Prescription Drug Monitoring Programs: A Policy with Limited - - PowerPoint PPT Presentation


 
 Prescription Drug Monitoring Programs: 
 A Policy with Limited Impact 


• n the Opioid Painkiller Epidemic

Courtney R. Yarbrough

Ph.D. Candidate University of Georgia Department of Public Administration and Policy

Supported by a grant from the Robert Wood Johnson Foundation’s Public Health Law Research program (#72227)

Research Question

• What is the efgect of prescription drug

monitoring programs (PDMP) on prescribing for

• pioid and nonopioid analgesics through the

Medicare Part D program?

• Difgerence-in-difgerences estimation
• Physician-level prescribing, 2010-2013
• Looking at days supply of prescriptions for 

• pioids and nonopioid pain relievers, 

• xycodone, hydrocodone, and 


DEA Schedules II-IV

MOTIVATION: 
 THE OPIOID EPIDEMIC

Source: Centers for Disease Control and Prevention

Rates of prescription painkiller sales, deaths and substance abuse treatment admissions (1999-2010)

The Opioid Epidemic

• In 2012, U.S. patients filled 259 million

prescriptions for opioid painkillers, enough to medicate every American adult for a month.

• The U.S. consumes 80% of opioid painkillers in

the world (99% of hydrocodone).

• 1.9 million Americans have an opioid painkiller

substance abuse disorder. More than 4 million use the drugs non-medically.

• In 2014, there were almost 19,000 deaths

related to opioid painkiller overdose.

Source: New York Times, Jan. 16, 2016

POLICY RESPONSE: 


PRESCRIPTION DRUG MONITORING PROGRAMS

Prescription Drug Monitoring Programs

• Forty-nine states have now enacted PDMPs as a

primary response to prescription painkiller abuse.

• Online databases collect dispensing data from

pharmacies about prescriptions filled for controlled substances.

• Physicians can consult the PDMP to see if a

patient has multiple, overlapping prescriptions.


• PDMPs help uncover doctor shopping behavior

by providing physicians with a tool to verify a patient’s drug-seeking behavior.

Prescription Drug Monitoring Programs

• They vary state-to-state in operational details.
• Unsolicited reports
• Reporting frequency
• Registration requirements
• Statutes explicitly not requiring access
• Mandatory access

PDMP Literature

• Few studies have systematically studied the

efgects of PDMPs.

• The literature presents conflicting results on

PDMP efgectiveness.

• Most focus on ecological measures of outcomes

such as opioid-related deaths or treatment admissions at the state-level.

• Few contend with endogeneity of policy

adoption.

Contribution

• Observes individual-level responses to PDMPs

by the policies’ intended targets—physicians

• Examines possible switching between opioid

and nonopioid pain treatments

• Measures efgects on the most commonly abused
• pioids—oxycodone and hydrocodone
• Uses difgerence-in-difgerences estimator to

help control endogeneity of policy adoption

Prescription Drug Monitoring Programs

• For this study, I consider a state to have a PDMP

in time t if:

• 1. Dispensers are required to report.
• 2. Physicians have access.
• 3. The database is available online.
• I use a proportional value of PDMP if the

program was implemented in time t.

• I also measure if a state has a statute explicitly

not requiring physician PDMP access.

Online PDMP Implementation

Pre-2010: 29 States

Online PDMP Implementation

Pre-2010: 29 States 2010: MA (Dec.)

Online PDMP Implementation

Pre-2010: 29 States 2010: MA (Dec.) 2011: FL, KS*, OR*

Online PDMP Implementation

Pre-2010: 29 States 2012: AK*, DE, MT, NJ*, RI, SD*, TX, WA 2010: MA (Dec.) 2011: FL, KS*, OR*

Online PDMP Implementation

Pre-2010: 29 States 2012: AK*, DE, MT, NJ*, RI, SD*, TX, WA 2010: MA (Dec.) 2013: AR, GA*, WI*, WY* 2011: FL, KS*, OR*

Online PDMP Implementation

Pre-2010: 29 States 2012: AK*, DE, MT, NJ*, RI, SD*, TX, WA 2010: MA (Dec.) 2013: AR, GA*, WI*, WY* 2011: FL, KS*, OR* Control: MD, MO, NE, NH, PA

Data – Dependent Variables

• ProPublica Prescriber Checkup database (2010-2012)

and Centers for Medicare and Medicaid Services (2013)

• Number of prescriptions filled through Medicare Part D

at the drug-provider-year level

• All providers included with at least 50 Part D fills per

year

• Drugs suppressed if < 10
• Aggregated according to drug categories (from

Medicare Formulary Reference File) to form 7 DVs

Data – Dependent Variables

• Logged days supply of a physicians prescribing

that is for:

• 1. Opioid painkillers
• 2. Nonopioid painkillers
• 3. Hydrocodone
• 4. Oxycodone
• 5. Schedule II Opioids (including oxycodone)
• 6. Schedule III Opioids (including hydrocodone)
• 7. Schedule IV Opioids (e.g., tramadol)

Data – Independent Variables

• State-Level
• PDMP (proportional [0,1])
• “No Required Access” Statute (proportional [0,1])
• County-Level
• Part D Enrollment
• Per Capita Medicare Costs
• Percent of Population White, Black, Hispanic, Asian, and

Other

• Median Income
• HHI of Physician Prescribing
• Provider-Level
• Provider Sex
• Medical Specialty Dummies
• State Fixed Efgects
• Year Fixed Efgects

Empirical Model

• OLS models with state and year fixed efgects
• n = 789,569 at the physician-year level
• Excluding the 29 states with PDMPs prior to

2011 and including state and year fixed efgects transforms the models into the algebraic equivalents of difgerence-in-difgerences models with the coeffjcient for PDMPst becoming the DID interaction term.

