Congress recently began hearings on proposals to combat opioid abuse. Opioid abuse is a serious problem across the country and shows little sign of slowing. In March 2018, the CDC reported a huge increase in emergency room visits for opioid overdoses. Most parts of the country experienced an increase of nearly one-third from 2016 to 2017 and increased nearly 70% in the Midwest during that same period. Once thought to be primarily a rural problem (rising 21%), opioid overdoses increased 54% in large central metro areas, according to the CDC.
Overdose deaths were nearly double the number of fatal car accidents in the United States in 2016. According to data analyzed by the New York Times, about 64,000 people died of opioid overdoses in 2016. By contrast The Insurance Institute for Highway Safety counted 37,461 deaths in fatal car accidents. The website Vox points out more people died of opioid abuse in 2016 than all the soldiers who died in the Vietnam War. In other words, opioid abuse is a public health crisis of epic proportions.
Opioid abuse is also huge headache for managed care executives. Millennium Laboratories analyzed CDC data and found the cost of drugs lost to fraud and abuse is just the tip of the iceberg. For every $1 spent on unnecessary opioid prescriptions, another $41 is lost to medical costs. For every overdose death, there are 130 chronic abusers and 825 nonmedical, i.e., recreational, users. For every overdose death there are 10 substance abuse treatments and 32 emergency room visits. This includes medical emergencies, emergency room visits, doctor shopping and both necessary and unnecessary treatment costs. Even for those who are not abusing opioids, the temptation to divert opioids to the illicit market is significant. The street value of $1 worth of opioids purchased at a local pharmacy ranges from $6 to $12 according to Office of Inspector General.
Congressional proposals to combat opioid abuse include:
- More funds allocated for drug treatment;
- Research on non-addictive pain relievers;
- Limits on the number of pills in any one opioid prescription;
- Improved tracking of opioid prescriptions.
President Trump has even called for tougher measures against drug dealers.
Arguably the best idea is H.R. 3528, The All Prescriptions Conveyed Securely Act. If passed, the bill would require prescriptions for controlled substances under Medicare Part D to be transmitted electronically. Prescribing software would have to meet stringent requirements to transmit prescriptions in ways that are secure; and, allow physicians to track any concurrent prescription for opioid painkillers. New York State tried this approach several years ago and found it reduced opioid use.
Most doctors have been prescribing non-controlled substances electronically for years with few problems. However, until recently federal law prohibited e-prescribing of controlled substances. The DEA was concerned that without proper security protocols, e-prescribing would facilitate diversion of drugs to the illicit market and further exacerbate abuse of controlled substances. The DEA issued final rules regulating e-prescribing software design and security protocols in 2010. E-prescribing of controlled substances is now legal in all 50 states. It should probably be mandatory in all 50 states.
Transmitting prescriptions electronically allows physicians to communicate their intentions directly with pharmacies. The alternative: handing patients instructions scribbled on a blank form ripped from a prescription pad is difficult to track. Tracking e-prescriptions electronically allows doctors to detect drug seeking behaviors, like doctor shopping for concurrent prescriptions and filling prescriptions for more opioids than any one doctor would authorize.
Health IT Now, an advocacy group for health information technology, estimates H.R. 3528 would save $13 billion in federal spending over 10 years. The medication management consulting firm, Visante, estimates the savings at more than $2 billion annually for Medicare Part D and as high as $53 billion per year if rolled out nationally. Nearly two years ago I wrote about the benefits of e-prescribing for controlled substances, arguing it was a commonsense solution that was being ignored. It is no longer being ignored.
Many opioid abusers began innocently enough as patients with chronic pain or post-surgical pain. Patients generally found opioid pain relievers effective at controlling pain, even pleasant. That is until they became an irresistible craving. Mandatory e-prescribing may do little to stop abusers who have graduated to street opioids, like heroin and fentanyl. However, better tracking of opioid prescriptions will help prevent new chronic pain management patients from becoming new opioid abusers
Devon M. Herrick, PhD, is a health economist and former hospital accountant. He has written about health policy for over 20 years.