June 12, 2018
At the recent CRITICAL CONNECTIONS Opioid Crisis Symposium organized by Modern Healthcare, the complexity of the opioid problem was clear. As one of the worst epidemics the US has faced in its history, the causes and cures must be tackled from many directions including prevention, education, and treatment. Success will require greater alignment across both public and private stakeholders. It will take a village to stop this plague.
Opioid addiction comes from a tangled web of issues from an oversupply of pharmaceuticals to over-prescribing. Reducing the number of opioids providers prescribe can drive patients with a true need to street heroin and fentanyl – causing a ripple effect of opioid-related deaths. Shorter dosages of a smaller quantity of opioids to reduce the number of pills left over, require providers to be able to write refills based on patient needs. Clinicians are our most effective means of managing the battle against addiction, and they need tools and information to treat their patients effectively and avoid dangerous and deadly unintended consequences. Some of the major solutions include mandatory electronic prescribing of controlled substances (EPCS), in workflow access to prescription monitoring drug program (PDMP) data, and improved medication fill data.
Mandatory Electronic Prescribing of Controlled Substances
One way to significantly reduce the impact of the crisis is for the government to mandate the use of electronic prescribing of controlled substances across all states. Not only would it be easier to track opioid prescriptions, but each state would have more accurate data available to understand the extent of the epidemic in their own backyards. No more than a handful of states have passed laws that require EPCS, and only two—New York and Maine—have laws with real enforcement teeth. New York started its EPCS program, I-STOP, in 2016. As a result, EPCS participation is a bit higher than most states and we have seen that the rate of opioid prescribing has leveled off based on DrFirst’s prescribing data.
Reducing Complexity of Credentialing
Unfortunately, the current federal EPCS credentialing requirements are also complicated and create barriers for provider adoptions of e-prescribing of a controlled substance. Many providers report that they have stopped prescribing controlled substances altogether. Instead, these clinicians are referring patients to pain management specialists, delaying treatment, and putting the burden of scheduling, out-of-pocket costs, and causing unnecessary suffering for patients. Simplifying the credentialing requirements will support proper prescribing in the clinician’s office and may reverse this trend.
Realistic Utilization of Prescription Drug Monitoring Program (PDMP) Data
Mandatory EPCS paired together with integrated prescription drug monitoring programs in all states would also help slow the opioid crisis. Every state now has some type of PDMP, and 40 states require prescribers to view pharmacy fill data on controlled substances in their state’s PDMP database before prescribing an opioid. The benefits of access to the PDMP is undermined by the fact that many physicians feel that the process is cumbersome, therefore PDMP registries continue to be underutilized. Many doctors who attended the CRITICAL CONNECTIONS Symposium said they will not take the time to log into a PDMP website if they have to leave their EMR/EHR and prescribing workflow each time, only to have to re-enter a patient’s information to view his or her opioid history. For PDMPs to be used effectively, states must change their policies to allow access to this data from within the e-prescribing workflow.
End Exceptions to Improve PDMP Quality
Another critical public/private partnership should be focused on improving the overall content of state PDMPs. Today, for example, Narcan and Suboxone are used to reverse and treat the effects of overdoses. However, because these lifesaving drugs are dispensed differently, and used in so many different types of locations ranging from libraries to paramedic units, they don’t appear in PDMP registries, which are based on pharmacy dispensing data. These medications should be included in the PDMP data, where they could warn doctors not to prescribe opioids to patients who have already received them. It will take a coordinated effort to solve the problem of having more complete data in the PDMP.
Defining and Measuring Success
A final takeaway from the Opioid Crisis Symposium is a lingering lack of unanimous clarity on how we will measure success. A reduction in opioid prescribing is not a marker of victory in the war against opioid addiction. Only a drop in the number of overdoses and overdose-related deaths will show progress in winning this war. Our village needs to find a common measure of success to meaningfully align public and private efforts towards a common goal and present a united front against the opioid epidemic that is threatening our country.