American Journal of Law & Medicine

Combating the Prescription Painkiller Epidemic: A National Prescription Drug Reporting Program

Prescription painkiller abuse is the fastest growing drug problem in the United States. In the past year, approximately one out of twenty Americans reported misuse or abuse of prescription painkillers. Several factors contribute to the prescription painkiller epidemic. Drug abusers use various methods--such as doctor shopping, paying with cash, and filling prescriptions in different states--to avoid detection and obtain prescription painkillers for illegitimate uses. A few rogue physicians and pharmacists, lured by substantial profits, enable drug abusers by illegally prescribing or supplying controlled substances. Even ethical physicians rarely have adequate training to recognize and address prescription drug abuse, and as a result, prescribe painkillers to patients who are not using them for legitimate medical purposes. Similarly, although the majority of pharmacies have taken steps to combat drug abuse and reduce prescription painkiller dispensing, under current reporting systems, pharmacists lack visibility into several important indicators of drug abuse. As a result, even the most vigilant pharmacists find it extremely difficult to identify and detect drug abuse with certainty.

While state governments have established prescription drug monitoring programs (PDMPs) to crack down on prescription drug abuse, these programs have proven to be inadequate. The programs currently suffer from inadequate data collection, ineffective utilization of data, insufficient interstate data sharing, and constraints on sharing data with law enforcement and state agencies. By contrast, third-party prescription payment systems run by pharmacy benefit managers (PBMs) or health insurers have been effective in detecting prescription drug abuse. This paper suggests that a national prescription drug reporting program building on existing PBM networks could be significantly more effective than existing state PDMPs in detecting prescription drug abuse.

CONTENTS

I. Introduction

II. The Prescription Painkiller Epidemic

III. Contributors to the Prescription Painkiller Epidemic
     A. How Abusers Obtain Painkillers
        1. Tools to Evade Detection
     B. Rogue and Untrained Physicians
     C. Pharmacies' Role in the Prescription Painkiller Epidemic
        1. Problems with Pharmacies' Lack of Visibility
        2. Rogue Pharmacists

IV.  Laws Addressing the Prescription Painkiller Problem
     A. Federal Laws
     B. State Laws
        1. State Prescription Drug Monitoring Programs

V.   A Solution: Utilizing Current PBM Networks to Combat
     Prescription Drug Abuse
     A. Existing PBM Networks
     B. A National Reporting System for Controlled Substances
        Dispensing

VI. Conclusion

I. INTRODUCTION

Prescription painkiller abuse is the fastest growing drug problem in the United States and is classified as a health epidemic by the Centers for Disease Control and Prevention (CDC). (1) In the past year, approximately one out of twenty Americans reported misuse or abuse of prescription painkillers, and nearly 17,000 Americans died from prescription painkiller overdoses. (2) Prescription painkiller abuse is estimated to cost the United States more than $125 billion dollars every year. (3)

Several factors contribute to the prescription painkiller epidemic. Drug abusers use various methods--such as doctor shopping, paying with cash, and filling prescriptions in different states--to avoid detection and obtain prescription painkillers for illegitimate uses. A few rogue physicians and pharmacists enable drug abusers by illegally prescribing or supplying controlled substances. Other physicians do not have adequate training to recognize and address prescription drug abuse, and as a result, prescribe painkillers to illegitimate patients. The majority of pharmacies have taken steps to combat drug abuse and reduce prescription painkiller dispensing in recent years. However, under current reporting systems, pharmacists lack the ability to access several important indicators of drug abuse, making it extremely difficult to detect drug abuse with certainty. As a result, drug abusers are able to obtain prescription painkillers from even the most vigilant pharmacies. (4)

While state governments have established prescription drug monitoring programs (PDMPs) to crack down on prescription drug abuse, these programs have not succeeded. (5) The programs currently suffer from inadequate data collection, ineffective utilization of data, insufficient interstate data sharing, and constraints on sharing data with law enforcement and state agencies. By contrast, third-party prescription payment systems run by pharmacy benefit managers (PBMs) or health insurers have been effective in detecting prescription drug abuse. (6) These systems, however, currently do not process all painkiller prescriptions; prescription drugs purchased with cash instead of with insurance are not processed by PBMs or insurers, allowing drug abusers to evade detection. This Article argues that a national prescription drug reporting program building on existing PBM networks that are augmented to record cash purchases could be significantly more effective than existing state PDMPs in detecting prescription drug abuse.

