The Unethicality Of Prescription Drug Monitoring Programs To Prevent Drug Abuse
It is no secret that the rampant misuse and abuse of narcotics has plagued the United States for decades and still, the prevalence of this problem is astonishing. In 2016, SAMHSA reported an estimated 7.4 million Americans aged 12 or older had an illicit drug use disorder. In 2017, the CDC reported that over 70,000 people in the United States died from drug overdose. Obviously, illegal street drugs, such as heroin, are responsible for a large portion of these statistics, but the uncontrolled medical and non-medical use of prescription painkillers has likewise contributed a terrifying amount. In response, healthcare providers and state legislators have cooperatively enacted a number of policies to stem the abuse of prescription drugs, a great deal of which have been successful. Be that as it may, a couple of these methods that were previously regarded as astute replies to the opioid epidemic are now under fire by multiple researchers and lawmakers for their unforeseen cons and tensions. Namely, prescription drug monitoring programs (PDMPs), centralized databases that record the drugs doctors prescribe and drug distributors dispense, are the major method under contention. Given the already declining opioid prescription rates nationwide together with the existing policies to ensure they are curbed further, it is not only unnecessary to continue PDMPs but ethically vital that we discontinue them in light of the privacy concerns, confusion around pseudo-addictions, and fear of legal retribution they instigate.
To understand why prescription drug monitoring programs (PDMPs) are unnecessary, we must first familiarize ourselves with the full context of the actions already taken in response to the opioid epidemic and their effectiveness and wide-ranging, multipronged coverage. By March of 2018, US Pharmacist had confirmed “laws have been passed in all 50 states… to increase public access to naloxone,” a chemical antagonist able to reverse opioid overdose. A step in the right direction, multiple states have since taken further initiative to improve curative care. Ancillary law enforcement such as county health departments, probation and detention officers, and police aids, are now permitted to administer naloxone in 94% of US counties and retail pharmacies across the country have dispensed over twelvefold the amount of naloxone since 2013, implicitly authorizing family, friends, and any other potential bystanders to reverse an overdose (NIDA). Following, more than 2.5 times the number of pre-hospital overdose treatments have been reported and multiple analysts have lauded laypeople’s involvement in this turnabout (Lynn and Galinkin 70). Furthermore, Good Samaritan Laws which offer overdose victims immunity from legal penalty upon summoning emergency services have been enacted in 40 states and have decreased overdose deaths by nine to eleven percent (DPA). However, when a patient receives treatment in an emergency room for an opioid overdose, hospitals focus on the immediate issue and consequently, oftentimes fail to address the underlying addiction. Currently, only 47 percent of overdose patients are even referred to behavioral health providers upon discharge and considering only 18 percent of those who needed substance abuse treatment in 2016 were able to access it, this is a huge concern that is only recently being approached. But even this facet of the epidemic has an ongoing reply. In 2016, Congress passed the 21st Century Cures Act, reauthorizing the Substance Abuse and Mental Health Services Administration (SAMHSA) after a previous fallout and establishing a national, free, confidential, 24/7 treatment referral helpline that now receives a call volume of nearly a million. The helpline is capable of identifying local support groups, community-based organizations, and treatment faicilties. For underserved populations who cannot afford the cost of treatment, Congress has also created state-funded treatment programs and many state legislatures have dedicated substantial sums of money towards closing this access to treatment gap. Arizona, for instance, appropriated $10.5 million just three months ago to expand the reach of medication assisted treatment to the uninsured and underinsured (azpha.org). For addicted patients not yet in danger of overdose, a few states, Kentucky and Arizona particularly, have embraced the Angel Initiative which allows individuals struggling with addiction the option of turning their drugs in to a police precinct and requesting treatment without fear of prosecution. The passing of these laws has been met with tremendous success as hundreds of residents have taken advantage of the offered “way out” (Puente). On the preventive side of care, the potential to develop opioid dependence can frequently be entirely avoided by replacing opioid prescriptions with non-opioid treatments. The CDC recommends the most common chronic pain conditions, such as migraines, osteoarthritis, and fibromyalgia, be treated through a combination of the following rather than with opioids: self-care and education, nonpharmacological methods (low-impact aerobic exercise, interdisciplinary rehabilitation, cognitive behavioral therapy), and acute medications, especially first-line analgesics (acetaminophen, NSAIDs, etc.). The aforementioned models and practices are all effective in addressing the opioid epidemic without detracting from the integrity of the existing healthcare system and absolutely should and likely will be replicated in every state and clinic. More importantly, in combination they have proven to be effective in addressing every dimension of the opioid epidemic without the use of PDMPs, designating the latter as unnecessary.
