Unintended Consequences: Opioid Crisis Led to Prescription Monitoring, But Did It Help?

The overdose crisis in the United States – also called the opioid crisis – began in the late 1990s. Since then, over a million people have lost their lives to drug overdose. A majority of those overdose deaths – around 75 percent – involved opioids. The first phase of the opioid crisis primarily involved prescription opioids. Specifically, a new generation of more powerful prescription opioids, such as oxycontin, drove this initial phase. We know this because increases in overdose deaths mirrored an increase in opioid prescriptions between 1999 and 2010.

To address this problem, authorities in several states created prescription drug monitoring programs (PDMPs). The goal of PDMPs is to:

“…give clinicians access to data on controlled substances dispensed to a patient with the aim of reducing misuse and diversion of opioids due to overprescribing and doctor shopping.”

Doctor shopping is when a patient is denied access to prescriptions or prescription refills from one doctor and seeks other doctors for a prescription for the same or similar medication. The idea made logical sense. Since data showed an association between the increase in overdose deaths and the increase in opioid prescriptions, an attempt to control the number of prescriptions – and prevent manipulation of the prescribing system – seemed like a good place to reduce and reverse the overdose trend.

However, something else happened. As regulators tightened rules around prescriptions with initiatives like PDMPs, people who developed opioid use disorder (OUD) while on prescription medication often turned to illicit opioids such as heroin. To learn more about this phenomenon, lease navigate to the blog section of our website and read this article:

Opioids: The Pathway from Prescription to Addiction

That article describes how an individual might go from using a physician-prescribed medication to using a dangerous illicit drug that may result in overdose and death. This article discusses a study published in 2022 that analyzes the details of that pathway, and examines the detailed consequences of the PDMPs established between 2010 and 2015 with the intention of reducing the overall harm caused by the overdose/opioid crisis.

Prescription Monitoring Programs: Our First Step in Addressing the Opioid Crisis

As we mention above, PDMPs make sense. Between 1999 and 2010, opioid overdose rates increased alongside opioid prescription rates. Therefore, reducing prescription rates should reduce overdose rates.

Interviewed in the online science journal Science Daily, medical researcher Dr. Tongil Kim, a lead author on a study we introduce below, observes:

“Easy access to prescription opioids can further exacerbate opioid dependence and abuse. Mandated PDMP use can curb such doctor-shopping behavior.”

However, before state authorities put prescription monitoring programs in place, earlier evidence showed the potential negative consequences. Dr. Kim elaborates:

“Past research has shown that when facing restricted access to addictive substances, individuals simply seek out alternatives rather than limiting consumption. Therefore, it is critical to assess whether any curb on the supply of prescription opioids leads to an overall reduction in opioid consumption or whether patients simply seek out illicit alternatives, such as heroin.”

That critical assessment is the subject of the study “Electronic Prescription Monitoring and The Opioid Epidemic,” published in July 2022. The research effort had two primary goals:

1. To examine how prescription monitoring programs change prescribing patterns and practices.
2. To examine how patients respond to changes in prescribing. Do they seek alternatives or cease/limit consumption of the prescription medication?

To explore these two areas, the research team formulated two hypotheses:

Hypothesis 1: Mandating PDMP use reduces opioid prescription rates.

Hypothesis 2: Mandated PDMP use leads to greater abuse of heroin.

Let’s look at their data and learn whether they confirmed or refuted their hypotheses.

Prescription Monitoring and Prescription Rates: The Results

To assess the effect of PMDPs on prescribing rates and rates of opioid overdose, researchers used two primary sources.

For prescription rates, they used the QuintilesIMS Transactional Data Warehouse, which includes data on opioid prescriptions at close to 60,000 pharmacies across the country, and accounts for almost 90 percent of prescriptions in the U.S.

For opioid overdose deaths, they used the Wide-Ranging Online Data for Epidemiologic Research (WONDER) database created and maintained by the Centers for Disease Control (CDC). To identify opioid overdose deaths, researchers selected relevant medications/drugs from the Multiple Cause of Death option in the WONDER database menu.

We mention this because the information in WONDER is free and available to all, which means anyone reading this article can navigate there, now, and explore any data that interests them.

With that said, let’s look at the data related to hypothesis one: mandating PDMP use reduces opioid prescription rates.

States With Mandated PDMP Programs: 2010-2015

• 2010: 4
• 2011: 6
• 2012: 12
• 2013: 16
• 2014: 19
• 2015: 19

Data shows that the implementation of PDMP programs in these states led to a 6.1 percent decrease in opioid prescriptions between 2010 and 2015. That means the research team confirmed their first hypothesis: PDMPs did, in fact, reduce opioid prescribing rates.

Next, let’s look at the data related to hypothesis two: mandated PDMP use leads to greater abuse of heroin.

Prescription Monitoring and Heroin Use, Misuse, and Abuse: The Results

Here’s the data researchers collected and collated using information from both the QuintilesIMS prescription database and the CDC WONDER database.

Heroin Overdose Death Rate: PDMP States vs. Non-PDMP States 2010-2015

• 2010:
  • PDMP: 8 overdose deaths per million people
  • Non-PDMP: 8 overdose deaths per million people
• 2011:
  • PDMP: 12 per million
  • Non-PDMP: 11 per million
• 2012:
  • PDMP: 20 per million people
  • Non-PDMP: 16 per million
• 2013:
  • PDMP: 28 per million
  • Non-PDMP: 18 per million
• 2014:
  • PDMP: 30 per million
  • Non-PDMP: 22 per million
• 2015:
  • PDMP: 34 per million
  • Non-PDMP: 24 per million

This data shows that rates of heroin overdose death increased in PDMP states and non-PDMP states between 2010 and 2015, but heroin overdose death rates increases were significantly greater in PDMP states compared to non-PDMP states.

