Florida's Pill Mills and Prescription Monitoring Reduce Opioid Prescriptions For Heaviest Users

Florida's Pill Mills and Prescription Monitoring Reduce Opioid Prescriptions For Heaviest Users

(Novus reports to professionals in the treatment industry to help support those that work to handle the epidemic of addiction in the US.)

Since cracking down on "pill mills" in the state, and introducing the state's new prescription drug monitoring program (PDMP) a few years ago, Florida is reaping the benefits of reduced abuse and diversion of prescription opioids - especially among the heaviest (most at risk) users, says a new study. Florida's new laws and regulations have allowed state and local law enforcement to put hundreds of pill mills out of business in just the last few years. This alone has contributed directly to a reduction in opioid addictions and overdose deaths. And the state's new PDMP is helping doctors and pharmacists prevent "doctor shoppers" - people who go from doctor to doctor faking symptoms trying to get multiple opioid prescriptions. According to the study, just published in JAMA Internal Medicine, prescription and use statistics for narcotic painkillers were examined from July 2010 through September 2012. They included the many brands and types commonly diverted for illegal distribution and abuse, such as OxyContin, oxycodone, hydromorphone, hydrocodone, fentanyl and many others. "PDMPs and pill mill laws offer viable policy options to address the prescription drug abuse epidemic," said lead investigator Lainie Rutkow, JD, PhD, MPH, who is an associate professor at the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health in Baltimore. "While nearly every state now has a PDMP, a much smaller number of states have enacted pill mill laws. In states without pill mill laws, policy makers may want to consider introducing these types of laws, as they complement the goals of PDMPs," Dr. Rutkow told Medscape Medical News.

Study compared Florida with Georgia

To learn if anything has changed in Florida since the changes to its drug laws, statistics were gathered for Florida and also for Georgia as a "control" where no changes to drug laws have taken place. The comparison clearly illustrated how the changes in Florida's drug laws paralleled reductions in opioid prescriptions, diversions and abuse. The research looked at 2.6 million patients, 431,890 prescribers and 2829 pharmacies, across both states. Out of 480 million total prescriptions examined, 7.7 percent, or nearly 37 million, were for opioids. The study gathered three kinds of opioid statistics - the total number of opioid painkiller prescriptions, the total opioid volume (the strength of the pills in milligrams) and their "morphine milligram equivalent" - in the world of opioid science, morphine's basic strength is used as a yardstick against which the relative strength of all other opioids are measured. The study results found that Florida's pill mill crackdown and PDMP were associated with a 1.4 percent decrease in opioid prescriptions, a 2.5 percent decrease in opioid volume, and a 5.6 percent decrease in the morphine milligram equivalent. These reductions were seen only for prescribers and patients who had the "highest prescribing and usage rates."

Florida was the pill mill capital of the US

According to DEA statistics, the Sunshine State had over 900 unregulated "pain management clinics" by the year 2010. Among the 100 US physicians purchasing the greatest amounts of oxycodone, 90 were in Florida. The Centers for Disease Control labeled Florida "the epicenter of prescription drug diversion" because it had such weak regulatory oversight of pain management clinics and practices, very limited regulation of physicians' dispensing habits and no PDMP. Drug dealers came to Florida from all over the country to stock up and go back up north to sell them on the streets. Floridians cheered when the crackdown began on the state's infamous and notorious pill mills - those hundreds of storefront offices masquerading as medical pain clinics where anyone with some cash could walk out with bags full of prescription opioids. But when the PDMP was proposed, it was not so universally well-received. From the governor all the way down to many folks in the street, it was seen as a potential invasion of privacy. However, good sense finally prevailed. The program was legislated into effect in 2009, and eventually came on line in 2011. It has since played a vital role in the reduction of opioid diversion, addiction and overdoses, the study said.