However, not only are these propositions unneeded in regulating opioid overprescription, they pose morally reprehensible dangers in the form of privacy concerns, wrongful categorization of pseudo-addicts, and inciting fear of legal repercussions. In the domain of reactions to prescription drug abuse recognition, healthcare policy has been on the road to becoming increasingly influenced by law-enforcement agencies. PDMPs are simply the most recent tool of the police considering its origins in law enforcement and doctors have difficulty viewing it as an important component of patient safety. With that police tool in mind, many physicians see PDMPs as a thinly veiled means of police looking over their shoulders and for doctors who have to prescribe large amounts of opioids for legitimate reasons, this scrutiny from law enforcement agencies is undoubtedly a nuisance. From an ideological standpoint of respect to our healthcare providers, this is an ethical problem in and of itself. In application, most practitioners’ lack of formal training in substance abuse keeps them from correctly identifying the warning signs of abuse or drug diversion. A controlled study from East Carolina University reported “more than 40 percent of primary care physicians have difficulty in discussing… medication abuse with patients” and “more than 90 percent fail to detect symptoms of substance abuse” (Crozier et al.). Amid these knowledge-gaps and shortcomings of our continuing medical education system, PDMPs may mistakenly categorize caring and conscientious physicians as fraudulent prescribers despite their good faith and unfortunate lack of proper training. Notwithstanding, the issues only pile up from here. Some physicians who for valid reasons are relatively high prescribers are rightfully troubled by PDMPs as they can potentially be written off as prescribing inappropriately. The USA, notably, has a history of high profile criminal prosecutions of physicians who prescribe large amounts of opioids and under PDMPs, this backburner knowledge could make physicians reluctant to prescribe controlled substances in a psychological phenomenon known as the “chilling effect”. The chilling effect discourages physicians from prescribing necessary drugs for patients with genuine needs and under it, doctors feel pressure to lower dosages when compared to others in their cohort, even for patients who have been on stable regimens of opioids for years without trouble. In other words, there is a greater perceived legal risk for prescribing too much pain medication than for too little and ergo, no practitioner wants to be the highest prescriber. In this way, PDMPs can also drive patient dissatisfaction which has other consequences. Doctors who refuse to prescribe opioids out of concern about abuse are more likely to receive poor survey ratings, affecting their job security and reimbursement. This issue becomes especially deplorable when taking “pseudo-addicted” patients into account. These are individuals whose pain has not been managed by subtherapeutic analgesic doses and thus, have a history of receiving opioids from several physicians for authentically seeking a relief from pain, not support of an addiction. The impact of the chilling effect is doubly compounded for pseudo-addicts, deterring them from receiving legitimate prescriptions for their pain (Brushwood). Moreover, under PDMPs, patients with a past or present of opioid dependency would be at a higher risk of not obtaining sufficient treatment for valid conditions. Even worse, patients who unknowingly fall victim to the chilling effect could eventually be pushed into the illicit market. There are myriad reports of former patients trying stronger street drugs to self-medicate because they cannot get the prescription pills they need. In June of 2013 in Florida, the American Medical News network reported caution around prescribing opioids, due to a crackdown on opioid abuse, has been linked to a heightened use of heroin and overdose presentation in the emergency department. In a similar fashion, doctors disinclined to prescribe opioids under PDMPs may prescribe alternate medications instead in a subsidiary of the chilling effect known as the “substitution effect.” A disturbing proportion of these alternatives are inferior in effectiveness, bear worse side effects, are uncontrolled by the state, or a combination of all three. For instance, when a California law abolishing the triplicate prescription system to reduce prescribing of Schedule II drugs went into effect, prescribing of stronger Schedule III drugs increased to an alarming rate. As if the preceding downsides were not objectionable enough, PDMPs also stir up worries around doctor-patient privacy, confidentiality, and data security. Because of the sheer vastness of a single PDMP network and the countless number of pharmacies, doctors, staff, and federal workers that have access to the database, PDMPs are exceptionally susceptible to unscrupulous use and data leakage. Since their implementation in some states, there have already been a multitude of privacy breaches. One occurred in Florida in 2013: while investigating a criminal case, county prosecutors needlessly leaked the personal information of thousands of patients’ prescription drug histories, a surprisingly sizable portion of which was not relevant to the case at all. Civil rights lawyers have since been arguing for the downfall of the state-run PDMP, saying that any proposed changes to it will not help protect patient privacy. Such a culture around PDMPs makes it so that medical consultations are no longer a private affair and fuels a new merited discomfort between patient and provider. Altogether, prescription drug monitoring programs house a multitude of unintended consequences and have proven themselves an uncalled for, conceivably harmful intrusion on clinical autonomy.
However, given PDMPs’ perceived benefits to health regulators, public and private funders of health care, and law enforcement, they will likely remain and probably expand over time. Indeed, PDMPs are not outright inherently unethical. They have the potential to be useful and effective in the future minus all the drawbacks but achieving such a status requires collaboration from multiple stakeholders. Indeed, PDMPs will continue but this does not mean we have to accept it passively. Prescribers, dispensers, and patients (i.e. the average citizen) all have a moral obligation to shape PDMPs appropriately so that it caters the needs of providers and patients and accelerates a realization of its full benefits.