States with PDMP programs reported a 325 percent increase in heroin overdose deaths, while states without PDMP programs reported a 200 percent increase in heroin overdose deaths. This confirms hypothesis two: PDMP programs led to an increase in heroin misuse/abuse, as measured by heroin overdose deaths.

A study published in 2014 called “The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years” includes direct responses from heroin users on why they began using heroin. Here’s what the participants in the study said:

• 75% indicated they started with prescription opioids
• Reasons for cited for switching from prescription opioid to heroin included:
  • Heroin was more easily accessible
  • Heroin was less expensive
• In addition:
  • Heroin is easier to inhale or inject
  • Heroin is more powerful than many prescription opioids

That explains why millions of people, when faced with the choice to either discontinue opioid use or turn to illicit drugs, chose to use heroin. That’s not to condemn or indict this group of people. Indeed, it’s safe to assume most developed opioid use disorder (OUD) while using prescription medication. In the absence of prescription medication and the absence of evidence-based treatment for OUD – and to avoid opioid withdrawal – they saw illicit street heroin as the only alternative, and the only way to avoid the difficulties and dangers of opioid withdrawal.

Next, let’s look at the data on prescription opioid overdose during the study period.

Prescription Monitoring and Prescription Opioid Use, Misuse, and Abuse: The Results

Researchers also used the QuintilesIMS prescription database and the CDC WONDER database to collect, collate, analyze, and report the following data.

Prescription Opioid Overdose Death Rate: PDMP States vs. Non-PDMP States

• 2010:
  • PDMP: 64 overdose deaths per million people
  • Non-PDMP: 50 overdose deaths per million people
• 2011:
  • PDMP: 68 per million
  • Non-PDMP: 48 per million
• 2012:
  • PDMP: 66 per million people
  • Non-PDMP: 46 per million
• 2013:
  • PDMP: 64 per million
  • Non-PDMP: 18 per million
• 2014:
  • PDMP: 78 per million
  • Non-PDMP: 54 per million
• 2015:
  • PDMP: 96 per million
  • Non-PDMP: 60 per million

This data shows that rates of prescription opioid overdose death increased in PDMP states and non-PDMP states between 2010 and 2015, but prescription opioid overdose death rates increases were significantly greater in PDMP states compared to non-PDMP states.

States with PDMP programs reported a 50 percent increase in prescription opioid overdose deaths, while states without PDMP programs reported a 20 percent increase in prescription opioid overdose deaths.

That’s all the data we have to report from this study: we’ll elaborate on these results below.

Did Prescription Drug Monitoring Programs Work?

Yes.

They reduced opioid prescription rates, but they also had an unintended negative consequence.

Overall, what this study shows is that while the PDMP programs did reduce the prescription rates dramatically, they were also associated with a significantly greater increase in heroin overdose deaths in states that implemented them. It’s also important to note that the more restrictive the PDMP program, the larger the subsequent increase in heroin overdose deaths.

In the words of study author, Dr. Kim:

“We measured overdose deaths as a proxy [for determining the effect of PDMPs] and found a substantial increase, suggesting that the policy unintentionally spurred greater substitution.”

In reaction to these results, researchers reviewed the data to determine how it might help give clues to mitigate the substitution effect. They observed that in areas where heroin was difficult to obtain and access to OUD treatment was relatively easy, rates of substitution were far smaller. Therefore, they advise several evidence-based action steps to reduce substitution and decrease heroin overdose deaths.

How To Mitigate Unintended Harm Caused by PDMPs: Six Steps

1. Invest in OUD treatment capacity
2. Increase access to OUD treatment
3. Increase access to medications for opioid use disorder (MOUDs) including:

• Buprenorphine
• Methadone
• Naltrexone

4. Enhance harm reduction programs in areas with easy access to heroin and little access to OUD treatment
5. Restrict the availability of illicit heroin through federal, state, and local law enforcement efforts
6. Increase education on the dangers of:
   • Prescription opioids
   • Substituting illicit opioids for prescription opioids

The study authors observed that addressing the demand-side – i.e. people with OUD who turn to heroin – as well as the supply-side – prescription medication and illicit heroin – can help counteract the effects of the PDMP mandate, which is considered a supply-side change.

Reducing Harm: Learning What Works

Since experts recognized the facts about the opioid overdose crisis in the early 2000s, law enforcement authorities and policymakers at the federal, state, and local levels have implemented a variety of programs to mitigate the ongoing harm caused by the crisis. Early in the crisis, traditional approaches dominated our response. However, these approaches were characterized by restriction and enforcement, which are holdovers from an era when our approach to drug addiction was known as “The War on Drugs.”

These restrictive, punitive approaches did not work in the 1980s and 1990s to address the crack cocaine epidemic, and they did not work in the 2010s to address the opioid crisis. In the mid-2010s, law enforcement officials and public policymakers realized something important:

“We cannot arrest our way out of this crisis.”

What they also learned is that we cannot restrict our way out of this crisis, either. Rather, what we need to do is embrace the concept of harm reduction, as we describe in this article:

The Opioid Crisis: A New National Strategy

We know now that we need to follow the evidence. Evidence tells us that a comprehensive harm reduction strategy, including integrated support for people with OUD that addresses the whole person – not just the addiction – leads to the most favorable outcomes. When we support people on a clinical level, a social level, and offer them help with the basics of education, employment, and housing, outcomes improve for individuals, families, and communities impacted by the opioid crisis. We have the knowledge, we have the data, and – if we have the will – we can work together to end the overdose crisis sooner, rather than later.

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Pinnacle Treatment Centers

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