Viewpoint: Strategies to combat US opioid diversion

In the US, opioid diversion is one social challenge that crosses state and class boundaries alike. It includes any illegal exchange of prescription opiates, from "pill mill" cash transactions to "leftovers" shared among friends, and it's an increasing threat to public safety and health. In fact, between 2002 and 2006 alone, the number of prescription opioid overdoses increased by 98 per cent.

Opioid pain relievers are diverted more often than any other prescription pills, according to the Centers for Medicare & Medicaid Services (CMS). Oxycodone, codeine, methadone, hydrocodone, fentanyl, morphine, hydromorphone and meperidine are among the most commonly misused prescription medications, in part because of the euphoric effects they produce and the tolerance that patients build over time.

These controlled substances can be used to provide effective pain relief or be misused. They play an important role in both temporary and long term chronic pain relief and palliative care. Massive resources have been allocated around the world to regulate diverted legal drugs.

There have been two schools of thought on how to address drug use. The more traditional view on controlled substances has been to aggressively prohibit and/or regulate drugs that might be misused, licit or illicit. Criminalization of drug use, outside highly regulated prescribed use, has been the popular stance in much of the world. Resources have been prioritized with law enforcement on national, state, and local levels investigating and seizing product and imprisoning users, suppliers, and distributors. A lesser priority has been placed on providing education and resources for those seeking to change their drug use behavior in countries that have elected to focus on a prohibition and criminalization stance.

A more recent position on the role of drug use in society, drug liberalization, has been taken out of theory and put into practice by the changing drug policies of the Czech Republic, Portugal, and the Netherlands. Easy to access information and effective help for those seeking to change their substance use habits are a critical foundation for individuals and resources for these services are more heavily funded and prioritized in societies where drug use has been decriminalized. Where drug use is decriminalized, legalized, or laws and penalties are sharply reduced, the focus on societal priorities, including public safety, education, and health, increases without a prohibition or criminalization endgame.

The US and much of Europe continues to rely on a prohibition, regulation, and criminalization view of controlled substances. Thus far, the following strategies are among the most effective in deterring opioid diversion in the US on a larger scale within this prohibition and criminalization framework.

Keeping better patient and physician records

Fifty years ago, opioid diversion regulation wasn't a major concern, but it would have been much more difficult anyway. Electronic databases now give physicians, pharmacists, and government agencies much greater access to detailed patient records, and these parties can also share information to identify misuse and problematic trends. For example, pharmacists, government agencies, and law enforcement can access not only a patient's previous prescriptions, but they can also track the doctors who may write excessive prescriptions.

Documentation is one of the best ways to prevent shortages, overdoses and trafficking, but it still requires participation, and some states have stricter laws and regulations than others.

Federal laws and regulations override local drug laws, especially when people travel across state lines to procure and redistribute prescription opioids. As a result, more national agencies are incorporating opioid diversion information into their databases for tracking. Information sharing between states is also increasing and providing not only a better picture of possible regional profiles but allowing for organized operations to be recognized and dismantled.

One such database is intended solely to track the identities and activities of people who use, dispense, or prescribe opioids and other controlled substances. The Drug Enforcement Administration (DEA) manages the nationwide Controlled Substance Registration File, which increases accountability for prescribing physicians and has led to arrests, decreased diversion rates in high-traffic states, and greater transparency in federal medical care programs.

National Provider Identification numbers, DEA numbers, and other identifying information are helping to make fraud more difficult. Providers and patients are advised to keep all identifying paperwork secured to lessen the role of identity theft in opioid diversion. US providers are requested to regularly check LEIE (List of Excluded Identities/Entities) and EPLS (Excluded Parties List System) for those who have been banned for fraudulent activity. Patients need to provide photo identification when picking up opioids. Providers should screen for multiple listings of the same patients, verify that physicians and pharmacies dispensing are registered with the DEA, and check that deceased patients’ and providers’ information is not being utilized.

Treating a health risk, not prosecuting a crime

The World Health Organization (WHO) holds that controlled opioids are "indispensable" in reducing human suffering throughout the world, and warns countries like the U.S. to focus on preventing misuse and avoiding harm, rather than controlling illegal diversion, as an end-goal. Access to pain relievers is important but, in order to avoid systematic misuse, global experts recommend more insightful prescriptions rather than stricter regulations.

For example, in order to decrease diversion in the prison system, WHO reports have explored the importance of opioid access and access to substance use programs. They also emphasize the danger of seeking only to punish heroin and opioid use, especially among at-risk groups like pregnant women, because it could prevent them from getting life-saving help. Greater access to medically assisted detox services also decreases the rates of overdoses and continued misuse.

The National Prescription Drug Take Back Day hosted by the US DEA at sites across the country has been very successful. The last Take Back Day in September of 2014 netted 309 tons of pills for a grand total of 2,411tons of prescription pills taken out of circulation in just the last 4 years. This national event in September provides the public with a safe, legal way to dispose of expired, unused, or unwanted prescription drugs. This effort helps to reduce the availability of drugs being swapped, sold, stolen, or misused after they have been dispensed.

Addressing regional and cultural risks

As American states retain a great deal of autonomy, this philosophical ideal of states’ rights has lead to situations where information, legislation, and enforcement of strategies to decrease opioid diversion have been hampered. While Federal laws and regulations trump individual state laws and regulations, there are many areas left to the states to determine the exact methods and means of complying, which can lead to a patchwork of diverse enforcement and flawed information for national and regional comparisons. Collaborations with individual states and national authorities are one way to manage this issue. The other is further delineation of national requirements for gathering and reporting information and standardizing of enforcement.

