United States remains a national crisis. The HEALing Communities Study (HCS) will test whether Communities That HEAL (CTH), a community-engaged intervention, can decrease opioid-involved deaths in intervention communities (n = 33), relative to wait-list communities (n = 34), from four states. The CTH intervention seeks to facilitate widespread implementation of three evidence-based practices (EBPs) with the potential to reduce opioid-involved overdose fatalities: overdose education and naloxone distribution (OEND), effective delivery of medication for opioid use disorder (MOUD), and safer opioid analgesic prescribing. A key challenge was delineating an EBP implementation approach useful for all HCS communities.

METHODS

A workgroup composed of EBP experts from HCS research sites used literature reviews and expert consensus to: 1) compile strategies and associated resources for implementing EBPs primarily targeting individuals 18 and older; and 2) determine allowable community flexibility in EBP implementation. The workgroup developed the Opioid-overdose Reduction Continuum of Care Approach (ORCCA) to organize EBP strategies and resources to facilitate EBP implementation.

CONCLUSIONS

The ORCCA includes required and recommended EBP strategies, priority populations, and community settings. Each EBP has a "menu" of strategies from which communities can select and implement with a minimum of five strategies required: one for OEND, three for MOUD, and one for prescription opioid safety. Identification and engagement of high-risk populations in OEND and MOUD is an ORCCArequirement. To ensure CTH has community-wide impact, implementation of at least one EBP strategy is required in healthcare, behavioral health, and criminal justice settings, with communities identifying particular organizations to engage in HCS-facilitated EBP implementation.

A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018

OBJECTIVES

In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies.

METHODS

We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings.

RESULTS

The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed.

CONCLUSIONS

Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.

The state of the science in opioid policy research

OBJECTIVE

Characterize the state of the science in opioid policy research based on a literature review of opioid policy studies.

METHODS

We conducted a scoping review of studies evaluating the impact of U.S. state-level and federal-level policies on opioid-related outcomes published in 2005-2018. We characterized: 1) state and federal policies evaluated, 2) opioid-related outcomes examined, and 3) study design and analytic methods (summarized overall and by policy category).

RESULTS

In total, 145 studies were reviewed (79 % state-level policies, 21 % federal-level policies) and classified with respect to 8 distinct policy categories and 7 outcome categories. The majority of studies evaluated policies related to prescription opioids (prescription drug monitoring programs (PDMPs), opioid prescribing policies, federal regulation of prescription opioids, pain clinic laws) and considered policy impacts with respect to proximal outcomes (e.g., opioid prescribing behaviors). In total, only 29 (20 % of studies) met each of three key criteria for rigorous design: analysis of longitudinal data with a comparison group design, adjustment for difference between policy-enacting and comparison states, and adjustment for potentially confounding co-occurring policies. These more rigorous studies were predominately published in 2017-2018 and primarily evaluated PDMPs, marijuana laws, treatment-related policies, and overdose prevention policies.

CONCLUSIONS

Our results indicated that study design rigor varied notably across policy categories, highlighting the need for broader adoption of rigorous methods in the opioid policy field. More evaluation studies are needed regarding overdose prevention policies and policies related to treatment access. Greater examination of distal outcomes and potential unintended consequences are also warranted.

Prescriber and pharmacist understanding of revised Rhode Island pain management regulations

INTRODUCTION

Federal agencies and national associations have implemented action plans in response to the opioid crisis. Furthermore, over 30 states have enacted legislation with opioid-related restrictions, guidance, or requirements. Following recommendations from the governor-appointed Overdose Prevention and Intervention Task Force, the Rhode Island Department of Health developed an original and updated version of Pain Management Regulations in March 2017 and July 2018, respectively. Our study aimed to identify disparities in interpretation and misconceptions of the updated Rhode Island Department of Health new Pain Management Regulations.

METHODS

Our 29-question survey evaluated pharmacist and prescriber knowledge of regulations, with special attention given to pain management in patients with cancer.