The Article proceeds as follows. Section II describes the growing prescription painkiller epidemic in the United States. Section III explains the contributors to the epidemic: drug abusers with various tools to evade detection, rogue physicians and pharmacists, ethical but untrained physicians, and legitimate pharmacies that lack insight into several important indicators of drug abuse. Section IV then discusses various federal and state laws enacted to address the prescription painkiller problem, including state PDMPs. Finally, Section V concludes that an alternative, national controlled substance reporting framework building on existing PBM-pharmacy networks could provide a timely and cost-effective solution to the prescription painkiller epidemic.

II. THE PRESCRIPTION PAINKILLER EPIDEMIC

Prescription painkiller abuse is the fastest growing drug problem in the United States and is classified as a health epidemic by the Center for Disease Control (CDC). (7) While other types of prescription drugs are also commonly abused (central nervous system depressants and stimulants, for example), painkillers--drugs classified as opioid analgesics--are at the center of the prescription drug abuse problem. (8) These medications relieve pain by reducing the intensity of pain signals that reach the brain. (9) Opioid analgesics include the following common drugs: (10) Hydrocodone (Vicodin, Lortab, Lorcet); Oxycodone (OxyContin); Oxymorphone (Opana); Propoxyphene (Darvon); Hydromorphone (Dilaudid); Meperidine (Demerol); Diphenoxylate (Lomotil); Morphine (Kadian, Avinza, MS Contin); Codeine; Fentanyl (Duragesic); and Methadone.

In 2010, about twelve million Americans ages twelve or older--or about one in twenty Americans--reported nonmedical use of prescription painkillers in the past year. (11) Similarly, two million people reported using prescription painkillers nonmedically for the first time within the last year--about 5,500 per day. (12) Painkiller abuse has even hit maternity wards; a recent study estimates that every hour a baby is born in the United States with symptoms of withdrawal from opiates. (13)

Despite efforts to combat the problem, prescription painkiller abuse continues to increase at an alarming pace. Prescription painkiller sales have increased by over 300% in the last decade: sales increased from 1.75 kilograms per 10,000 people in 1999 to about 7.1 kilograms per 10,000 people in 2010. (14) The top U.S. pharmaceutical product, in terms of the number of dispensed prescriptions, is hydrocodone/acetaminophen (e.g., Vicodin), which accounts for nearly 137 million prescriptions. (15) Indeed, in 2010, enough prescription painkillers "were sold to medicate every American adult with a typical dose of 5 mg of hydrocodone every 4 hours for 1 month." (16) In 2009, 1.2 million emergency room visits were related to abuse or misuse of prescription drugs (an increase of 98.4% since 2004). (17) The rate of substance abuse treatment admissions in 2009 was almost six times as high as in 1999. (18)

Unfortunately, abuse of prescription painkillers often leads to drug overdoses and death. In 2010, more than 38,000 deaths in the United States were attributable to drug overdoses and prescription painkillers were responsible for nearly 17,000 of these fatalities. (19) In fact, deaths attributable to prescription painkillers are more than those from cocaine and heroin related overdoses combined. (20) Following the trends in prescription painkiller abuse, the number of drug overdoses has increased substantially. In fact, the number of painkiller-related deaths rose from 4,041 deaths in 1999 to 16,651 deaths in 2010, which was an increase of over 312%. (21)

