The Kill Pill: Prescribing a solution to the American drug crisis

A prescription may endow a drug with a façade of legitimacy, an illusion of medical necessity – but it does not make it any less deadly. Seventeen-year-old Alexia Springer, a high-school junior at Centreville High School in Virginia discovered this one night at a party with friends. Described by many as “selfless” and “kindhearted,” Springer played varsity soccer, earned good grades, and was Homecoming Princess. “Even if you didn’t know her,” one Centreville senior noted, “you knew of her.”

But Springer, like most teenagers, was not averse to experimentation. At a crowded house party, an older classmate handed her a morphine pill. Springer snorted it and spent the rest of the party drinking and consuming more prescription drugs. The next morning, she didn’t wake up. A medical examiner later found that the cocktail of substances in her system – the booze and pharmaceuticals from the night before – had killed her.

Springer’s premature death is just one story in a much larger crisis: the prescription drug epidemic. The Drug Enforcement Agency (DEA) has called prescription drug abuse “the nation’s fastest growing drug problem.” Every day, 2,500 American adolescents between the ages of 12 and 17 abuse a prescription drug for the first time. And in the past few years, opioid use has quietly proliferated among all age groups and geographic spaces. Some states even have more opioid prescriptions than people, with Alabama, Tennessee, and West Virginia all boasting a prescription-per-100-residents ratio of 137. The consequences of such rampant misuse are devastating. In 2014, prescription drug overdoses killed 25,760 Americans, claiming substantially more lives than cocaine and heroin combined.

Compared to cocaine or heroin, which are more often associated with the glamor and intrigue of organized crime, prescription drugs seem more mundane. They come in three major classes, as defined by the Centers for Disease Control and Prevention (CDC): opioid painkillers, such as Vicodin and OxyContin, for pain relief; benzodiazepines, such as Xanax and Valium, to alleviate anxiety; and amphetamine-like drugs, such as Adderall and Ritalin, which treat attention-deficit and hyperactivity disorder. The unchecked distribution of pain-relieving drugs in recent years has much to do with the present crisis. Since 2009, the sales of painkillers have jumped 300 percent, and between 2007 and 2011 doctors wrote 14.1 percent more prescriptions for hydrocodone and 26.6 percent more for oxycodone.

The costs of this over-prescription and the ensuing overuse are extraordinary. The American health care system is already financially unsustainable, consuming close to one-fifth of the national gross domestic product. Prescription drug abuse costs insurers $72.5 billion every year, which increases the price of health insurance premiums. Another $50 billion is lost to reduced labor productivity and criminal justice expenses. For context, the aggregate economic cost of pharmaceutical abuse is almost double the 2016 federal education budget.

In the face of these dismaying statistics and individual tragedies, state policymakers have cobbled together a path forward: prescription drug monitoring programs (PDMPs), electronic databases that state authorities use to track the dissemination of controlled substances. Typically operated by a state’s health department or pharmacy board, PDMPs record every exchange of federally controlled drugs – from the initial prescription in a doctor’s office to the eventual purchase at a pharmacy – allowing officials to hold individual physicians and pharmacists directly responsible for the drugs they prescribe.

So far, PDMPs have been a policymaker’s dream. They offer state authorities access to information critical to holistically reducing prescription drug abuse without boxing them into specific policy solutions. Broadly, PDMPs prevent overconsumption of prescription drugs by giving doctors a clearer picture of their patients’ prescription drug history, inhibit “doctor shopping,” where addicts visit multiple physicians for prescriptions, by pinpointing sources of above-average distribution, and supplement law enforcement investigations. But because they provide only data, and come with no existential recommendations for a specific course of action, PDMPs also allow states to establish their own anti-drug priorities. In this way, the programs are revolutionizing the way states and municipalities tackle the drug crisis and deploy data-driven and localized solutions.

Though technological advances have radically changed how PDMPs work today, they have long been a favorite tool of state administrators combatting drug use. In 1918, New York State adopted the country’s first PDMP, a paper database that recorded only the distribution of cocaine, morphine, and heroin. On top of the limited scope of early monitoring measures, their constitutionality was not yet formally established. It wasn’t until 1977, that the Supreme Court ruled in Roe v. Whalen that PDMPs were a lawful exercise of a state’s police powers. Decades later, in the 1990s, as crime rates reached record highs, states began to modernize their PDMP programs. In 1990, Oklahoma began to store and transmit data electronically, and in 1995, Nevada expanded the list of monitored drugs.