RESULTS

Thirty-two prescribers and 33 pharmacists completed the survey. The survey identified significant variance in regulation knowledge. Pharmacists correctly identified diagnosis exclusions 13-84% of the time, with a much greater understanding when diagnosis language was used instead of ICD-10 codes. Prescribers correctly identified exclusions 24-46% of the time, with little difference noted when using diagnosis language versus ICD-10 codes. The majority (59.3%) of pharmacists misclassified patients with no prescription dispensed in 30 days as patients who would be considered opioid-naïve. Both prescribers and pharmacists commonly misidentified the frequency with which the prescription drug monitoring program needs to be checked, although in both scenarios were stricter than the regulations themselves. In addition, there were significant differences in interpretation regarding naloxone co-prescribing requirements and patient awareness of naloxone co-prescribing between prescribers and pharmacists.

CONCLUSION

Our findings outline several misinterpretations that affect access to chronic and cancer-related pain opioid prescriptions, despite several Rhode Island Department of Health-initiated interventions. When adopting regulations, states should proactively develop educational initiatives to avoid access challenges for patients with diagnoses of exclusion.

Prescription Drug Monitoring Programs and Prescription Opioid-Related Outcomes in the United States

Prescription drug monitoring programs (PDMPs) are a crucial component of federal and state governments' response to the opioid epidemic. Evidence about the effectiveness of PDMPs in reducing prescription opioid-related adverse outcomes is mixed. We conducted a systematic review to examine whether PDMP implementation within the United States is associated with changes in 4 prescription opioid-related outcome domains: opioid prescribing behaviors, opioid diversion and supply, opioid-related morbidity and substance-use disorders, and opioid-related deaths. We searched for eligible publications in Embase, Google Scholar, MEDLINE, and Web of Science. A total of 29 studies, published between 2009 and 2019, met the inclusion criteria. Of the 16 studies examining PDMPs and prescribing behaviors, 11 found that implementing PDMPs reduced prescribing behaviors. All 3 studies on opioid diversion and supply reported reductions in the examined outcomes. In the opioid-related morbidity and substance-use disorders domain, 7 of 8 studies found associations with prescription opioid-related outcomes. Four of 8 studies in the opioid-related deaths domain reported reduced mortality rates. Despite the mixed findings, emerging evidence supports that the implementation of state PDMPs reduces opioid prescriptions, opioid diversion and supply, and opioid-related morbidity and substance-use disorder outcomes. When PDMP characteristics were examined, mandatory access provisions were associated with reductions in prescribing behaviors, diversion outcomes, hospital admissions, substance-use disorders, and mortality rates. Inconsistencies in the evidence base across outcome domains are due to analytical approaches across studies and, to some extent, heterogeneities in PDMP policies implemented across states and over time.

The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review

Policy Points This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high-risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient-related outcomes.

CONTEXT

In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction.

METHODS

We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health.

FINDINGS

Seventy-one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws.

CONCLUSIONS

Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health-related outcomes.

Prescription drug monitoring programs and drug overdose deaths involving benzodiazepines and prescription opioids

BACKGROUND AND AIMS

In the US, benzodiazepine overdose deaths increased at an alarming rate in the past two decades. Benzodiazepines were also the most common drugs involved in prescription opioid overdose deaths. Benzodiazepine prescribing has been monitored by Prescription Drug Monitoring Programs (PDMPs), but little was known about whether PDMPs reduced drug overdose deaths involving benzodiazepines.

DESIGN AND METHODS

This study used a difference-in-difference design with state-quarter aggregate data on drug overdose deaths. The primary data source was Mortality Multiple Cause Files in 1999-2016. Three age-adjusted rates of drug overdose deaths were examined, including those involving benzodiazepines, those involving prescription opioids, and those involving both benzodiazepines and prescription opioids. The policy variables included PDMP data access for benzodiazepines and mandatory use of PDMP data for benzodiazepines. Linear multivariable regressions were used to assess the associations of PDMP policies specific to benzodiazepines with drug overdose death rates, controlling for other state-level policy and socioeconomic factors, state and time fixed effects, and state-specific time trends.

