New CDC Prescription Surveillance System Publishes First Report
In the wake of a rise in prescription overdose deaths, every state except Missouri now has its own prescription drug monitoring program (PDMP).1 The progam is intended to garner more data about circulating controlled substances, which could help policy makers better understand how to curb the prescription drug overdose epidemic.
The Prescription Behavior Surveillance System (PBSS) is one particular arm of PDMPs. An ongoing, population-based surveillance system, the PBSS gathers its data directly from the pharmacies, culling controlled substance rates by state and quantifying data on potential misuse behaviors, like patients using multiple prescribers, paying for drugs with cash, overlapping their prescriptions, etc.
On October 16, 2015, the Centers for Disease Control and Prevention (CDC) released the PBSS’s first official report,2 offering the most recent data from 2013. Eight states contributed data in time for the first report, including California, Delaware, Florida, Idaho, Louisiana, Maine, Ohio, and West Virginia.
Expanding a National Surveillance System
“Currently there are a total of 11 states that report PDMP data to the PBSS. Several more states have been invited, and are at various stages in the process required to join,” said Debra Houry, MD, MPH, the Director of the National Center for Injury Prevention at CDC.
“Further expansion of the system is expected in the future, but will occur in a measured fashion to ensure that the scalability of the system is adequate to support the expansion.” This likely will require additional funding, namely from the Food and Drug Administration (FDA) and the Brandeis University Center of Excellence, a data analysis center in Waltham, Massachusetts that oversees the system.
There are other challenges to expanding the scope of the PBSS, as well. Federal laws prohibit the release of confidential information about patients who receive treatments for substance abuse.
“Controlled substances utilized by substance abuse programs for medication-assisted therapy [MAT], such as methadone, are not dispensed by a pharmacy, but rather are dispensed on site by the substance abuse programs themselves, and thus are not subject to PDMP reporting,” noted the report.
Also, state laws vary as to what constitutes a controlled substance, or what type of pharmacy must contribute data to PDMPs. These aspects could be considered limitations of the data.
The following is a summary of the PBSS’s 2013 report.
Prescription Drug Rates
The report found that:
- Opioid analgesic prescription rates approached one prescription per state resident, making them far more prescribed than benzodiazepines or stimulants in every state.
- For all drug classes, Louisiana had the highest rate of prescriptions, while California had the lowest rate.
Factoring in demographics, the report also found that:
- Females in every state were prescribed opioids and benzodiazepines far more often than males.
- Males were prescribed stimulants at or above the rate for females, specifically in 5 states (California, Delaware, Idaho, Maine, and Ohio).
- Louisiana had the highest prescribing rate for every age group (except for the 25-34 age group).
- Opioid prescribing rates increased steadily by age in California and Idaho.
Type of Opioids
As noted, Louisiana was ranked first for opioid prescriptions. A majority (65%) of its prescriptions were for short-acting (SA) hydrocodone (Vicodin, Lortab)—3.8 times that of Delaware, which had the lowest rate of opioid prescriptions by contrast (21%). The reverse was true with SA oxycodone (Percocet), which was far more popular in Delaware (43%) than in Louisiana (15%).
Delaware and Maine had more association with long-acting (LA) and extended-release (ER) opioids, like fentanyl LA, methadone, and oxycodone LA (Oxycontin), and ranked highest in mean daily opioid dosage and percentage of opioid prescriptions written for >100 morphine milligram equivalents (MMEs) per day. Overdose risk increases with higher dosages of opioids.
Additional PBSS statistics showed other risks for overdose deaths, like overlapping prescriptions with benzodiazepines3 and aggressive opioid regimens for opioid naïve patients.
In West Virginia, in 1 out of every 5 days of treatment with an opioid, patients were also taking a benzodiazepine. Previous PDMP reports have found that despite the additive depressant effects of concurrent benzodiazepine administration, they are still commonly prescribed with opioids.4
Overlapping LA opioid prescriptions were also common in 6 out of 8 states. There is no clinical justification for overlapping opioid prescriptions, although previous studies also have found the trend to be very common, sometimes accounting for a quarter of all LA/ER prescriptions.5
Particularly in West Virginia and Idaho, it was very common for LA/ER opioids to be prescribed to opioid naïve patients (no opioids in previous 60 days). Such dosages were higher than overall daily opioid dosages but lower than LA/ER daily opioid dosages for all patients.
The PBSS enables compilation of population-based metrics, which reveal patterns of misuse behaviors that can be identified and targeted for prevention. For instance, opioid misuse is often associated with a patient seeing multiple prescribers at one time, something referred to as a multiple-provider episode (MPE) or doctor shopping.
- Ohio had the highest MPE rates for drug Schedules I, II, and II-IV, while Louisiana had the lowest.
- The highest MPE rates were with middle-aged patients (aged 35 to 54), particularly for drug schedules II, III, and IV, typically indicative the drugs were being used for purposes other than pain control.
- In addition, people in the yournger age range (18 to 34) “were almost universally more likely” to engage in an MPE than patients age 55 of older.
The PBSS defines an MPE as a patient filling prescriptions from 5 or more prescribers at 5 or more pharmacies for a particular class of drugs during a 6-month period, a fairly restrictive definition by other analyses’ standards.6 Because of this, the report could have underestimated actual MPE rates.
How a patient pays for their prescriptions could also be indicative of misuse behavior. Granted, some patients may find it more convenient to pay for their prescriptions with cash, it has been found that patients engaged in MPEs do typically pay for the prescriptions with cash.7
Florida and California showed the highest rates of cash payments for opioids and controlled substances. However, it would be hard to surmise higher cash payment rates as a marker for misuse potential, as cash rates do generally correspond inversely with Medicaid usage, the report noted. Consequently, Florida and California had lower Medicaid rates than most of the other states.