Federal involvement in PMDPs emerged from legislative action in 2002, when Congress began funding the Harold Rogers Prescription Drug Monitoring Program. The Bureau of Justice Affairs, in charge of funding the program, sought to enhance state PDMPs by constructing a national infrastructure for information-sharing. Rather than let each state run its PDMP individually, the Bureau believed that the campaign against pharmaceutical abuse might be more effectively advanced with interstate cooperation.

Until recently, modern, computerized forms of PDMPs have attracted broad political support. As of 2015, there are operational PDMPs in 49 states, with the single exception of Missouri. At least 15 of these programs have been created in the last decade alone, while many others have been reformed or improved. PDMPs can also allow health care professionals to target at-risk individuals and stage effective early interventions. Funding for the Harold Grant Program peaked in 2010 at $10 million; 2014, funding fell to $7 million, back to 2004 levels. In 2005, Congress redoubled its commitment to prescription drug monitoring, passing the National All Schedules Prescription Electronic Reporting Act, which also funded state drug control measures. From 2011 to 2014, however, the Act’s funding was not restored. A 2015 attempt to reauthorize and amend it has passed the House of Representatives, but made little progress since.

In spite of this lapse in funding, PDMPs have achieved notable success in driving down rates of doctor shopping and overdose deaths in recent years. Two years after Florida implemented its own PDMP in 2010, the number of deaths associated with oxycodone overdoes was halved. A University of Florida College of Medicine policy report found “the early success of Florida’s system has caused numerous unscrupulous doctors and rogue pharmacy operations to move out of the state.” New York and Tennessee, just a year after PDMPs were established in 2012, saw drops in doctor shopping of 75 percent and 36 percent, respectively. States without PDMPs experience drastically different outcomes. Some fraudulent practitioners in Florida, for instance, made their way to Georgia, which at the time lacked an operational PDMP.

But beyond just stopping abuse, PDMPs have also played a significant role in public outreach and health education. In 2008, officials in Wilkes County, North Carolina started Project Lazarus, a program for community-based drug prevention. The Project used data collected by the country’s PDMP to create presentations to community groups, allowing attendees to see firsthand the widespread devastation wrought by prescription drug abuse. The PDMP data also mobilized community support for North Carolina’s drug control efforts. The effects of Project Lazarus were almost immediate: Between 2009 and 2011, overdose deaths fell by 69 percent, and hospitalizations attributed to drug misuse fell by 15 percent.

PDMP contributions to public health have begun to appear in the criminal justice system as well. Drug courts, which impose programs of treatment and rehabilitation on nonviolent substance abusers in lieu of jail time, benefit considerably from PDMP data. In Kentucky, for instance, about two-thirds of drug courts rely on PDMP data, in conjunction with other monitoring measures, like hair and urine samples, to interrupt cycles of drug abuse. When offenders appear to be obtaining unusual quantities of prescription drugs, which might indicate illicit diversion of controlled substances, PDMP data is used to keep offenders on the correct treatment track.

Despite their resounding success at the state level, PDMPs are far from perfect, even with more funding. There is still much progress to be made on issues of privacy, interstate cooperation, and program scale. Specifically, the federal government has long been concerned about the viability of nationwide PDMP interoperability, referring to the potential for states’ PDMPs to cooperate to yield better public health outcomes. In Section 1141 of the 2012 Federal Food, Drug, and Cosmetic Act, Congress asked the nation’s federal health authorities to develop “recommendations on interoperability standards to inform and facilitate the exchange of prescription drug information across State lines.” Currently, the Department of Health and Human Services identifies several obstacles to streamlined interstate sharing of PDMP information. First, different states authorize different types of users to access PDMP data. Second, federal agencies that provide health care – the Department of Veterans Affairs, Indian Health Service, and the Department of Defense – have yet to share their data on prescription drug use with state PDMPs, leaving gaps in the health records of users. Finally, technical idiosyncrasies in software, workflow, and training make electronic collaboration cumbersome for PDMPs between states.

