Tom Sullivan, MD

	In October 2017, the Trump administration declared the opioid crisis a 

 While the impact of this declaration currently remains unclear due to the lack of serious funding, the severity of the problem is undeniable: 7.3 Americans die every hour from 

-a dramatic 52% increase from 3.8 per hour in 2015. Worse yet, this number is conservative as many 

Why do we keep prescribing heroin to patients?

	Over the last several years, numerous states have responded to the crisis by mandating and implementing electronic prescription drug monitoring programs (PDMPs) and the electronic prescribing of controlled substances (EPCS). Currently, 

 have either mandated EPCS or have pending legislation. Only one state (Missouri) has a PDMP that is being implemented county by county since its governor signed an executive order after the legislature failed to pass a bill.

	EPCS reduces the opportunity for fraudulent prescriptions by increasing security, while PDMPs help prescribers to be well-informed about their patients’ prescribing histories, making it easier to identify “doctor shoppers.”

	These technologies hold great promise for helping physicians combat the opioid battle, but legislators and regulators must put more funding and positive incentives behind efforts to encourage their use. In addition, current complexities of registering to use these tools and integrating them into prescribers’ workflows need to be streamlined.

Electronic Prescribing of Controlled Substances 

	Enhanced security features within the U.S. Drug Enforcement Agency (DEA) EPCS rule reduce the fraud and abuse of controlled substance prescriptions. Prescribers can be authenticated and prescriptions can be transmitted to pharmacies securely without risk of alteration or diversion. With proper analytics, EPCS can also help clinical leaders of group practices confidentiality identify and talk to physicians who have prescribing practices that are very inconsistent with peer specialties.

	Even though only 11 states mandate the use of EPCS, all 50 states have authorized its use. 

 that as of September 2016, 88% of pharmacies were accepting and processing EPCS, and that the rate of EPCS prescribing had grown 256% between 2015 to 2016. Despite the rapid adoption, only 20% of prescribers were enabled for EPCS and just 14% of all controlled substances were sent electronically to pharmacies.

Next: One likely reason for the slow adoption of EPCS nationwide

	EPCS prescribing rates also vary greatly among states. New York, which has mandated EPCS since March 2016, has 

 EPCS-enabled and sent almost 92% of its controlled substance prescriptions electronically in 2016. By contrast, Minnesota, which has a mandate but no enforcement provision, has much lower EPCS adoption: in 2016 just 14% of prescribers were EPCS-enabled and less than 20% of the controlled substance prescriptions were sent electronically.

	New York, which was the first state to implement penalties for noncompliance, provides a good example of how a combination of legislative requirements and technology can help reduce opioid-prescription rates. Since initiating its I-STOP program, the number of painkillers prescribed to New York City residents has 

	One likely reason for the overall slow adoption of EPCS nationwide is the complex, time-consuming process for supplemental DEA registration and credentialing. Nevertheless, in states like New York that penalize prescribers for non-use, physicians and health systems are more motivated to invest the time and money to comply with the requirements. In states that lack mandates and penalties, prescribers are more likely to not adopt EPCS and continue with paper despite transmitting the great majority of their legend drugs electronically.

	State controlled PDMPs increase prescriber visibility into patient drug histories through the collection and analysis of prescribing and dispensing data. If the data is made available and user friendly at the point of care, prescribers would be better equipped to assess risk and have meaningful conversations with patients.

	Unfortunately, even when PDMP technology is available, prescribers don’t always consult these databases because the process can be onerous. Typically, PDMP data is not integrated into electronic health record ((EHR) workflows so a physician must leave the system, access PDMP data with a separate log-in ID and then return back to the EHR.

Next: "The opioid epidemic is exacting a lethal toll on the country"

	Some states, like Ohio, allow for streamlined access of PDMP information from within the prescriber’s EHR. This feature promotes much greater use and better face time discussions with patients.

	Going into 2018, states should consider better incentives to encourage the wider use of programs and technologies that provide physicians with greater transparency into their patients’ consumption of controlled substances, reduce the opportunity for fraudulent prescriptions and give prescribers better tools to identify risk and facilitate intervention when necessary.

What can physicians do to help curb the opioid epidemic?

	Efforts to restrict the supply of opioid-based medications, though well-intentioned, often lead to unintended consequences, such as the increased use of illicit drugs like fentanyl or heroin. In fact, 

 in the United States has risen five-fold during the past decade.

	To address this complex health crisis, the industry needs to consider a multi-prong approach that includes:

	·       Strengthening EPCS regulations with positive incentives to encourage wider adoption.

	·       Reducing the complexities and costs of onboarding doctors for EPCS, especially since prescribers seeking EPCS certification must have pre-existing DEA licenses.

	·       Equipping physicians with PDMP data in a timely manner that is meaningful, practical and not disruptive to workflows.

	·       Educating physicians and pharmacists on the benefits of EPCS, including the additional convenience, security and reduced stigma for patients in treatment.

	·       Expanding initiatives that increase physician involvement in addiction-prevention efforts, including programs that educate providers about alternative therapies and encourage the wider use of technologies that help identify at-risk patients, so interventions can be initiated earlier.

	The opioid epidemic is exacting a lethal toll on the country. We must redouble and accelerate efforts to slow-and hopefully reverse-the current opioid epidemic. As we move into 2018, we need to make it easier for prescribers and all stakeholders to become more engaged and consider these additional approaches, particularly regarding PDMP and EPCS expanded use.

, MD, is a board-certified cardiologist and internal medicine specialist with over 40 years of clinical practice. He is chief strategy officer of e-prescribing and medication management solutions provider DrFirst. 

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The opioid epidemic is exacting a lethal toll on the country. We must redouble and accelerate efforts to slow-and hopefully reverse-the current opioid epidemic.

Author | Tom Sullivan, MD

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