Monitoring Prescription Drug Abuse in the States
Stan Orchowsky, Ph.D., Research Director, Justice Research and Statistics Association
Prescription drug abuse is a growing national problem. Drug-related poisonings are now the leading cause of death due to unintentional injury in the United States; the number of unintentional overdose deaths per year involving opioid pain relievers nearly quadrupled from 1999 to 2007, while overdose deaths due to these drugs in 2007 were nearly twice those due to cocaine, and over five times those due to heroin (PMDP Center of Excellence at Brandeis). According to the National Survey on Drug Use and Health (NSDUH), of the 3.1 million individuals 12 or older estimated to have used an illicit drug for the first time in 2009, 28.6% initiated use with prescription drugs, second only to those initiating with marijuana (59.1%). The same survey found that 20.6% reported non-medical use of prescription drugs in their lifetime. According to the Centers for Disease Control's Youth Risk Behavior Surveillance System, in 2013 almost 18% of high school students reported having taken prescription drugs without a doctor's prescription one or more times during their life.
The rise in the misuse and abuse of prescription drugs has been attributed to their increased availability over the last decade, a result of increased prescribing. Increased prescribing in turn has been driven by more aggressive treatment of pain in response to patient advocacy groups, the development of new drugs, particularly opiates, to meet this demand, and more aggressive marketing by pharmaceutical companies.
Beginning in FY 2002, Congress appropriated funds to the U.S. Department of Justice to support the Prescription Drug Monitoring Program (PDMP). Prescription monitoring programs help prevent and detect the diversion and abuse of pharmaceutical controlled substances, particularly at the retail level where no other automated information collection system exists. Prescription data are provided in automated form by pharmacists and/or practitioners, allowing states to collect and analyze prescription data efficiently.
Currently, 49 states, plus the District of Columbia and Guam, have created PDMP legislation and have operational PDMPs. The majority of state PDMPs monitor Schedule II-V drugs, as classified by the Federal Controlled Substances Act. These include commonly prescribed drugs with the potential for abuse, such as oxycodone (OxyContin), Adderall, Vicodin, anabolic steroids, Xanax, and Valium.
A variety of state agencies administer PDMPs, but state Boards of Pharmacy are the most common program administrators (see table below).
State Agencies Administering PDMPs
|Boards of Pharmacy||20||39.1%|
|Departments of Health||13||25.5%|
Source. Prescription Drug Monitoring Training and Technical Assistance Center (www.pdmpassist.org)
In most states, pharmacists and physicians (and other practitioners) can access PDMP information. States may also allow access to: law enforcement for drug investigations; licensing and regulatory boards for investigations into prescription violations by health care professionals; state Medicaid programs; and medical examiners or coroners investigating cause of death. In 28 states, researchers are authorized by statute to request PDMP data for study (see table below).
State that Authorize Research Use of PDMP Data
|Illinois||North Dakota||West Virginia|
Twenty-six Statistical Analysis Centers (SACs) responded to a recent survey about whether they are working with their state's PDMP. Most said they have no involvement with their state's program or its data. Responses from those involved in work in this area are provided below.
The Arizona Criminal Justice Commission (ACJC), which houses the Arizona SAC, was awarded a $374,408 grant by the Bureau of Justice Assistance under the Harold Rogers Prescription Drug Monitoring Program: Data-Driven Multi-Disciplinary Approaches to Reducing Rx Abuse. ACJC staff, including staff from the SAC, will use the grant funds in Maricopa County to build on the successful work that the Arizona Prescription Drug Misuse and Abuse Initiative has already accomplished in four pilot counties. ACJC will be working with Mercy Maricopa Integrated Care and the Maricopa County Department of Public Health to support community-based substance abuse coalitions in their implementation of the Rx Initiative. Mercy Maricopa Integrated Care, which is the Regional Behavioral Health Authority for Maricopa County, will oversee the work of the community-based substance abuse coalitions and the Maricopa County Department of Public Health will facilitate access to county-level data to inform implementation of the Arizona model.
In Georgia, the PDMP data are extremely restricted and all identifying information is "deleted or destroyed" after a year. The SAC obtained about six months' worth of information from the agency that manages the database, but no additional data have been acquired.
The Ohio SAC has been working closely with several agencies, including the Department of Health, the Department of Mental Health and Addiction Services, and with individual coroners to look at this issue from the perspective of overdoses. The SAC does not currently work with the PDMP, but hopes to meet with PDMP staff to find out what data they have available, and then incorporate the PDMP data with other datasets. Several state agencies are already working together on projects, so it may be possible to collaborate on a larger project that would utilize the data each agency houses.
The South Dakota SAC is minimally involved with the PDMP. Staff compile statistics yearly to compare data relating to types and amounts of drugs prescribed from year to year.
