I had always assumed that I would remember my first code. I don’t, but I do remember my first time coding a patient who could have been my peer. He was young and otherwise healthy. His housemates had heard a loud thud but ignored it. Later, they found him lying lifeless on the ground. He was a known heroin user.

In Connecticut, like in many states, prescription medications are the most common drugs of abuse.¹ Prescription opioids are known gateways to heroin as patients seek stronger, cheaper, and easier-to-acquire agents. Patients addicted to opioid medication are 40 times more likely to be addicted to heroin.² More than two-thirds of heroin addicts previously abused prescription opioids.³

One major driver of the opioid epidemic has been the proliferation of prescription pain medicine. The United States consumes nearly all (98 percent) the world’s supply of hydrocodone.⁴

How did this happen? In 1999, in response to popularized claims that chronic pain was undertreated at epidemic proportions, the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative, requiring a pain-intensity rating at all patient encounters.⁵ This was disseminated to the rest of the health care system two years later by The Joint Commission, which instituted pain management standards. Pharmaceutical companies seized the opportunity and aggressively campaigned, convincing physicians, patients, and regulators that opioids were safe for chronic non-cancer pain. The misinformation was so explicit that Purdue Pharma, makers of Oxycontin, eventually pled guilty to federal criminal charges.⁶

From 1991 to 2013, Oxycontin prescriptions skyrocketed from 76 million to nearly 207 million annually. As the prescriptions increased, so did the number of related ED visits, which more than than doubled between 2004 and 2011.⁷ More recently, the trend has turned lethal. Opioid-related deaths doubled in just one year, killing 5,500 in 2014.⁸

Well aware of these deadly trends, I initially welcomed the arrival of Connecticut’s prescription drug monitoring program (PDMP), a central database holding statewide accounts of Schedule II-V controlled substances. Signed into law in the summer of 2015, Public Act 15-198 was hailed as legislation that took “necessary and smart steps to stem prescription drug abuse and overdose deaths.”^9,10

Unfortunately, the bill creates busywork for doctors, and new evidence suggests that the extra work is not making an impact. The bill mandates that practitioners check each patient’s record in the PDMP. We must check every controlled substance prescription written to last more than three days. For patients who receive prescriptions chronically, providers must recheck the PDMP every 90 days.

PDMPs have sprung up nationwide over the past decade with much fanfare. Sadly, their impact hasn’t lived up to their hype in decreasing opioid prescriptions, especially when looking at data from states that instituted mandates. According to a study from Brandeis University, after adopting mandates, Kentucky, New York, and Tennessee had decreases in opioid prescriptions rates ranging from 7 percent to 11.6 percent for commonly prescribed opiates.¹¹ When taking into consideration that at the same time nationwide opioid prescribing decreased by 4.6 percent, there is even less association between PDMPs and prescribing behavior. Over a similar time frame, Florida launched a PDMP that was not mandatory and had similar results as the states in which it was mandated—the rate of Schedule II opiates dropped by 12.5 percent and total pain prescriptions dropped by 7.1 percent.¹²

The trouble largely lies in theory versus practice. Initially, I heard some rumblings around our department about the new alert popping up on our electronic medical record log-in screen. As with all alarms, it soon faded into the background noise of irrelevant red boxes that clogged the screen.

Connecticut’s experience does not appear to be isolated. In California, only 9.8 percent of prescribers and pharmacists registered to use its PDMP in 2014.¹³ While one study in Annals of Emergency Medicine found a change in prescribing behavior after viewing a PDMP query, this finding is suspect. In that study, 17 physicians had research assistants running their queries.¹⁴ Funny, I can’t seem to find my research assistants.

For busy ED providers, time spent accessing a multistep website distracts from real patient care. Just as we don’t blindly check troponins on every patient with chest pain, it makes as little sense to check the PDMP for every patient with pain who may receive opioids. Moreover, emergency physicians only write 5 percent of all opioid prescriptions despite handling 28 percent of all acute care visits.¹⁵ Without sufficient outcomes to justify its burden in the ED, PDMP appears to be little more than a shiny new toy for politicians to pay lip service to a social epidemic while vilifying physicians for overprescribing.