Some states see significantly higher rates of opioid diversion, thanks to an assortment of factors and demographics. For example, Florida's aging population and odd jurisdiction system made the state a magnet for users and dealers from other states. Between 2003 and 2009, the state's drug overdose deaths increased by 61 per cent and the Florida Department of Health finally did something about it.

Today, overdose deaths are back on the decline in Florida, thanks to a series of statewide raids and legislative changes. In 2010, physicians were finally forced to register for the ability to dispense opioids straight out of their offices. Florida’s S2272 provided for greater state oversight of pain management clinics, which were largely unregulated until that time, and pop up clinics had capitalized on this loophole situation. This law allows for greater regulation of prescription practices, enhanced penalties, and a 72-hour limit on narcotic prescriptions purchased in cash. In 2012, a statewide task force was created to prevent the diversion and misuse of prescription drugs.

Iowa has had great success with a “lock-down” provision for Medicaid and Medicare users who are found to be misusing prescription drugs. Once the user is proven to be misusing opioids or other controlled substances, they are “locked in” to the use of only one approved primary care physician, pharmacy, hospital, and emergency room to lessen the opportunities for doctor and pharmacy shopping. This provision has saved Iowa $2m annually since its implementation.

Opioid diversion through the lens of drug liberalization

Drug liberalization detractors have long focused on campaigns of hyperbole and myth to reinforce the idea that drug legalization or decriminalization will cause chaos and destruction. These ideas have not been supported by evidence when the practice of decriminalization or outright legalization has been employed. Fear mongering in the form of ideas such as highly increased drug use by youth and general use, increased drug related crime, drug tourism to areas where drug use is legalized, and increased overdose deaths and addiction as well as drug related health issues have not held to be true in countries where drug liberalization has been implemented.

In Europe, Portugal, the Czech Republic, and the Netherlands have moved to decriminalize or legalize drug use with few ill effects and, on many indicators of drug concerns, these countries are showing better outcomes than their prohibition driven neighbors.

Drug decriminalization or legalization policies and strategies rely often on substance harm guidelines for sliding regulation. As a drug has more potential for harm to an individual’s health in the event it is misused, greater regulation can be attached to its possession, distribution, availability, and use. In the Netherlands, drug policy relates directly to the idea of harm potential of a particular drug and potentially more harmful drugs are subject to greater penalties.

Portugal decriminalized all drugs in 2001 but has emphasized a system of provision of drug programs, performance of community service, and/or fines for transgressors. The Cato Institute published research on the aftereffects of the decriminalization. While overall drug use in Portugal didn’t decrease, related negative consequences of drug use did, including the drug overdose death rate was halved, the rate of new HIV infections attributed to drug use declined, and users seeking help for their drug using habit had increased significantly.

Portugal’s regionally based Commissions for the Dissuasion of Drug Addiction provides a civil response to those who transgress the law. These Commissions are composed of a lawyer, a psychiatrist, and a social worker who determine what penalties are faced by a substance user.

The Commission members don’t have the power to compel someone to attend treatment but they can suspend fines and penalties imposed if treatment is completed. This strategy allows for a lessened stigma for seeking help and puts the control in the substance user’s hands to determine if they pay a fine, perform community service, or seek a program for help. Mandated treatment has lowered rates of success than when an individual freely chooses to commit to change.

Shifting priorities and resources from prohibition based strategies to an emphasis on public health, safety, and education may be an effective way to free up resources from illicit drug control to the rising, but still highly neglected, need for education and programs for those misusing prescription drugs, including opioids.

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References:

Drug Diversion in the Medicaid Program: State Strategies for Reducing Prescription Drug Diversion in Medicaid - Department of Health & Human Services; January 2012. Retrieved February 22, 2015

DEA and Partners Collect 309 Tons of Pills on Ninth Prescription Drug Take-Back Day - Drug Enforcement Administration;  Retrieved March 4,2015

Drug Liberalization - Wikipedia. Retrieved March 6, 2015

Drug Decriminalization in Portugal: Lessons for Creating Fair and Successful Drug Policies - The Cato Institute;  April 2, 2009. Retrieved March 6, 2015

Strategies to Prevent Opioid Misuse, Abuse, and Diversion That May Also Reduce the Associated Costs - Hahn, Kathryn L; American Health & Drug Benefits 4(2):107-114. Retrieved February 24, 2015

Decline in Drug Overdose Deaths After State Policy Changes -- Florida, 2010–2012 - Centers for Disease Control and Prevention; Morbidity and Mortality Weekly Report 63(26);569-574. Retrieved February 24, 2015

Estimating the Prevalence of Opioid Diversion by 'Doctor Shoppers' in the US; PLoS One 8(7), 2013. Retrieved February 26, 2015

High Rates of Opioid Prescriptions Among Women Raise Birth Defect Fears - The New York Times. January 22, 2015. Retrieved February 24, 2015

Ensuring balance in national policies on controlled substances: Guidance for Availability and Accessibility of Controlled Medicines - World Health Organization; Retrieved February 26, 2015

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Faith Moore is public relations coordinator at Saint Jude Retreats, an alternative to traditional drug and alcohol treatment centers and rehabs.