RESULTS

No significant associations were found between PDMP data access for benzodiazepines and changes in drug overdose death rates involving benzodiazepines and/or prescription opioids. Similarly, no significant associations were found between mandatory use of PDMP data for benzodiazepines and changes in drug overdose death outcomes.

DISCUSSION AND CONCLUSIONS

This study suggested no evidence that PDMP policies specific to benzodiazepines were associated with reduction in benzodiazepine overdose death rates. Future research is warranted to examine detailed features of PDMPs and continuously monitor the impacts of PDMP policies on benzodiazepine-related consequences.

The association between pain clinic laws and prescription opioid exposures: New evidence from multi-state comparisons

OBJECTIVES

States in the US are controlling opioid prescribing to combat the opioid epidemic. Prescription Drug Monitoring Programs (PDMPs) were widely adopted, whereas less attention was given to pain clinic laws. This study examined the associations of mandatory use of PDMPs and pain clinic laws with prescription opioid exposures.

METHODS

State-level quarterly prescription opioid exposures reported to the National Poison Data System during 2010-2017 were analyzed. The primary outcome was age-adjusted rates of prescription opioid exposures per 1,000,000 population. The primary policy variables included the implementation of mandatory use of PDMPs alone, the implementation of pain clinic laws alone, and the implementation of both mandatory use of PDMPs and pain clinic laws. Linear regressions were used to examine the associations, controlling for other opioid policies, marijuana policies, socioeconomic factors, state fixed effects, time fixed effects, and state-specific time trends.

RESULTS

Requiring mandatory use of PDMPs alone was not associated with significant changes in prescription opioid exposures. The implementation of pain clinic laws with or without concurrent mandatory use of PDMPs was associated with 5 fewer prescription opioid exposures per 1,000,000 population or a 9 % reduction compared to the pre-policy period (p < 0.01). Further analysis revealed that the reduction associated with pain clinic laws was pronounced in exposures reported by healthcare facilities.

CONCLUSIONS

This multi-state study provided new evidence that the implementation of pain clinic laws was associated with a significant reduction in prescription opioid exposures. Pain clinic laws may deserve further evaluation and consideration.

Prescription drug monitoring programs operational characteristics and fatal heroin poisoning

BACKGROUND

Prescription drug monitoring programs (PDMP), by reducing access to prescribed opioids (POs), may contribute to a policy environment in which some people with opioid dependence are at increased risk for transitioning from POs to heroin/other illegal opioids. This study examines how PDMP adoption and changes in the characteristics of PDMPs over time contribute to changes in fatal heroin poisoning in counties within states from 2002 to 2016.

METHODS

Latent transition analysis to classify PDMPs into latent classes (Cooperative, Proactive, and Weak) for each state and year, across three intervals (1999-2004, 2005-2009, 2010-2016). We examined the association between probability of PDMP latent class membership and the rate of county-level heroin poisoning death.

RESULTS

After adjustment for potential county-level confounders and co-occurring policy changes, adoption of a PDMP was significantly associated with increased heroin poisoning rates (22% increase by third year post-adoption). Findings varied by PDMP type. From 2010-2016, states with Cooperative PDMPs (those more likely to share data with other states, to require more frequent reporting, and include more drug schedules) had 19% higher heroin poisoning rates than states with Weak PDMPs (adjusted rate ratio [ARR] = 1.19; 95% CI = 1.14, 1.25). States with Proactive PDMPs (those more likely to report outlying prescribing and dispensing and provide broader access to law enforcement) had 6% lower heroin poisoning rates than states with No/Weak PDMPs (ARR = 0.94; 95% CI = 0.90, 0.98).

