Health Policy Analysis

In the United States, the prevalence of prescription drug abuse comes second to the use of marijuana in regard to illicit drug abuse (Grecu,2019). There has been an increase in the diversion of prescription medication for non-medical purposes as well as for self-medication. More than 16.7 million Americans that are 12 and older have misused and abused prescription drugs at least once in their lifetime according to the 2012 National Survey on Drug Use and Health (McHugh, 2014). In 2013, over 249 million prescriptions for opioids were given by providers and in 2016, it was estimated that 48.5 million persons in the U.S. aged 12 years and older reported the use of illicit drugs and/or the misuse of prescription drugs within the previous year (Centers for Disease Control and Prevention, 2018).  The CDC reports show that most non-medical users of prescription opioids received opioids from family and friends who in turn had obtained the drugs as prescriptions from their providers (Jones, Paulozzi, & Mack, 2014) 

The Prescription Drug Monitoring Program (PDMP) was developed as an electronic database that can be used to track controlled substance prescriptions and can be accessed only by authorized personnel like practitioners and pharmacists statewide (Centers for Disease Control and Prevention, 2016). The program provides data that includes information on dispensed medications and the dosage prescribed. With prescription drug abuse on the rise, the PDMP was created to promote the safety of patients by i.) identifying patients who try to obtain opioids from not just one but multiple providers, ii.) allowing clinicians to calculate the total amount of opioids that are prescribed each day, and iii.) identifying patients that are prescribed other drugs (like benzodiazepines) that increase their risk of opioid abuse (Centers for Disease Control and Prevention, 2016). On August 27, 2013, practitioners in New York State were required to begin checking the prescription monitoring program registry before writing prescriptions for controlled substances in schedule II-IV. The current requirements for checking the PDMP vary from state to state but the CDC recommends at least once in 3months or prior to every opioid prescription. The PDMP has been mostly focused on monitoring opioid use, and the PDMP believes that monitoring opioid prescriptions and improving the way that opioids are prescribed will help ensure safer and more effective chronic pain management for patients. They also believe it can help reduce abuse, misuse, and overdose with opioids. However, there are some other prescription drugs such as antibiotics that are also being misused but are not being monitored as intensely.

In the United States, there is significant resistance to antibiotics such as penicillin and cephalosporins by pneumococcus and it is believed to have first stemmed from cefotaxime and ceftriaxone treatment failure in the treatment of bacterial meningitis in children. Vancomycin overuse and misuse have also been implicated in the recent emergence of vancomycin-resistant enterococci (VRE). Methicillin-resistant strains of staphylococcus aureus (MRSA) have also been reported in the US since 1961, and some hospital-associated infections have been related to MRSA and have been reported since 1968. Now, today there are reports of community-acquired infections that have also been brought about by MRSA, and infections caused by MRSA can be both minor and severely life-threatening in children and adults. (Keith, 2009).

Antibiotics are another group of prescribed drugs that have also been misused in the US (Gaur and English, 2006). Over the years, antibiotics have served in the treatment of serious life-threatening infections and antibiotic resistance is becoming a serious human health threat across the globe. Some patients may try to solicit antibiotic prescriptions from their providers without testing to prove the need for the antibiotics. Some patients may discontinue their medications once they feel better and may try to keep their remainder of the medication for use at a later time. In some other countries, some patients can even have access to antibiotics even without a prescription. This misuse and abuse have contributed to the prevalence of antibiotic-resistant bacteria and are responsible for the most recent increases in resistance. Increases in resistance to antibiotics can have detrimental effects on human health, for example, certain surgeries and therapies like bowel surgery, hip replacement, treatment for leukemia, etc. may no longer be successful without antibiotics that can help reduce post-op infections and complications (Pruden et. al., 2013). Surveillance of antibiotic use is crucial for helping manage and curtail the spread of infectious bacterial diseases, However, it is not made a priority for drug monitoring. It is important to reduce unnecessary and inappropriate uses of antibiotics to help control the prevalence of antibiotic resistance in different populations (Huijber et al., 2019). This then raises the question of what can be done to ensure that prescription drugs like antibiotics are also tracked and monitored.

