Striking a Balance Between Opioid Surveillance and Patient Privacy

Big data, in the form of prescription data monitoring programs (PDMPs), is thought to have slowed the opioid epidemic by reducing physician-shopping patients from filling medically unnecessary prescriptions. However, privacy advocates argue that patient and clinician data in PDMPs could be compromised.¹

State Mandates Save Lives

As of 2018, 39 states enforce some type of mandate for clinicians and pharmacists to consult a state PDMP before patients can obtain scheduled substances.¹ The schedule of drugs included in the states’ mandates, however, differs significantly from state to state: some states, such as West Virginia, cover only opioids, whereas others, such as Connecticut, now include medical marijuana to prevent interactions with other controlled substances.^1,2

“By reviewing a patient’s PDMP profile, a prescriber can better judge if a patient has visited another clinician for the same or similar drugs,” said Josh Rising, MD, director of healthcare programs at The Pew Charitable Trusts, Washington, DC. “A suspicious PDMP report may prompt a physician to have a conversation with the patient about possible problems with pain management and refer the patient to a pain specialist, or to conduct screenings for substance use disorder and refer the patient to treatment.”

A 2017 study found that the more rigorous the PDMP mandates, the greater the decrease in opioid deaths (found to reach up to 18% reduction).³ In states with medical marijuana dispensaries, the opioid overdose death rates declined by 16%.³

“Some more recent literature suggests that mandatory checking may help reduce overprescription or doctor shopping,” said Bryce Alexander Pardo, PhD, from the School of Public Policy at the University of Maryland in College Park. “I would also hope that PDMP administrators start using PDMPs to investigate doctors who prescribe way beyond the median [number of prescriptions].”

State Medicaid programs are at the forefront in attempting to curtail multiple provider visits by opioid abusers in a short period of time. To prevent frequent visits, Medicaid reimburses or “locks in” patients to a specific prescriber.

When North Carolina Medicaid implemented a “lock-in” program, a study found that the mean number of prescriptions for opioids and benzodiazepines declined by 17% and 43%, respectively, in per person per month prescription claims. Private insurers have also adopted a reimbursement lock-in in which they pay for only medically necessary prescriptions based on unusual prescribing patterns. Medicare is scheduled to adopt the policy in 2019.

Incentives Encourage More Clinicians to Use PDMPs

Although state mandates for clinicians and pharmacists to use PDMPs are not universal, the patchwork of state programs has sparked innovative incentives to encourage more clinicians and pharmacists to access the databases by²:

• delegating office staff, usually nurses, to check the PDMP;
• providing mobile device access;
• allowing simultaneous multiple patient record retrievals;
• streamlining enrollment with state license;
• training clinicians and pharmacists who need to access the PDMP;
• providing real-time reporting, as is possible with Oklahoma’s program;
• sending prescribers unsolicited reports to flag potential abusers; and
•  integrating data with electronic medical records

When the state of Florida, in which opioid overdoses increased dramatically, allowed clinicians to count their PDMP access as “meaningful use” for participation in Medicare and Medicaid programs, physician registrations increased 7-fold in just 1 month.⁴ “This was an interesting development because we were gearing up to figure out ways to encourage voluntary use and use data to convince the skeptics, but then the state stepped in and made use of the PDMP mandatory,” explained Chris Delcher, PhD, assistant professor of health outcomes and biomedical informatics at the University of Florida in Gainesville. “There is a growing body of literature showing that PDMP mandates curb high-risk prescribing.”

Social Media Begets “Digital Epidemiology”

Another way that big data contributes to the epidemiology of opioid abuse is through social media. In a study in which 11 million Twitter posts were analyzed with machine-learning, opioid use (here, oxycodone and acetaminophen/oxycodone) was found to rarely be isolated from use of other drugs.⁵ “One of the most important findings in our research that examined over 2.3 million tweets that we identified as being relevant to prescription opioid abuse, was the high volume of conversations related to poly drug abuse,” said Tim K. Mackey, MAS, PhD, associate professor and director of the Global Health Policy Institute at the University of California San Diego School of Medicine. “Although we were unable to identify more longitudinal trends or issues associated with transition in use, this finding indicates that opioid abuse cannot be viewed in isolation, and that clinicians need to be cognizant of the high potential for multiple use and concurrent use of other drugs for their patients [with an opioid addiction].”

Unintended Consequences of Reporting

Despite the success of PDMP mandates, critics claim that patients may seek illicit substances if their prescribers are flagged in the system for unusual prescribing patterns, and prevented from issuing new prescriptions.¹ A North Carolina study that indicated success in thwarting doctor shoppers through a lock-in for prescribers also estimated that patients would be 55% more likely to seek illegal substances elsewhere if they could not go to multiple clinicians and pharmacies.¹

Another potential quandary for clinicians and patients is when pregnant opioid abusers are referred to other clinicians, who may not have expertise in both obstetrics and addiction medicine.⁶ Because of the stigma surrounding mothers who abuse opioids, many women are unable to receive adequate treatment for their addiction. In addition, federal law requires clinicians to alert child protective services when they discover an infant born with neonatal abstinence syndrome or other substance abuse.

“In some states, giving a woman a diagnosis of opioid use disorder also mandates a report to child protective services, which then disrupts the provider/patient relationship [and] threatens the mother’s custody of not only her upcoming child but also potentially her other children,” explained Robert Levy, MD, assistant professor of family medicine and community health at the University of Minnesota in Minneapolis. “It introduces the legal system into a medical relationship, further complicating treatment and disposition.”

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References

1. Butler JM, Becker WC, Humphreys K. Big data and the opioid crisis: balancing patient privacy with public health. J Law Med Ethics. 2018;46(2):440-453.

2. The Pew Charitable Trusts. Prescription drug monitoring programs: evidence-based practices to optimize prescriber use. December 2016. https://www.pewtrusts.org/~/media/assets/2016/12/prescription_drug_monitoring_programs.pdf-accessed-october-4. Accessed October 4, 2018.

3. Pardo B. Do more robust prescription drug monitoring programs reduce prescription opioid overdose? Addiction. 2017;112(10):1773-1783.

4. Delcher C, Wang Y, Young HW 2nd, Goldberger BA, Schmidt S, Reisfield GM. Trends in Florida’s prescription drug monitoring program registration and utilization: implications for increasing voluntary use. J Opioid Manag. 2017;13(5):283-289.

5. Kalyanam J, Katsuki T, Lanckriet GRG, Mackey TK. Exploring trends of nonmedical use of prescription drugs and polydrug abuse in the Twittersphere using unsupervised machine learning. Addict Behav. 2017;65:289-295.

6. Saunders JB, Jarlenski MP, Levy R, Kozhimannil KB. Federal and state policy efforts to address maternal opioid misuse: gaps and challenges. Womens Health Issues. 2018;28(2):130-136.