CONCLUSION

There is a consistent, positive association between state PDMP adoption and heroin poisoning mortality. However, this varies by PDMP type, with Proactive PDMPs associated with a small reduction in heroin poisoning deaths. This raises questions about the potential for PDMPs to support efforts to decrease heroin overdose risk, particularly by using proactive alerts to identify patients in need of treatment for opioid use disorder. Future research on mechanisms explaining the reduction in heroin poisonings after enactment of Proactive PDMPs is merited.

Mandatory use of prescription drug monitoring program and benzodiazepine prescribing among U.S. Medicaid enrollees

BACKGROUND

In the past two decades, the U.S. saw an alarmingly increasing trend of benzodiazepine prescribing. Mandatory use of Prescription Drug Monitoring Programs (PDMPs) was suggested to have the potential to reduce opioid prescribing, but little is known about its impacts on benzodiazepines. This study examined whether PDMP data use mandates were associated with changes in benzodiazepine prescribing in the U.S. Methods: Aggregate state quarterly prescription drug records of benzodiazepines for Medicaid enrollees during 2010-2017 were obtained from the U.S. Medicaid State Drug Utilization Data. Three population-adjusted outcome variables were evaluated, including quantity, dosage, and Medicaid spending of benzodiazepine prescriptions per quarter per 100 Medicaid enrollees. The primary policy variable was the state-wide implementation of PDMP data use mandates for benzodiazepines. To account for between-state variations in mandates, an additional policy variable was considered to indicate strong mandates on PDMP data use, which required all prescribers to query a patient's PDMP records for first prescribing and subsequent prescribing at least every 12 months. Linear regressions with difference-in-difference approach were used to assess the associations between PDMP data use mandates and benzodiazepine prescribing, controlling for state-level time-varying policy and socioeconomic covariates. Results: The state-wide implementation of PDMP data use mandates for benzodiazepines was not associated with quantity, dosage, or Medicaid spending of benzodiazepine prescriptions. Strong mandates on PDMP data use were not associated with any benzodiazepine prescribing outcomes, either. Conclusions: There was no evidence for the associations between PDMP data use mandates for benzodiazepines and changes in benzodiazepine prescribing among Medicaid enrollees. Future research is warranted to replicate the study in other populations using individual patient records and continuously monitor the trends in benzodiazepine prescribing in association with PDMPs.

The effectiveness of prescription drug monitoring programs at reducing opioid-related harms and consequences: a systematic review

Background

In order to address the opioid crisis in North America, many regions have adopted preventative strategies, such as prescription drug monitoring programs (PDMPs). PDMPs aim to increase patient safety by certifying that opioids are prescribed in appropriate quantities. We aimed to synthesize the literature on changes in opioid-related harms and consequences, an important measure of PDMP effectiveness.

Methods

We completed a systematic review. We conducted a narrative synthesis of opioid-related harms and consequences from PDMP implementation. Outcomes were grouped into categories by theme: opioid dependence, opioid-related care outcomes, opioid-related adverse events, and opioid-related legal and crime outcomes.

Results

We included a total of 22 studies (49 PDMPs) in our review. Two studies reported on illicit and problematic use but found no significant associations with PDMP status. Eight studies examined the association between PDMP status and opioid-related care outcomes, of which two found that treatment admissions for prescriptions opioids were lower in states with PDMP programs (p < 0.05). Of the thirteen studies that reported on opioid-related adverse events, two found significant (p < 0.001 and p < 0.05) but conflicting results with one finding a decrease in opioid-related overdose deaths after PDMP implementation and the other an increase. Lastly, two studies found no statistically significant association between PDMP status and opioid-related legal and crime outcomes (crime rates, identification of potential dealers, and diversion).

Conclusion

Our study found limited evidence to support overall associations between PDMPs and reductions in opioid-related consequences. However, this should not detract from the value of PDMPs’ larger role of improving opioid prescribing.

