Prescription Drug Monitoring Programs: A Policy with Limited Impact - - 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 effect of prescription drug monitoring

programs (PDMP) on prescribing for opioid and nonopioid analgesics through the Medicare Part D program?

• Difference-in-differences 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

Findings

• No significant changes in overall opioid prescribing
• 6.3% decrease in days supply prescribed per

physician for oxycodone

• Evidence of substitution toward Schedule IV opioids

and nonopioid analgesics

• State statutes that explicitly do not require physician

access neutralize the effects of PDMPs.

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
• pioid painkiller overdose.

Source: New York Times, Jan. 16, 2016

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 (41)
• Reporting frequency (daily - 21)
• Registration requirements (21)
• Statutes explicitly not requiring access (16)
• Mandatory access (15)

PDMP Literature

• Few studies have systematically studied the effects
• f PDMPs.
• The literature presents conflicting results on PDMP

effectiveness.

• 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 effects on the most commonly abused
• pioids—oxycodone and hydrocodone
• Uses difference-in-differences 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 Effects
• Year Fixed Effects

Empirical Model

• OLS models with state and year fixed effects
• n = 789,569 at the physician-year level
• Excluding the 29 states with PDMPs prior to 2011

and including state and year fixed effects creates a difference-in-differences framework.

Pre-trend Analysis

Results

PDMP PDMP Statute

Conclusion: A Limited Effect for PDMPs

• PDMPs do not appear to decrease physician

prescribing of opioid painkillers overall.

• They have a small but targeted effect with respect to

the high-profile drug oxycodone.

• Back-of-the-envelope calculation shows a decrease
• f ~104 days supply per doctor.
• Statutes explicitly not requiring physician use of a

PDMP have the effect of reversing these reductions.

Conclusion: A Limited Effect for PDMPs

• Hydrocodone prescribing seems to remain

unchanged, despite also being heavily abused.

• Small substitution effects from Schedule II to

Schedule IV drugs and nonopioids analgesics might prevent some adverse effects 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 (e.g., mandates and registration requirements)

• Measure the effect of PDMPs for the prescribing
• utliers
• Analyze the relationship between PDMPs and

individual pain management

Limitations

• Studies using claims data outside Medicare may

arrive at different 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 of the effect.

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 opioid

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 effects of PDMPs on
• verdose 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 effect for deaths, overall opioid abuse, or heroin abuse.

• Rutkow et al. (2015) observe significant but modest decreases in opioid

sales in Florida after the state’s implementation of a PDMP and Pill Mill regulations.

Prescriber Checkup Dataset

Results

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)

Raw Difference-in-Differences

Summary Statistics

Part One Results: Any Prescribing