Our country is dealing with an epidemic - the abuse of opiates. While we have come a long way in physician and pharmacist awareness, new technical approaches are available to significantly reduce the abuse and the resultant death rate. Let’s not make opiates evil, they are a critical part of treatment plans for patients that have pain that is not reduced using traditional acetaminophen, ibuprofen, or other NSAIDs. Opiates are also effective in the treatment of attention disorders. Your friends, neighbors, and co-workers benefit from the use of opiates, especially those battling cancer-induced pain, as well as those in hospice conditions.
While they are medically necessary, opiates are abused and over-used — leading to a death rate equivalent to a 747 crashing once a week. Further, there is an immeasurable cost on society from recovery programs, incarceration, non-productivity, and broader emotional trauma. To get an idea of scale, in 2014, healthcare providers wrote 259 million prescriptions for painkillers (CDC, 2015) - that’s almost one prescription for everyone over the age of 18 in America every year! In addition to increased prescribing, between 1998 and 2008, the resultant death rate due to overdoses grew over 300% according to addiction.com. It is worthwhile seeing this CDC infographic from 2014 to get an even broader picture of the problem. More stringent controls at the state level are beginning to show a drop in the non-medical consumption and over-prescription of opiates, and consequently, a slight reduction in death rate. While early success can be credited to prescriber education and implementation of state-level Prescription Drug Monitoring Programs (PDMPs), we can improve clinical efficiency, speed the discovery of fraudulent behaviors, and leverage world-class tools in a cost-effective, shared services model.
The figure at the right shows that, within the bulk of non-medical users of opiates, the intentional sharing by, or theft from, family members is the primary source of illicit supply. As the use (or abuse) continues greater than 200 days, the primary source shifts to obtaining prescriptions from multiple doctors..."doctor shopping". This brings about a few observations:
- Efforts to reduce or eliminate theft of opiates before dispensing have been highly successful, and therefore additional efforts offer a minimal contribution to non-medical consumption (credit to the DEA Office of Diversion Control).
- For those who are early in their illicit use or are only periodic abusers, the predominant source of the opiate is a knowing family member. This family member is being prescribed the medication and coping with diminished supplies (i.e. theoretically more pain) while giving some or all of their supply away.
- For those with higher incidence of non-medical use (200-365), the graph shifts substantially to show the greater dependence - where they are willing to pursue prescriptions from multiple providers or willing to pay dealers or friends and relatives for the opiate.
While overdoses of opiates can occur at any stage in the dependence cycle, it would be prudent for us to focus on the sources of supply to those who have more incidence of use in the past year. Incremental spending on recovery programs take time, money, and skilled professionals to turn the tide on the consumption. The financial incentives for those caught up in the illicit acquisition and distribution makes it difficult to change hearts and minds. Given these assumptions, we are best served addressing the clinical flow through application of new technologies, improving existing tools, and access to reference data, to identify and interdict the acquisition and distribution channels. We need to increase the awareness of the practitioner while minimizing time and errors, while also rooting out those few complicit prescribers.
According to the article, "Mandatory Use of Prescription Drug Monitoring Programs" (JAMA, 2015, Haffajee, Jena, Weiner), while 49 states have implemented a PDMP, only 20 require registration, and a handful have mandated use of the PDMP. Their research clearly supports that there are barriers at the practitioner level to implementation of mandates, as well as the causes of non-compliance with the mandates. While some barriers relate to policy and context of use, I have observed that many of the remaining barriers can be solved technologically. Examples include:
- Compliance and technical usability are most often compromised. IF the practitioner checks the PDMP, instead of getting a match to a unique individual (with one or more additional records), it presents a series of candidates that the practitioner has to review and correlate with the patient sitting in front of them - burning valuable clinical time. The States that mandate the use of the PDMP may not have 100% registration compliance, still don't have 100% usage compliance once registered, and even those that use it may dismiss its use because of the impact on patient-facing time.
- Very few PDMPs are executed such that they can see across state boundaries. Consequently, the "doctor shoppers" can easily hide by simply crossing state lines.
- The PDMP does nothing to support identification of fraudulent identities. None of the PDMPs that I have reviewed include a check to see if the person exists, is dead or alive, or is known to use multiple aliases.
While I love to point out what's wrong, I need to do two more steps:
- Do No Harm - No technical solution should prevent a practitioner, who has not proven themselves fraudulent, from providing care that they deem necessary - no matter what the PDMP of tomorrow says. At the same time, practitioners who are "Pill Machines" (wittingly participate in the distribution for non-medical use), need to be identified with more precision matching and real-time analytics through both e-prescribing and fulfillment at a pharmacy, practitioner's office, or even a hospital.
- Offer the Fix: PDMP of Tomorrow - Equip the practitioners with a tool that can:
- Make a real-time determination at the point of care, or point of fulfillment, with hyper-accurate identity matching (so the practitioner doesn't have to find the problematic records).
- Provide verification of the liveliness of the patient (i.e. not on the Death Master File) and not a known fraudulent identity.
- Identify inter-state "doctor shoppers" by correlating events across state lines.
Most of the PDMPs are excellent implementations given the budget constraints at the state level. When mandated for use, they demonstrate a clear impact on the reduction of prescriptions (JAMA, 2015, Haffajee, Jena, Weiner), but at a cost to the practitioner that limits deeper success. The tools I describe above need an inter-state view, as well as matching engines and analytical tool suites that are best acquired in a shared model. Finally, the tools need to be exposed securely such that e-prescription platforms, EHRs, pharmacies, and the like can easily access these enriched features while not hindering the practice of medicine. A shared, nationwide or regional PDMP that leverages the state of the art in referential matching, real-time behavior analytics, and accurate national data sets indicating fraudulent IDs will provide a cost-effective and highly-effective approach.
I would love to know your thoughts. In future entries, I will cover emerging disincentives to practitioner participation, including addicts and suppliers who are rejected in their attempts to obtain more opiates turning to doctor review sites and social networking with negative reviews.