Stop us if you’ve already heard this factoid: Unintentional drug overdoses, led by opioid overdoses, have surpassed car accidents as the leading cause of injury-related death in the U.S. That more people are dying of overdoses from prescription painkillers and heroin is a well-established, and tragic, trend across the country.
The question to ask next is pretty clear: What can we do to slow, and ultimately stop, these needless deaths as soon as possible? A recent study by researchers at the Centers for Disease Control and Prevention (CDC) and the University of California, San Diego, aims to help answer that very question. Specifically, the new research makes recommendations for how we can do better at preventing opioid overdoses. The study was published in the Journal of Pain, which is put out by the American Pain Society.
The researchers looked at data tracking prescription opioid use among Medicaid beneficiaries, including how many pharmacies a patient uses in a specific period of time. Some state Medicaid programs restrict patients to using a single pharmacy if they go above a certain threshold that signals they’re getting enough of a painkiller like oxycodone or hydrocodone to indicate a possible problem with dependence or addiction.
The thing is, that cut-off point varies from state to state. In Kentucky, if you use three pharmacies in two consecutive 180-day periods, you’ll be restricted to using just one pharmacy, while in Washington State if you visit four pharmacies within 90 days, that’s when the limit will kick in. In Michigan it’s three pharmacies within a three-month period.
The researchers on the new study say that a standardized, evidence-based definition of what constitutes high-risk prescription opioid use behavior — meaning a level with an elevated risk of overdose — would help all states identify patients at risk and, hopefully, reduce the number of unintentional deaths from these medications. It would also have the benefit of not penalizing patients who have a legitimate reason for using multiple pharmacies, including frequent travel that takes them away from a home pharmacy, insufficient supply at one or more local pharmacies and insurance coverage that favors some pharmacies over others.
What Signals an Overdose is Likely?
To help determine more accurate criteria for preventing overdose, the researchers looked at records of more than 90,000 adult Medicaid enrollees in multiple states who were long-term opioid users. All used three or more opioid prescriptions for at least 90 days in 2008 through 2010. The researchers found that in a 90-day period, use of four or more pharmacies had the highest odds for overdose. The rate of overdose rose even more among people who received two of the same type of prescription painkillers with overlapping days of supply, what’s known as “overlapping prescriptions.”
For patients whose use of overlapping prescriptions and multiple pharmacies cannot be medically justified, nationwide restriction programs could limit opioid prescriptions for a patient to a single designated physician and one pharmacy. (Prescription drug monitoring programs, or PDMPs, also monitor prescription opioid use in each state, but these are separate from Medicaid’s system.)
In an email to Addiction.com several of the study authors pointed out the significance of focusing on “pharmacy-shopping” when it comes to potentially preventing some opioid overdoses. According to one of the researchers, Michele K. Bohm, MPH, part of the CDC’s Injury Center, “when people talk about ways to get excessive amounts of prescription opioids, more attention is paid to ‘doctor-shopping.’ Pharmacy-shopping is often neglected. In fact, more research has focused on the relationship between doctor-shopping and opioid drug abuse,” Zang notes, adding that “patients on prescription opioids may have legitimate reasons to get drugs from multiple doctors – for example, getting these drugs from a dentist [following oral surgery] or an ER doctor, or having another practitioner fill a prescription on behalf of a patient’s primary care doctor within the same medical practice.”
The researchers say that if prescription opioids obtained from multiple doctors are found to be legitimate, a patient may visit a small number of pharmacies — fewer than four— to fill the prescription. On the flip side, if someone is abusing or misusing the drug, he or she may visit multiple pharmacies to avoid suspicion. A previous study using West Virginia Prescription Drug Monitoring Program data found that only 20% of doctor-shoppers exhibited pharmacy-shopping, while over half of pharmacy-shoppers exhibited doctor-shopping too. “This implies that presumably pharmacy-shopping may be a more appropriate behavioral indicator than doctor-shopping in terms of identifying patients who misuse or abuse prescriptions,” says Bohm, and these people are at a higher risk of overdosing.