The abuse of, and overdose deaths from, prescription painkillers have imposed significant costs on the nation. A recent study has estimated that nonmedical use of prescription opioids in 2006 cost $42 billion for lost productivity, $8.2 billion for criminal justice costs, $2.2 billion for drug abuse treatment, and $944 million for medical complications. (22) Furthermore, the financial impact to health insurers from nonmedical use of prescription painkillers is estimated to be $72.5 billion in direct healthcare costs annually. (23) Aggregating these two estimates of mostly distinct cost factors, prescription painkiller abuse costs the United States more than $125 billion dollars annually. (24)

Beyond the obvious societal costs, prescription painkiller abuse has significant adverse consequences for both crime and national security. There is a significant relationship between drug abuse and crime. (25) Drug abusers often commit crimes to feed their addiction. Indeed, recent news reports reveal that "[a] wave of pharmacy robberies is sweeping the United States as desperate addicts and ruthless dealers turn to violence to feed the nation's growing hunger for narcotic painkillers." (26) Similarly, "[o]piate painkillers and other prescription drugs, officials say, are driving addiction and crime like never before, with addicts singling out the homes of sick or elderly people and posing as potential buyers at open houses just to raid the medicine cabinets." (27)

The increasing demand for prescription drugs has led to increases in the robberies of pharmacies, hijacking of pharmaceutical delivery trucks, and thefts of other goods that can be sold for drugs or money to buy drugs. There were a total of 129 pharmaceutical cargo thefts across the country between 2006 and 201 1. (28) In 2009 alone, $184 million worth of prescription drugs was stolen by cargo thefts. (29) Pharmacies have also been hit hard by pharmaceutical thefts. There were 686 armed robberies of pharmacies in 2010, up 81% from 2006. (30) During this same period, the number of pills stolen from pharmacies increased from 706,000 in 2006 to 1.3 million in 2010. (31)

Moreover, other thefts related to drug abuse are growing increasingly common. There have been numerous reports of nursing home workers stealing drugs prescribed to the elderly people they care for (32) and thefts of prescription pads from hospitals. (33) There has even been an increase in sick and elderly individuals selling their own pain medications; a San Francisco police officer reports having "arrested countless drug dealers," but "only recently did he begin to notice that many of them resembled his grandparents." (34)

Prescription drug abuse is also on the rise in the military, threatening our national security. (35) According to a recent survey commissioned by the Institute of Medicine of the National Academies, misuse of prescription drugs in the military increased from two percent of active duty service members in 2002 to eleven percent in 2008, the most recent year for which information is available. (36) Moreover, because the penalties for illicit drug use in the military are steep, the survey likely underreports drug use. (37) The report noted that drug misuse among soldiers on active duty has important adverse effects on military readiness. (38) The military has responded to the prescription drug abuse problem by implementing various policies and programs on substance use disorders, (39) including prescription monitoring and restriction programs. (40)

Drug abuse is also on the rise among defense contract workers. One contractor in Afghanistan recently told new sources that, despite an absolute prohibition, drugs and alcohol were commonplace in the facility where he worked. (41) He said, "[t]here's no way if we ever came under attack that they'd be able to do anything to protect or repel an invasion or an attack." (42)

Prescription painkiller abuse has also had a devastating effect on military veterans. Numerous veterans have succumbed to drug overdoses, often from painkillers prescribed by Veterans Administration (VA) doctors. (43) Moreover, the painkiller abuse problem among veterans is growing at an even faster rate than in the civilian population. While total prescriptions written by VA doctors between 2002 and 2011 increased 37%, the number of prescriptions VA doctors wrote for oxycodone rose 150%. (44) And while prescriptions for hydrocodone/acetaminophen (Vicodin, for example) written by U.S. physicians for civilians rose 68% from 2002 to 2011, prescriptions of the drug by VA doctors increased 360% during the same period. (45)

III. CONTRIBUTORS TO THE PRESCRIPTION PAINKILLER EPIDEMIC

This Section identifies the contributors to the prescription painkiller epidemic. Drug abusers use various methods to avoid detection and obtain prescription painkillers for illegitimate uses. …

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