Why diverted prescription opioids are so difficult to track

When it comes to diversion of prescription opioids for illicit use, keeping track of all the prescription opioids, in all their many formulations, is a truly huge task. There are literally dozens and dozens of opioid painkillers in some form or other. As soon as law enforcement thinks it has a lock on one, another jumps in to take its place, and another and another. For example, we've been hearing about OxyContin for years as the bad guy that caused countless tragedies. Indeed it has a terrible history of abuse, addiction and overdose deaths. But OxyContin is only one of countless prescription opioids. Almost all of them can be abused, and many routinely are. First of all, the active opioid in OxyContin is oxycodone. Let's take quick look to see what the oxycodone scene really involves. Oxycodone isn't just OxyContin, it's not just one pill, or even several pills, or even pills at all in some cases. Oxycodone is a whole range of opioid formulations, all with their own specialized medical uses and purposes. The trouble is, almost all of these formulations can be targets for theft and diversion, from the nation's hospitals and pharmacies and even from mom, Uncle Kilroy and the old lady next door. Oxycodone is the active opioid ingredient in prescription painkillers such as OxyContin, as we mentioned above, and also in Roxicodone, Oxecta, OxyIR, Endone, Oxynorm, OxyNEO, and if you go overseas, a mind-boggling ton of others. Some of these are designed to make abuse difficult, but addicts continue to find ways around those safeguards. Oxycodone is available as both a single-ingredient medication, as both immediate release and as time release (OxyContin is a time release version). Each comes in a variety of strengths or milligrams of opioid content, increasing the range and numbers of inventories ripe for the picking in unguarded pharmacies and medical facilities. Oxycodone is also provided for IV/IM administration. Not a lot of trafficking in this closely guarded formulation, but nevertheless another potential target for abuse. Combination products are also available - oxycodone mixed with non-narcotic ingredients such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen. These are all available as immediate release formulations, and also in a variety of strengths. Oxycodone is also available as a combination with naloxone, as a time-release tablet. Naloxone is a medication widely used to reverse the dangerous effects of opioids on the central nervous system, especially as emergency treatment for opioid overdose. But when it's combined with oxycodone, the naloxone acts to limit the amount of the "high" that can be achieved when abusing the pill, especially if it's crushed and dissolved for injection, or tampered with in some other manner. Obviously, this is probably the only form of all these versions of oxycodone that is not high on the list for theft and diversion - you can't get high on it! Bottom line, however, oxycodone can be administered orally, intranasally, intravenously, intramuscularly or by subcutaneous injection, or rectally. And that's just one of dozens and dozens and dozens of opioid pain relievers potentially reaching the illicit marketplace. When you add on the other drugs of abuse, such as benzodiazapines, the list gets even longer and more unwieldy. Clearly, having and using a prescription drug monitoring program goes a very long way to help track the enormously complex problem of prescription drug abuse.

If we pay attention and work together we can continue to make progress

In the US, more than 12 million people abuse opioid drugs, 100,000 of them are rushed to emergency wards, and more than 16,000 deaths are related to opioid overdose, often in combination with other prescription drugs such as benzodiazepines as well as alcohol. In Australia, 91 percent of injecting drug users reported using oxycodone in 2015. And the same is true in many other countries. Since there are so many prescription pain relievers already available, many experts continue to query the introduction of new brands and formulations. "Are these really necessary?" is the usual question. Fortunately, many physicians across the country are responding to the call for more care and restraint in prescribing opioids. Combined with the good effects of new laws such as those in Florida, this is helping reverse "the prescription opioid epidemic." In Florida, health officials and law enforcement, along with medical personnel and pharmacists, are working together to help turn back what until recently was a tidal wave of prescription drug abuse in the state. "Sales of opioids are highly correlated with rates of injuries and death from their use, so it's very important that we now know that pill mill laws and prescription drug monitoring programs working together can reduce sales to the heaviest users," Dr. Rutkow said. "Most prescribers support policies that limit access to opioids. Given this support, and the reductions we have seen in this study, other states may want to consider this as a viable regulatory strategy for addressing opioid abuse in their communities." Here at Novus, we applaud the state's efforts to defeat the prescription opioid epidemic. And we are dedicated to helping our patients break free from opioid dependence and get their lives back.

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