Preventing prescription drug abuse is about more than simply controlling distribution of these medications. That became clear during a panel discussion held during the Nov. 14-15 AAFP State Legislative Conference here, when speakers addressed specific aspects of the abuse problem that affect their respective states. The consensus: The best ways to battle this problem involve cooperation among physicians, pharmacists and law enforcement officers.
Robert Twillman, Ph.D., director of policy and advocacy for the American Academy of Pain Management, provides a detailed analysis of research findings on prescription drug abuse during the 2014 AAFP State Legislative Conference.
Members of the panel highlighted innovative tools being used to combat prescription drug abuse. For example, speakers focused on broadening the use of technology to identify prescription recipients, often combined with legislation aimed at controlling the use of these prescriptions.
It's an approach similar to that the Academy has advocated for years and that led to the development of a position paper(15 page PDF) on the dual issues of pain management care and opioid abuse approved by the AAFP Board of Directors in 2012. Among recommendations included in the paper are calls for research to identify evidence-based strategies to optimize pain management, as well as for all states to implement prescription drug monitoring programs, areas also covered during the conference panel discussion.
What the Research Shows
According to Robert Twillman, Ph.D., director of policy and advocacy for the American Academy of Pain Management, of the tens of thousands of prescription drug overdose deaths in the United States each year, more than 75 percent can be attributed to use of multiple drugs. Furthermore, he suggested, the rates of prescription overdose may be higher in recent years because people are misusing more often -- not because a greater number of individuals are misusing.
- According to speakers at the AAFP State Legislative Conference last month in New Orleans, innovative technology and new drug formulations are among tools being used to combat prescription drug abuse.
- Many states are sharing information about the types of prescription medications an individual receives, as well as how often he or she receives the products.
- One initiative in North Carolina brought together the medical community and law enforcement to reverse spiraling rates of prescription drug abuse.
FDA draft guidance(www.fda.gov) regarding abuse-deterrent formulations (ADFs) of opioid analgesics call for manufacturers to caution users about altering a drug or using it for a purpose other than that stated in the prescription. These written warnings on medication containers have been effective in reducing abuse, said Twillman. To date, the FDA has approved four extended-release ADF opioid products, most recently, Purdue Pharma's hydrocodone-only Hysingla ER.
Twillman cautioned, however, that "abuse-deterrent" is actually somewhat of a misnomer because a medication might discourage crushing or melting but could still be chewed, for example. He outlined some of the policies his organization supports, including the following:
- A decision to use an ADF should be made by the prescriber in consultation with the patient.
- Risk assessment related to an opioid prescription should include assessment of individuals who come in contact with the patient.
- Patients who do not require an ADF should not be forced to pay for one.
Some states are taking direct action to address the prescription drug crisis, Twillman noted. These states include Massachusetts, which passed legislation creating a formulary committee to identify ADF opioid products. Other states, such as Indiana and Pennsylvania, have also adopted legislation that would invoke new rules governing safe and effective prescribing of opioids.
In the past four years, several states have proceeded quickly to require use of a state-operated prescription monitoring program (PMP). These online databases, which can track all of the controlled substances that are prescribed to a patient and provide the prescriber's name and the dispensing pharmacy, are intended to warn physicians about possible diversion of a prescription drug. In New York, for example, medical professionals are required to check the database for every prescription they write.
Project Lazarus President and CEO Fred Brason II discusses how a community-wide coalition in one North Carolina county has helped reduce prescription drug abuse.
But that wasn't always the case, according to Marty Allain, J.D., director of Indiana's PMP, which is known as INSPECT.
"There was no PMP mandate prior to 2010 other than (in) Nevada," said Allain, who also is NARxCHECK senior manager for the National Association of Boards of Pharmacy. "Representatives and senators at the state level said, 'We have to do something.'"
Now, all states have a PMP except Missouri, where state lawmakers have yet to pass legislation that would create a database, Allain told conference participants. He also pointed out that before 2011, states were not sharing their PMP data, which made it harder for physicians, law enforcement and other health care professionals to track prescriptions across state lines.
"It wasn't even on the radar screen in 2005, and now governments are sharing information," Allain said. Twenty-seven states share PMP data, and he expects 30 will be doing so by the end of 2015. Still, he noted, usage of the database among prescribers remains low. For every 10 prescriptions that are written in Indiana, the database is only checked once.
"I think it's because the provider doesn't have time to access the site," Allain said.
Yet despite the low participation rate, Indiana has reported a 20 percent decrease in patients who had a high volume of prescriptions. And in New York, the number of individuals who obtained a prescription for a controlled substance has decreased by 9.5 percent.
Aware that the time commitment can be demanding for physicians, states are working to improve their programs to allow single-click access to a patient's PMP report directly from an electronic health record. Data is being integrated among state health information networks to eliminate the need to manually enter patient demographics.
Allain cautioned that the intent of the program is to reduce drug diversion and potential overdose or misuse and it should not be interpreted as a law enforcement tool. "This isn't about finding drug diverters," he said. "It's about getting a good medical history in the hands of providers."
Another panelist, Fred Brason II, is president and CEO of Project Lazarus, a nonprofit public health organization established in Wilkes County, N.C., in 2008 to combat spiraling drug overdose deaths. He discussed the scope of opioid abuse and effective ways to fight it at the local level. A former hospice chaplain, Brason knows firsthand the benefits opioid pain relievers can bring at the end of life, but he's also all-too-familiar with the havoc they can wreak when misused.
As head of an agency that works to increase public awareness about responsible pain management policies and provide substance abuse treatment, Brason said that beyond treating the individual, reducing the incidence of overdoses requires a community-wide effort that brings together physicians and other health care professionals working in mental health and emergency settings and law enforcement officials.
The volume of prescription medication in circulation is the first warning sign, said Brason. There were enough painkillers prescribed in 2010 to supply the entire U.S. population for 30 days, he noted, citing reports that 75 percent of individuals who died of an overdose had obtained a prescription within the previous 30 days.
Educating the community about the seriousness of prescription drug abuse was an initial hurdle for Project Lazarus. In North Carolina, counties with a high incidence of overdose events began by collecting data on mortality rates, hospital admissions, prescriptions and the number of prescribers who were registered in a prescription database. Various stakeholder groups formed coalitions in which the state health department took the lead role. Emergency departments created protocols for chronic pain patients that prohibited refills of controlled substances, limited dosages to 10 tablets, and required use of the prescription database.
The results were swift and impressive, said Brason. From 2009 to 2011, Wilkes County reported an 89 percent drop in the number of overdose cases. ER visits plunged, and substance abuse among students was cut in half.
Brason said he advises people to follow four basic steps when using pain medication:
- Take medications only as prescribed,
- Store prescription medications securely away from children,
- Dispose of unused or outdated medication, and
- Never share medications with someone else.
Project Lazarus also promotes "pill take-back events," during which unused medication can be properly disposed of by pharmacies or hospitals. That's important, according to Brason, because sharing medication is a lesser known cause of overdose. Often, families mistakenly think that a medication that is effective for one person at a specific dosage can be used by another at the same dosage.
Not so, said Brason.
"What's good for Mommy might be enough to kill Johnny."
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