Co-prescription network reveals social dynamics of opioid doctor shopping

This paper examines network prominence in a co-prescription network as an indicator of opioid doctor shopping (i.e., fraudulent solicitation of opioids from multiple prescribers). Using longitudinal data from a large commercially insured population, we construct a network where a tie between patients is weighted by the number of shared opioid prescribers. Given prior research suggesting that doctor shopping may be a social process, we hypothesize that active doctor shoppers will occupy central structural positions in this network. We show that network prominence, operationalized using PageRank, is associated with more opioid prescriptions, higher predicted risk for dangerous morphine dosage, opioid overdose, and opioid use disorder, controlling for number of prescribers and other variables. Moreover, as a patient's prominence increases over time, so does their risk for these outcomes, compared to their own average level of risk. Results highlight the importance of co-prescription networks in characterizing high-risk social dynamics.

Impact of Schedule IV controlled substance classification on carisoprodol utilization in the United States: An interrupted time series analysis

BACKGROUND

In January 2012, the Drug Enforcement Agency (DEA) classified carisoprodol as a Schedule IV controlled substance at the US federal level. We aimed to examine the effect of this policy on the use of carisoprodol in a commercially-insured population.

METHODS

This interrupted time series study included individuals with musculoskeletal disorders in the IBM MarketScan Commercial Database between December 2009 and February 2014. We used comparative segmented linear regression to assess changes in the proportions of patients who filled/newly filled carisoprodol each month.

RESULTS

A total of 13.3 million patients were included. 29 states with no scheduling prior to the DEA classification had lower baseline prevalence of carisoprodol use compared to 17 states that had scheduled carisoprodol individually before 2010 (11.0 vs. 21.1 patients with fills per 1000 patients). The federal scheduling was associated with an immediate decline (-1.12 per 1000 patients, p < 0.01) and decreasing trend in prevalence (-0.07 per 1000 patients per month, p = 0.02). This effect was not modified by existing state-level scheduling status. During the first, second, third, and fourth 6-month periods after federal scheduling, the relative difference between observed and predicted prevalence was 7.8%, 10.5%, 13.4%, and 19.8%. Similar patterns were observed for carisoprodol initiation. Overall, declining use was more pronounced among younger age groups and patients with injury.

CONCLUSIONS

Schedule IV controlled substance classification at the federal level was associated with a moderate reduction in the dispensing of carisoprodol regardless of whether scheduling was already present at the state level.

Prescription drug monitoring programs: Assessing the association between "best practices" and opioid use in Medicare

OBJECTIVE

To estimate the impact of implementing prescription drug monitoring program (PDMP) best practices on prescription opioid use.

DATA SOURCES

2007-2012 Medicare claims for noncancer pain patients, and PDMP attributes from the Prescription Drug Abuse Policy System.

STUDY DESIGN

We derived PDMP composite scores using the number of best practices adopted by states (range: 0-14), classifying states as either no PDMP, low strength (0 < score < median), or high strength (score ≥ median). Using generalized linear models, we quantified the association between the PDMP score category and opioid use measures-overall and stratified by disability/age. Sensitivity analyses assessed the general Medicare sample regardless of pain diagnoses, individual PDMP characteristics, and compared GEE model findings to models with state fixed effects.

PRINCIPAL FINDINGS

Compared to non-PDMP states, strong PDMP states had lower opioid cumulative doses (-296 mg; 95% CI: -512, -132), days supplied (-7.84; 95% CI: -10.6, -5.04), prescription fill rates (0.97; 95% CI: 0.95, 0.98), and mean daily doses (-2.31 mg; 95% CI: -3.14, -1.48) but greater prevalence of high opioid doses in disabled adults, whereas there was little or no change in older adults. Findings in states with weak PDMPs were substantively similar to those of strong PDMPs. Results from sensitivity analyses were mostly consistent with main findings except there was a null relationship with mean daily doses and high doses in models with state fixed effects.

CONCLUSIONS

Comprehensive or minimal adoption of PDMP best practices was associated with mostly comparable effects on Medicare beneficiaries' opioid use; however, these effects were concentrated among nonelderly disabled adults.