New York and Tennessee, just a year after PDMPs were established in 2012, saw drops in doctor shopping of 75 percent and 36 percent, respectively.

The federal government can rectify these issues, in part, by finally standardizing PDMP practices across state lines. A good place to start is to mandate that PDMPs in all states permit doctors and pharmacists to access data. This way, healthcare providers have a better picture of their patients’ prescription drug histories. Inter-agency cooperation can also bolster PDMP performance. The Bureau of Justice Assistance, which funds many state PDMPs, and the Department of Health and Human Services should evaluate the latest health technology and build a standard model of PDMP technical infrastructure, predicating future grant funding on adherence to that model. Standardization will enable easier information sharing and interstate PDMP coordination.

Ironically, another dilemma posed by PDMPs lies in their success at curbing access to prescription drugs. Some critics fear that a crackdown on prescription painkillers might inadvertently drive painkiller addicts to resort to heroin, a chemically similar and far deadlier opioid, instead. Overall, nonmedical consumers of painkillers are at a higher risk of experimenting with, and eventually becoming addicted to, heroin, a potentially much larger problem.

These worries are not unfounded. In 2010, the manufacturers of OxyContin produced a pill that resisted dissolution and crushing, making it harder to ingest through injection and inhalation. Between 2009 and 2012, the use of OxyContin amongst a surveyed population of drug users fell from 47.4 percent to 30.0 percent, but the rate of heroin use nearly doubled. These results illustrate a confounding reality of drug control policy: Even the most well-intentioned measures can have radically unpredictable ramifications. In this particular case, a mechanism to deter opioid abuse resulted in the drug users simply substituting OxyContin with heroin. There is no clear course of federal action that can resolve this paradox – though the usual calls for greater investments in drug rehabilitation and non-punitive criminal justice measures may have a positive effect.

A final problem area for PDMPs is their use by law enforcement agencies. In 2012, the PDMP Training and Technical Assistance Center at Brandeis University unveiled a training guide that enthusiastically called for a closer integration between PDMP systems and law enforcement. The guide found that suspicious patterns of doctor shopping and prescribing are more easily recognized and corrected when law enforcement can readily access PDMP data and that the coordination of PDMP analytics with timely policing can dramatically reduce prescription drug abuse. Today, only four states allow parole and probation officers to view PDMP data. Greater use of PDMP information in correctional systems may reduce drug-related offenses and recidivism and encourage abusers to seek medical attention for their addictions.

But long after the Roe v. Whalen case in 1977, fears of unconstitutionality still linger. Many health care providers are worried that PDMP expansion, and the warrantless sharing of PDMP data with law enforcement, might constitute a violation of the privacy agreement between patients and physicians. In 2014, the Oregon chapter of the American Civil Liberties Union (ACLU) went so far as to challenge the DEA’s procurement of data from the Oregon state PDMP. The ACLU asserted “that the Fourth Amendment privacy rights of Oregonians are violated when the federal government can access their private medical information without first demonstrating any wrongdoing.” And, in an amicus brief filed by several state medical associations, supporters of the ACLU argued: “With unsupervised law enforcement access to their prescription care records, patients may fear to fill prescriptions and thereby compromise their care.” An Oregon federal judge later ruled in favor of the ACLU’s advocacy.

For all their drawbacks, PDMPs have scored irrefutable victories in the fight against substance dependency. They visibly reduce prescription drug abuse and inform state responses, all while saving taxpayer dollars. Still, PDMPs demand answers to the age-old questions of privacy, the powers of law enforcement, and technology. And while the federal government may not be able to singlehandedly rectify these matters, it should, at the very least, embrace a program of information-sharing and technological standardization across state lines. These measures may not do as much to ameliorate the concerns of civil rights advocates, but, barring a constitutionally-grounded invalidation of PDMPs, they will help states better manage the consumption of sensitive substances and undercut the viability of illicit distributors.

Admittedly, the challenges to PDMPs posed by the 21st century are mired in bureaucratic complexity and may never be fully demystified, given the private nature of personal health data-monitoring. But the ultimate benefits of an overhauled national PDMP system – communities that are safer and healthier, parents spared from the grief of outliving their children, and happier, independent Americans – will no doubt be felt universally.