The Utah SAC is indirectly involved with the PDMP through its parent agency, the Utah Commission on Criminal and Juvenile Justice (CCJJ, the State Administering Agency), and through the Utah Substance Abuse Advisory Council (USAAV), which is staffed by the CCJJ. The USAAV periodically requests data from PDMP (which is housed in the Department of Commerce, Division of Occupational and Professional Licensing), most often related to the prescription opiate problem and prescription practices by providers. The information is used for provider education and training, as well as for making policy recommendations to the legislature. While the SAC has not conducted research using PDMP data, they would be available if a project were developed that involved this type of analysis.
The Crime Research Group, the contractor for the Vermont SAC, is not currently involved with the PDMP effort. The group, however, recently released the Vermont Prescription Monitoring System 2013 Annual Report, which summarizes VPMS surveillance data for all Schedule II - IV prescriptions that were dispensed from Vermont-licensed pharmacies from 01/01/2010 through 12/31/2013. Aggregate totals of all controlled substance prescriptions and recipients are presented in the report, and trend data are also broken out by drug type, recipient age, recipient sex, as well as recipient county.
The Virginia SAC was given access to de-identified Prescription Monitoring Program (PMP) data in November 2014. These data include over 65 million re-cords of prescriptions since January 2010. The SAC is in the early stages of gaining familiarity with the data. Staff are looking at various trends in the data, and then using what is found to ask new questions. Examples of this work include:
- Comparing trends in opioid prescriptions across the state with trends in seizures of prescription opioids in arrests (using data from the Virginia Department of Forensic Science).
- Identifying the number of opioid prescriptions that were written by out-of-state doctors and then filled in Virginia.
- Finding ways in which the Director of the Virginia PMP can use the data to better inform policy makers.
In addition, a researcher from the SAC has been included on the Data and Monitoring Workgroup, attached to the Governor's Task Force on Prescription Drug and Heroin Abuse. Part of this effort involves working with the PMP data and finding new ways the PMP can be used to reduce prescription drug abuse. Although this effort is still in the early stages, the SAC's own work with the PMP has informed the workgroup's initial recommendations to the Task Force. The workgroup will continue meeting, and the SAC will continue to provide analyses of PMP and other data. As the SAC moves forward and expands its understanding of these data, it hopes to connect patterns in the PMP data with data on seizures, emergency room visits, and fatal drug overdoses.
In 2009-2010, the Wyoming SAC (WYSAC) used State Justice Statistics funding to conduct a study of the Wyoming PDMP housed in the State Board of Pharmacy. The study details statewide prescribing patterns of Schedule II and above drugs as recorded through PDMP. Scheduled drugs, such as opioids, sedative/hypnotics, anxiety-reducing drugs, and stimulants, among others, have high potential for abuse.
The Wyoming PDMP data included nearly 4 million prescriptions filled for 477,515 unique Wyoming persons during the period 2004-2009. Almost one third of the total Wyoming population in each year of the study filled at least one prescription for a scheduled drug. By a broad margin, the most prescribed scheduled drugs were opioid analgesics; opioids alone accounted for over half of all prescriptions in the PDMP each year. Substantial differences were found in per capita prescriptions at the county level, with one Wyoming county in 2009 filling more than 3.5 times the number of prescriptions for opioid analgesics (per 1,000 population) than the county with the lowest rate.
Zolpidem (a sleep aid drug sold under the trade name Ambien and others) and alprazolam (Xanax and others) were second and third in percentage of all prescriptions filled behind opioid analgesics. The average per prescription tablet quantity for zolpidem increased by 48% from 2004 to 2009, as did the average per prescription days of supply. Overall, during the period from 2005 to 2009, opioid analgesic prescriptions per 1,000 population statewide were up 21%, sedative/hypnotics up 37%, and anxiolytic drugs were up 33%. The PDMP analysis is ongoing.
The SAC is a member of the Wyoming Prescription Drug Abuse Stakeholders Group, which meets monthly. The group is made up of representatives of the healthcare community, law enforcement, government, and community members, and works to prevent the increasing abuse of prescription medications while ensuring that they remain available for patients in need. The group seeks to help doctors, nurses, pharmacists, other healthcare professionals, law enforcement, and the general public become more aware of both the use and abuse of prescription medication.
Under the guidance of the Bureau of Justice Assistance (BJA), Global Justice Information Sharing Initiative partners and subject matter experts from across the country developed a new resource: Call to Action and Issue Brief: Justice System Use of Prescription Drug Monitoring Programs-Addressing the Nation's Prescription Drug and Opioid Abuse Epidemic. Focusing on states' prescription drug monitoring programs (PDMPs), this resource offers justice practitioners and policy makers valuable, practical, hands-on sections such as the PDMP best-practices checklist, a compendium of resources and references (including BJA's Law Enforcement Naloxone Toolkit and website), and next steps to help them address this critical public safety and public health challenge.
Other useful resources include:
- Bureau of Justice Assistance Prescription Drug Monitoring Program
- Prescription Drug Monitoring Program Center of Excellence at Brandeis. Briefing on PDMP Effectiveness (April 2013)
- Prescription Drug Monitoring Training and Technical Assistance Center - State PDMP Websites
- National Association of State Controlled Substances Authorities - Prescription Monitoring