In a 2017 study on the PDMP impact on opioid use in older disabled and nondisabled Medicare beneficiaries in 10 U.S states, it was found that the implementation of the PDMP was associated with significant reductions in the total volume of opioids dispensed by about 2.4 kg/month. The daily number of prescriptions however did not change but there were changes in the type/potency of opioids prescribed, and or the days supplied for each prescription decreased as well. The study shows that the use of PDMPs can influence provider prescribing behavior and can be effective for reducing prescription drug misuse (Moyo et al., 2017). The information obtained from the PDMP can help clinicians make informed decisions, like consulting with the other providers to discuss assigning opioid prescriptions to a single provider for a patient. It can also help providers determine if there is a need to taper or discontinue opioid prescription for a patient especially if a patient appears to continue obtaining opioids from multiple providers.

In the instances that concerning information may be found about a patient on the PDMP system, a provider can also screen the patient for any signs of abuse or misuse of opioids and offer counsel and treatments to the patients for any confirmed opioid abuse disorders. As of now, the CDC states that the PDMPs continue to be one of the most promising interventions statewide and that is used to inform clinicians and clinical practice, improve opioid prescribing and ensure patient safety especially for patients that can be at risk for opioid misuse, abuse or diversion. Findings from the use of PDMP have shown some change in clinical practice of prescribing opioids by some providers and a decrease in the admission rate of patients for substance abuse. This goes to show that programs like the PDMP which has been thoroughly used to monitor opioid prescription can have many advantages and benefits in the fight against prescription drug abuse, especially when made mandatory (Ali, 2017). 

Therefore, regarding the earlier question on what can be done to monitor and track antibiotic prescription, misuse, and abuse, one can argue that incorporating antibiotics into the PDMP program and prudently tracking the prescription and use of antibiotics may have similar advantages. Others may argue that rather than monitor the prescription of antibiotics, resources should be focused on environmental surveillance and studies conducted on the environmental influence/ impact in the development of antibiotic-resistant organisms. Few studies have been conducted on the environmental factors that contribute to antibiotic resistance, and some have offered possible solutions that can be implemented to reduce the environmental influence on antibiotic resistance (Huijber et al., 2019 and Pruden et. al., 2013). Although the implementation of a policy supporting environmental surveillance would be reasonable, we must also accept that antibiotic resistance in nature appears to be inevitable (Keith et, al., 2009), so it may be more beneficial to focus resources towards controlling that which we can control, which is the over-prescription of antibiotics and promoting the inclusion of prudent antibiotic surveillance for misuse and abuse into the PDMPs system. As mentioned by Keith, 2009, judicious use of antibiotics requires not just reducing the overall prescription of antibiotics but also requires prescribing antibiotics only when there are indications to do so, and prescription of appropriate agents. 

In 2016, a study was done in several countries in Asia, which involved the implementation of antibiotic stewardship programs (ASPs) aimed at reducing the inappropriate use of antibiotics. The interventions implemented included education and training, drug control or monitoring, use of computerized systems, infection control guideline programs, antibiotic rotation, etc. The implementation of ASPs was found to reduce the use and cost of antibiotics without compromising clinical outcomes of patients and for some of the programs with drug monitoring, mortality rates were reduced. The study shows the importance of drug monitoring, and the need to promote the appropriate use of antibiotics by drug monitoring (Lee, 2018).

It appears that prescription drug monitoring has shown promise in its ability to help curtail the prevalence of prescription drug abuse and it can also potentially show promise for revealing more about the factors that contribute to prescription drug misuse of antibiotics and can help providers carefully steward over the prescription of drugs that have been abused.  As in the case of mandating opioid monitoring, it may also be safe to project that if antibiotics prescriptions are also rigorously monitored, the information obtained can help guide the clinical practice of health providers. Using the information providers can also screen patients to determine who may be at risk of abuse or misuse of antibiotics and can use the information found to try to counsel patients on antibiotic abuse, its effects, the role of antibiotics for the treatment of some diseases but not for others, discourage patients from self-diagnosis and encourage patients to adhere to treatment plans (Gaur and English, 2006) The prescription and use of antibiotics judiciously can potentially help limit more clinically antibiotic-resistant genes from emerging and may help prevent the current issue of resistance from making antibiotics completely ineffectual especially as there aren’t new promising alternative treatments that have been developed.


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