ReviewWhat we know, and don’t know, about the impact of state policy and systems-level interventions on prescription drug overdose
Introduction
In 2011, drug overdose was the leading cause of injury death, reaching epidemic levels in the United States. Among deaths where the drugs involved were specified, three quarters (over 16,000) of prescription drug overdoses involved opioid analgesics (CDC, 2014). While effective in treating cancer pain (Wiffen et al., 2013) and acute pain, such as in the perioperative setting (American Society of Anesthesiologists Task Force on Acute Pain Management, 2012), the evidence that opioids are effective at treating chronic, non-cancer pain safely over time is limited in quantity and quality (Haroutiunian et al., 2012, Noble et al., 2010). There are risks to opioid use including dependence, withdrawal, and overdose (Inturrisi, 2002). Because of their euphoric properties, they are also a candidate for diversion for nonmedical use. Yet, opioids are commonly prescribed: In 2010, an estimated 20% of patients presenting to physician offices in the United States with pain symptoms or diagnoses were prescribed opioids (Daubresse et al., 2013).
More than 125,000 people have died from overdoses involving prescription opioids during 1999–2010, and the number of such deaths per year quadrupled during this time period (CDC, 2011). Interestingly, opioid sales have increased in lock step during this period (CDC, 2011). While prescribing of opioids has increased and prescribing of non-opioid pain medications (e.g., non-steroidal anti-inflammatory drugs; NSAID) has decreased, changes in patient-reported pain severity seem to be insufficient in explaining shifts in prescribing (CDC, 2011, Chang et al., 2014).
Although it is a complicated picture, many overdose deaths can be linked to prescriptions from medical providers. For example, in a study of drug overdose fatalities in North Carolina, nearly half filled a prescription for at least one of the drugs that contributed to their death within 60 days of dying (Hirsch et al., 2014). In a study of opioid analgesic overdoses in an employer-sponsored insurance claims database, one-quarter of nonfatal overdoses were daily users with a prescription, 43.5% were other (intermittent) users with a prescription, and 31% used the opioid without a prescription (Paulozzi et al., 2014).
Several factors increase risk for drug overdose at the individual, community, and systems level. Individuals at higher risk include men; 35–54 year olds; whites and American Indians/Alaskan Natives; individuals at lower incomes; patients with mental health conditions; and patients receiving a high daily dose, prescriptions from multiple prescribers/pharmacies, and opioids combined with benzodiazepines. At the community level, those living in rural areas and communities with higher levels of use of prescription drugs prone to abuse are at higher risk (Paulozzi, 2012). Factors at the systems level include payer (with Medicaid incurring a higher rate of opioid prescriptions and adverse events such as ED visits and neonatal abstinence syndrome compared to other payers; Creanga et al., 2012, Raofi and Schappert, 2006) and prescriber volume (with those at high prescribing rates accounting for a greater proportion of patient deaths; Dhalla et al., 2011).
States operate the major levers that control access to drugs through prescription origination points (such as physician practices, emergency departments, hospitals, and pharmacies), payment and reimbursement (such as through insurers and pharmacy benefit managers), and public education (such as through campaigns and community initiatives). Innovative state policy and systems-level preventive interventions have been proposed to address the problem of opioid analgesic overdose at a population level. Table 1 summarizes these interventions and explains the state role. We sought to understand the evidence available on the effectiveness of such interventions on intermediate outcomes, such as provider and patient behavior, as well as health outcomes, such as fatal and nonfatal overdose. Previous reviews have investigated specific interventions (e.g., PDMPs), but none have integrated the strategies within one comprehensive, broad-scoped review across multiple strategies—a unique focus of the current paper.
Section snippets
Data sources and searches
With the assistance of a librarian, MEDLINE was searched for research articles evaluating on state policy and systems-level interventions published from 1946 to 2014 with search terms including, but not limited to, “drug overdose”, “analgesics/opioid”, “health education”, “patient education”, “organizational policy”, “prescription”, “monitoring”, “guideline”, “legislation”, “insurer”, “formulary”, and “drug utilization review”, resulting in over 500 citations. Additional articles were
Results
Fig. 1 illustrates the number of studies reviewed by type of intervention, and the type of outcomes measured in the studies. There was substantial variation in the number of studies by intervention, with a greater number of studies found for PDMPs, naloxone education and distribution programs, and clinical guidelines than for insurer strategies, state legislation, safe storage and disposal, and provider/patient education. There also were large differences in the types of outcomes studied, with
Discussion
States have a variety of tools they can use with the potential for curbing the prescription drug overdose epidemic, particularly overdose due to opioid analgesics. Over the past several years, as the overdose epidemic has received increased attention, states have made astounding gains in prevention innovation. State and systems-level strategies have much promise for changing opioid prescribing, influencing patient misuse, and reducing nonfatal and fatal overdose from opioid analgesics.
Role of funding source
No funding was provided for this work beyond salary support.
Contributors
Tamara M. Haegerich served as the lead author and edited the manuscript. Tamara M. Haegerich, Leonard J. Paulozzi, Brian J. Manns, and Christopher M. Jones contributed to construction of the literature search, selection of articles, review of articles, summarization of evidence, construction of evidence tables, and generation of conclusions. All authors have read and approved the final version submitted to Drug and Alcohol Dependence.
Conflict of interest
No conflict declared.
Acknowledgments
We would like to thank Bill Thomas from the CDC Public Health Library and Information Center for assistance with the literature search and Noah Aleshire and Akshara Menon for their assistance in identifying state legislation. The conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Food and Drug Administration.
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