A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health

The opioid crisis has reached epidemic proportions in the United States with rising overdose death rates. Identifying the underlying factors that contribute to addiction vulnerability may lead to more effective prevention strategies. Supply side environmental factors are a major contributing component. Psychosocial factors such as stress, trauma, and adverse childhood experiences have been linked to emotional pain leading to self-medication. Genetic and epigenetic factors associated with brain reward pathways and impulsivity are known predictors of addiction vulnerability. This review attempts to present a biopsychosocial approach that connects various social and biological theories related to the addiction crisis. The emerging role of nutrition therapy with an emphasis on gastrointestinal health in the treatment of opioid use disorder is presented. The biopsychosocial model integrates concepts from several disciplines, emphasizing multicausality rather than a reductionist approach. Potential solutions at multiple levels are presented, considering individual as well as population health. This single cohesive framework is based on the interdependency of the entire system, identifying risk and protective factors that may influence substance-seeking behavior. Nutrition should be included as one facet of a multidisciplinary approach toward improved recovery outcomes. Cross-disciplinary collaborative efforts, new ideas, and fiscal resources will be critical to address the epidemic.

The Role of Pharmacists in Safe Opioid Dispensing

Opioid misuse, abuse, and diversion continues to be a public health issue. Pharmacists (particularly those who work in the community setting) form the vanguard of health-care providers facing the opioid crisis because they have the opportunity to interact with patients more frequently than primary care or specialty medical providers. These frequent interactions give pharmacists more opportunities to properly counsel patients on prevention and to reinforce appropriate use of opioid medications. Pharmacists should be aware of the strategies for reducing opioid misuse, abuse, and diversion, including understanding mandates on prescription limitations; knowing how to use prescription drug monitoring programs; knowing when drug take-back programs are occurring; educating patients on the risks of opioid abuse, safe storage, and proper disposal of unused medications; identifying "red flag" behavior that may indicate opioid misuse; using assessments that help identify a patient's risk for opioid abuse; interacting with other health-care professionals to discuss a patient's care; understanding how abuse-deterrent opioids work and their limitations; preparing for opioid overdose management and understanding the local regulations on naloxone availability; and knowing when to refer patients to addiction services. Using these strategies, pharmacists have an opportunity to potentially reduce opioid abuse and improve patient outcomes.

Assessing The Impact Of State Policies For Prescription Drug Monitoring Programs On High-Risk Opioid Prescriptions

Policies and practices have proliferated to optimize prescribers' use of their states' prescription drug monitoring programs, which are statewide databases of controlled substances dispensed at retail pharmacies. Our study assessed the effectiveness of three such policies: comprehensive legislative mandates to use the program, laws that allow prescribers to delegate its use to office staff, and state participation in interstate data sharing. Our analysis of information from a large commercial insurance database indicated that comprehensive use mandates implemented during 2011-15 were associated with a 6-9 percent reduction in opioid prescriptions with high risk for misuse and overdose. We also found delegate laws to be associated with reductions of a similar magnitude for selected outcomes. In general, the effects of all three policies strengthened over time, especially beginning in the second year after implementation. Our findings support comprehensive use mandates and delegate laws to optimize prescribers' use of drug monitoring programs, but the results will need updates in the context of evolving state opioid policies-including the increasing integration of drug monitoring data with electronic health records.

Association of Naloxone Coprescription Laws With Naloxone Prescription Dispensing in the United States

IMPORTANCE

To mitigate the opioid overdose crisis, states have implemented a variety of legal interventions aimed at increasing access to the opioid antagonist naloxone. Recently, Virginia and Vermont mandated the coprescription of naloxone for potentially at-risk patients.

OBJECTIVE

To assess the association between naloxone coprescription legal mandates and naloxone dispensing in retail pharmacies.

DESIGN, SETTING, AND PARTICIPANTS

This was a population-based, state-level cohort study. The sample included all prescriptions dispensed for naloxone in the retail pharmacy setting contained in IQVIA's national prescription audit, which represents 90% of all retail pharmacies in the United States. The unit of observation was state-month and the study period was January 1, 2011, to December 31, 2017.