Pre-trend Analysis

Results

Outcome PDMP Coefficient t-score PDMP Statute Coefficient t-score Opioids 0.0072 (-0.78) 0.038*** (-3.27) Nonopioids 0.025*** (-2.61) 0.0065 (-0.53) Oxycodone

• 0.063***

(-5.77) 0.061*** (-4.52) Hydrocodone

• 0.0021

(-0.23) 0.0078 (-0.66) Schedule II

• 0.039***

(-3.53) 0.040*** (-2.93) Schedule III

• 0.0045

(-0.50) 0.012 (-1.04) Schedule IV 0.023** (-2.42) 0.017 (-1.45)

Results

PDMP PDMP Statute

Conclusion: A Limited Efgect for PDMPs

• PDMPs do not appear to decrease physician

prescribing of opioid painkillers overall.

• They have a small but targeted efgect with

respect to the high-profile drug oxycodone.

• Back-of-the-envelope calculation shows a

decrease of ~104 days supply per doctor.

• Statutes explicitly not requiring physician use of

a PDMP have the efgect of 
 reversing these reductions.

Conclusion: A Limited Efgect for PDMPs

• Hydrocodone prescribing seems to remain

unchanged, despite also being heavily abused.

• Small substitution efgects from Schedule 2 to

Schedule 4 drugs and nonopioids analgesics might prevent some adverse efgects of opioid use.

• PDMPs have in recent years shown only limited

success in reducing opioid prescribing, suggesting that they need to be strengthened and/or additional policy tools are required.

Next Steps

• Exploit other variation in PDMP characteristics

to understand what works.

• Measure the efgect of PDMPs for the prescribing
• utliers.
• Examine changes in states that have begun to

require physician consultation of the PDMP for every prescription written.

• Analyze the relationship between PDMPs and

individual pain management.

Limitations

• Studies using claims data outside Medicare may

arrive at difgerent results.

• DID models control for unobservable time-

invariant sources of endogeneity; however, time-variation sources may persist.

• Other policy changes related to opioid abuse

prevention are not included (e.g., Pill Mill legislation).

• If many patients are crossing state lines to non-

PDMP states, the models may overestimate size

• f the efgect.

COURTNEY R. YARBROUGH
 UNIVERSITY OF GEORGIA
 cryarb@uga.edu

Thank you

Medicare Part D Data

• Beneficiaries include age-eligible (65+ YO) and

disability-eligible (from SSDI) individuals.

• 1/3 of all beneficiaries had ≥ 1 opioid prescription.
• 25% of observations in data were from claims by

disability-eligible patients. 44% of disabled beneficiaries had ≥ 1 opioid prescription; 23% were chronic users. 1/3 have a musculoskeletal diagnosis (e.g., back pain).

• MedPAC found evidence for 170,000 cases of doctor

shopping in 2008 claims.

• Inpatient hospital stays increased 10.6% annually among

Medicare patients 1993-2012.

Source: Social Security Administration Credit: Lam Thuy Vo/NPR

Opioids: A Gateway Drug

• Heroin poisoning deaths have tripled since 2010

(10,574 in 2014).

• Both opioid painkillers and heroin are opiates and
• perate through similar channels on the brain,

producing comparable euphoria.

• 80% of new heroin users are previous abusers of
• pioid painkillers.
• Users report transitioning to heroin because the

drug is much less expensive and more accessible than prescription opioids.

• Suspicions that opioid-abuse policies have driven to

rise in heroin use appear to unsubstantiated (Compton, Jones & Baldwin, 2016).

PDMP Literature

• Simeone and Holland (2006) find a decrease in per capita supply of
• pioids but no change in treatment admission.
• Reifler et al. (2012) find slower growth in opioid overdoses and

treatment admission in PDMP states from 2003 to 2009.

• Paulozzi, Kilbourne & Desai (2011) find insignificant efgects of

PDMPs on overdose mortality or opioid consumption rates but find evidence of switching between Schedule II and Schedule III opioids.

• Radakrishnan (2014) finds decreased abuse of oxycodone on the

intensive margin and fewer SUD treatment admissions but no efgect for deaths, overall opioid abuse, or heroin abuse.

• Rutkow et al. (2015) observe significant but modest decreases in
• pioid sales in Florida after the state’s implementation of a PDMP

and Pill Mill regulations.

Prescriber Checkup Dataset

Results

Raw Difgerence-in-Difgerences

Summary Statistics

Part One Results: Any Prescribing