While the number of deaths annually due to drug overdoses in the United States has been climbing steadily since 2000, over the last several years the rate of increase has accelerated. The main factor responsible for this rise has been the increasing use and abuse of prescription and non-prescription opioids, which has reached such a scale that it is frequently referred to as the opioid epidemic, or the opioid crisis. Many tactics have been suggested for addressing the opioid epidemic, including the use of certain information technology tools by health care providers. Ultimately, the solution to the opioid epidemic will require many different tools, among which health information technologies can play an important part.
The annual rate of deaths in the U.S. due to opioid overdoses continues to rise from already historically high levels. In 2015, the most recent full calendar year for which official data are available from the CDC, there were 52,404 deaths due to drug overdoses in the U.S., of which 33,901 involved an opioid. Preliminary estimates for 2016 suggest that there were over 64,000 drug overdose deaths, of which 53,180 involved an opioid. In response to this situation, President Trump declared the U.S. opioid epidemic to be a public health emergency on October 26, 2017.
In addition to the loss of life, substance use disorder involving opioids has real economic consequences. One study put the total societal cost of prescription opioid abuse in 2007 at $55.7 billion while another study estimated the total economic cost in 2013 of prescription drug abuse to be $78.5 billion. Considering the full range of opioids and recognizing the significant recent increase in the use of synthetic variants, the current economic cost of the whole opioid epidemic is likely substantially higher. Opioid use has even been cited as a significant factor in the decrease in labor force participation, potentially contributing as much as 20% of the total decline.
Opioid abuse in the U.S. appears to be rooted in legal prescription drug use, which can serve as a gateway to illicit opioids. In 2015, over a third of U.S. adults were prescribed opioids, of which over a quarter may have been at risk of substance use disorder. This resulted in almost 2 million Americans with prescription opioid dependencies. Critically, prescription opioid use is a significant risk factor for later use of illicit opioids. While in past years most of the opioid overdose deaths were due to heroin and prescription opioids, fentanyl and related synthetic opioids have recently become the most significant contributors to opioid overdose deaths.
Numerous recommendations have been put forth and a number of entities are initiating efforts to address this crisis. Cigna has announced that it will no longer be covering OxyContin prescriptions through its employer plans. The FDA has begun requiring makers of some prescription opioids to provide training for prescribers. (This may be particularly helpful since a negative correlation has been identified between the quality of the medical school attended by doctors and the volume of opioids prescribed.) Major pharmacy chains have also recently announced initiatives aimed at the opioid epidemic – CVS announced that it would be limiting prescriptions of opioids to seven-day supplies, while Walgreens has launched an educational campaign.
Containing and reducing the scale of the opioid epidemic will require many different tactics. In an excellent perspective piece recently published in JAMA, the authors identify ten specific steps that the federal government should take to address the opioid epidemic. Overall, the recommendations are consistent with some of the actions being taken by industry players noted herein. Helpfully, the authors divide the recommendations into those intended to prevent individuals from developing substance use disorders involving opioids in the first place and recommendations intended to treat those who already have substance use disorders involving opioids.
While it may be tempting to focus on preventing individuals from becoming dependent on opioids in the first place, such a strategy will do little to address the millions of Americans already suffering from substance abuse disorders. During the recent debate over one of the several bills to ‘repeal and replace’ Obamacare, $4.5 billion per year over ten years was added for substance use disorder treatment, to try to gain support from certain members. Some experts believe that this amount is significantly less than would be necessary to deal with the full scope of the issue, suggesting that $14 billion in the first year and over $183 billion over a decade would be necessary to address the need. A quick back-of-the-envelope calculation suggests that these estimates of $14 billion for the first year and $183 billion over a decade may be more accurate than $4.5 billion per year. Using the proposed bundled weekly rate for outpatient opioid treatment under Tricare ($126 per week) as a proxy for the average cost for a week of outpatient treatment for an individual for substance use disorder, and recognizing that there appear to be at least 2 million Americans with substance use disorders involving opioids, yields an annual cost of just over $13 billion.
Although there may be some indirect roles that health information technology (HIT) tools such as electronic health records (EHRs) and health information exchange (HIE) could play in supporting treatment of substance use disorders involving opioids, the real opportunity for HIT is associated with prevention. The most significant HIT tools that have been utilized to try to prevent the number of individuals with substance use disorders involving opioids from increasing are prescription drug monitoring programs (PDMPs) and electronic prescribing of controlled substances (EPCS). In addition, EHRs with built-in clinical guidelines and/or warnings may also serve a useful role.
PDMPs are state-run databases to which prescribers and dispensers of controlled substances report, that can be used by law enforcement to identify potential cases of drug diversion, and by clinicians to identify potential cases of drug-seeking behavior. While state laws regarding participation and utilization vary, the trend appears to be toward required reporting and even required use. In states that require for prescribers to check the PDMP prior to prescribing a controlled substance, prescribing of opioids has decreased substantially. While mandating PDMP use by prescribers may help decrease the number of opioid prescriptions written, it has also been shown to lead to an increase in illicit opioid use, as individuals with substance use disorders shift from prescription opioids to street drugs like synthetic fentanyl or heroin. Therefore, while mandated PDMP use may help to decrease the number of new individuals with substance use disorders involving opioids, other tools will need to be used to address those already suffering from substance use disorders involving opioids.
EPCS refers to the use of stand-alone electronic prescribing tools or the electronic prescribing functions in EHRs to send electronic prescriptions for controlled substances to pharmacies. Because EPCS involves the use of strong prescriber identity authentication and encrypted transmission, it can help to reduce the incidence of fraudulent prescriptions. Several states have already mandated that all controlled substances must be electronically prescribed, while others have considered such legislation.
Opioid overdose deaths in the U.S. have reached historically high levels, to the degree that many refer to the situation as an epidemic or crisis. A coordinated strategy comprised of numerous individual tactics will be necessary to address this situation. While the opioid crisis certainly will not be solved by technology alone, HIT tools, including PDMPs and EPCS, have the potential to play a significant role.