While our new law does not specifically punish doctors for noncompliance, physicians not following the mandates may be at risk for liability. The state statute is under the controlled substance section of the law, which carries serious penalties for noncompliance if imposed.

Recently, a doctor in Texas was investigated after his patient (to whom he had prescribed controlled substances) caused a deadly motor vehicle crash. The police were able to seek a search warrant for the clinic, citing the doctor failed to follow the state medical boards rules for treating chronic pain including a pain management agreement.¹⁶ Ultimately, he was found guilty of fraudulent actions, but the case shines light on the potential for legal repercussions of opioid prescribing.

We should be willing to accept some responsibility for the epidemic, but so should the general community. Patient education has a role to play. For example, in New York City and in California, governing bodies issued voluntary ED guidelines and created posters for educating patients on opioid restrictions.¹⁷ Temple University Hospital in Philadelphia saw a 20 percent decrease in opioid prescriptions for chronic pain after introducing voluntary guidelines; this reduction was sustained over a year later. All 31 eligible prescribing physicians completed a survey, and 100 percent supported the use of those guidelines.¹⁸

PDMPs may yet prove their worth in the fight against the opioid epidemic. Targeting and integrating alerts into electronic medical records would seem useful. Although at least 31 states have the authority to send such alerts, relatively few states do. Massachusetts piloted unsolicited targeted electronic alerts and found that 82 percent of providers did not realize their patients were inappropriately receiving prescriptions from multiple prescribers. After six months, detected doctor shopping activity was reduced by 50 percent.¹⁹

We must not deny that physician behavior is part of the opioid problem, and we can be a part of the solution. However, our maximum impact is unlikely to be realized if we act merely as automatons of states’ ineffectual policing. With government cooperation improving PDMPs, developing initiatives to decrease pressure to prescribe potentially harmful drugs, and providing increased patient support, we should see improvements in curbing addiction. This can be accomplished while retaining the right to rationally prescribe without viewing our patients as guilty until proven innocent.

Dr. Solnick is an emergency medicine resident at the Yale Emergency Medicine Program in New Haven, Connecticut.

References

1. Shelton J. Forum: How to stop an epidemic? Support Connecticut bill on opiate abuse. New Haven Register website..
2. Today’s heroin epidemic. CDC website.
3. Why heroin has made a comeback in America. The Economist website.
4. Report of the International Narcotics Control Board for 2008. INCB website.
5. Mularski RA, White-Chu F, Overbay D, et al. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006;21(6):607-612.
6. Gounder C. Who is responsible for the pain-pill epidemic? The New Yorker website.
7. The DAWN report: highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Substance Abuse and Mental Health Services Administration website.
8. Drug overdose deaths hit record numbers in 2014. CDC website.
9. Substitute for Governor’s H.B. 6856 Session Year 2015. Connecticut General Assembly website.
10. Gov. Malloy hails final legislative passage of bill combating substance abuse and opioid overdoses. Connecticut State website.
11. Mandating PDMP participation by medical providers: current status and experience in selected states. PDMP Center of Excellence website.
12. 2012-2013 Prescription Drug Monitoring Program annual report. Florida Health website.
13. Kim T, Small M, Hwang C, et al. Controlled substance utilization review and evaluation system: a tool for judicious prescribing. LA County Department of Public Health website.
14. Baehren DF, Marco CA, Droz DE, et al. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010;56(1):19-23.e1-3.
15. Safe prescribing. California ACEP website.
16. Berlin J. Revised TMB rules target nefarious prescribers, but physicians say the rules are a burden. Tex Med. 2016;112(1):28-35.
17. New ER guidelines to prevent opioid prescription painkiller abuse. Mike Bloomberg website.
18. del Portal DA, Healy ME, Satz WA, et al. Impact of an opioid prescribing guideline in the acute care setting. J Emerg Med. 2016;50(1):21-27.
19. Electronic alerts for prescribers: Massachusetts Prescription Monitoring Program experience. PDMP Center of Excellence website.