EXPOSURES

State legal intervention mandating naloxone coprescription.

MAIN OUTCOMES AND MEASURES

Number of naloxone prescriptions dispensed. State rates of naloxone prescriptions dispensed per month per 100 000 standard population were calculated.

RESULTS

The rate of naloxone dispensing increased after implementation of legal mandates for naloxone coprescription. An estimated 88 naloxone prescriptions per 100 000 were dispensed in Virginia and 111 prescriptions per 100 000 were dispensed in Vermont during the first full month the legal requirement was effective. In comparison, 16 naloxone prescriptions per 100 000 were dispensed in the 10 states (including the District of Columbia) with the highest opioid overdose death rates and 6 prescriptions per 100 000 were dispensed in the 39 remaining states. The number of naloxone prescriptions dispensed was associated with the legal mandate for naloxone coprescription (incidence rate ratio [IRR], 7.75; 95% CI, 1.22-49.35). Implementation of the naloxone coprescription mandate was associated with an estimated 214 additional naloxone prescriptions dispensed per month in the period following the mandates, holding all other variables constant. Among covariates, naloxone access laws (IRR, 1.37; 1.05-1.78), opioid overdose death rates (IRR, 1.06; 95% CI, 1.04-1.08), the percentage of naloxone prescriptions paid by third-party payers (IRR 1.009; 1.008-1.010), and time (IRR, 1.06; 95% CI, 1.05-1.07) were significantly associated with naloxone prescription dispensing.

CONCLUSIONS AND RELEVANCE

These study findings suggest that legally mandated naloxone prescription for those at risk for opioid overdose may be associated with substantial increases in naloxone dispensing and further reduction in opioid-related harm.

Effects of mandatory prescription drug monitoring program (PDMP) use laws on prescriber registration and use and on risky prescribing

BACKGROUND

Comprehensive mandatory use laws for prescription drug monitoring programs (PDMPs) have been implemented in a number of states to help address the opioid overdose epidemic. These laws may reduce opioid-related overdose deaths by increasing prescribers' use of PDMPs and reducing high-risk prescribing behaviors.

METHODS

We used state PDMP data to examine the effect of these mandates on prescriber registration, use of the PDMP, and on prescription-based measures of patient risk in three states-Kentucky, Ohio, and West Virginia-that implemented mandates between 2010 and 2015. We conducted comparative interrupted time series analyses to examine changes in outcome measures after the implementation of mandates in the mandate states compared to control states.

RESULTS

Mandatory use laws increased prescriber registration and utilization of the PDMP in the mandate states compared to controls. The multiple provider episode rate, rate of opioid prescribing, rate of overlapping opioid prescriptions, and rate of overlapping opioid/benzodiazepine prescriptions decreased in Kentucky and Ohio. Nevertheless, the magnitude of changes in these measures varied among mandates states.

CONCLUSIONS

These findings indicate that PDMP mandates have the potential to reduce risky opioid prescribing practices. Variation in the laws may explain why the effectiveness varied between states.

Good Samaritan harm reduction policy and drug overdose deaths

OBJECTIVE

To examine the effects of a harm reduction policy, specifically Good Samaritan (GS) policy, on overdose deaths.

DATA SOURCES/STUDY SETTING

Secondary data from multiple cause of death, mortality records paired with state harm reduction and substance use prevention policy.

STUDY DESIGN

We estimate fixed effects Poisson count models to model the effect of GS policy on overdose deaths for all, prescription, and illicit drugs, controlled substances, and opioids, while controlling for other harm reduction and substance use prevention policies.

DATA COLLECTION/EXTRACTION METHODS

We merge secondary data sources by state and year between 1999 and 2016.

PRINCIPAL FINDINGS

We fail to identify a statistically significant effect of GS policy in reducing overdose deaths broadly.

CONCLUSIONS

While we are unable to identify an effect of GS policy on overdose deaths, GS policy may have important effects on first-stage outcomes not investigated in this paper. Given recent state policy changes and rapid increase in many categories of overdose deaths, additional research should continue to examine the implementation and effects of harm reduction policy specifically and substance use prevention policy broadly.

Systematic Literature Review of Prescription Drug Monitoring Programs

Prescription opioid abuse has become a serious national problem. To respond to the opioid epidemic, states have implemented prescription drug monitoring programs (PDMPs) to monitor and reduce opioid abuse. We conducted a systematic literature review to better understand the PDMP impact on reducing opioid abuse, improving prescriber practices, and how EHR integration has impacted PDMP usability. Lessons learned can help guide federal and state-based efforts to better respond to the opioid crisis.

The changing landscape of naloxone availability in the United States, 2011 - 2017

Opioid overdose deaths have been on the rise in the United States since 1999. Naloxone is a competitive opioid antagonist that rapidly reverses opioid overdose. The implementation of naloxone access laws and development of naloxone formulations that can be administered by laypersons have coincided with changes in the landscape of naloxone availability in the United States. Using data from IQVIA's National Prescription Audit^® we present the number of naloxone prescriptions dispensed quarterly from 2011 through the second quarter of 2017. The data demonstrate that nationwide naloxone dispensing increased nearly eight-fold from the fourth quarter of 2015 to the second quarter of 2017. Narcan^® was the most commonly prescribed naloxone formulation as of the second quarter of 2017, accounting for 68% of prescriptions during that quarter followed by Evzio^® (20%). There was considerable variability in the extent to which states experienced increases in naloxone dispensing, which may represent a general state-specific response to the opioid crisis, rather than direct association with opioid overdose death rates in a particular state. Although naloxone access laws continue to increase the amount of naloxone dispensed, cost remains a concern in terms of wide distribution of the life-saving medication.

Association Between Prescription Drug Monitoring Programs and Nonfatal and Fatal Drug Overdoses: A Systematic Review

Background

Prescription drug monitoring programs (PDMPs) are a key component of the president's Prescription Drug Abuse Prevention Plan to prevent opioid overdoses in the United States.

Purpose

To examine whether PDMP implementation is associated with changes in nonfatal and fatal overdoses; identify features of programs differentially associated with those outcomes; and investigate any potential unintended consequences of the programs.

Data Sources

Eligible publications from MEDLINE, Current Contents Connect (Clarivate Analytics), Science Citation Index (Clarivate Analytics), Social Sciences Citation Index (Clarivate Analytics), and ProQuest Dissertations indexed through 27 December 2017 and additional studies from reference lists.

Study Selection

Observational studies (published in English) from U.S. states that examined an association between PDMP implementation and nonfatal or fatal overdoses.

Data Extraction

2 investigators independently extracted data from and rated the risk of bias (ROB) of studies by using established criteria. Consensus determinations involving all investigators were used to grade strength of evidence for each intervention.

Data Synthesis

Of 2661 records, 17 articles met the inclusion criteria. These articles examined PDMP implementation only (n = 8), program features only (n = 2), PDMP implementation and program features (n = 5), PDMP implementation with mandated provider review combined with pain clinic laws (n = 1), and PDMP robustness (n = 1). Evidence from 3 studies was insufficient to draw conclusions regarding an association between PDMP implementation and nonfatal overdoses. Low-strength evidence from 10 studies suggested a reduction in fatal overdoses with PDMP implementation. Program features associated with a decrease in overdose deaths included mandatory provider review, provider authorization to access PDMP data, frequency of reports, and monitoring of nonscheduled drugs. Three of 6 studies found an increase in heroin overdoses after PDMP implementation.

Limitation

Few studies, high ROB, and heterogeneous analytic methods and outcome measurement.

Conclusion

Evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient, as is evidence regarding positive associations between specific administrative features and successful programs. Some evidence showed unintended consequences. Research is needed to identify a set of "best practices" and complementary initiatives to address these consequences.

Primary Funding Source

National Institute on Drug Abuse and Bureau of Justice Assistance.