Preventing opioid overprescribing during the COVID-19 pandemic

By Matt Phillion, PSQH

The U.S. has wrestled with the demons of the opioid epidemic for decades, and even a global pandemic can’t stop that. But so much has changed during the past year in terms of healthcare. The use of opioids, both appropriate and inappropriate, has appeared to change too, sometimes in surprising ways.

We know that overdoses quickened their pace in 2020, according to the CDC. The CDC identified over 81,000 drug overdoses in the 12 months ending in May 2020, the highest number ever in a 12-month period. And while those numbers were increasing prior to COVID-19, the latest data indicate the numbers accelerated further during the pandemic. According to the CDC:

• 37 of 38 U.S. jurisdictions with opioid data reported increases in synthetic opioid–related overdose deaths
• 18 of those jurisdictions saw increases of more than 50%
• 10 western states reported increases of more than 98%

G.T. LaBorde, CEO of IllumiCare, has spent a lot of time looking at opioid prescription data during the pandemic and has some thoughts on COVID-19’s impact on opioid over-prescription based on the numbers gleaned by IllumiCare’s software.

IllumiCare is an electronic medical record (EMR)–agnostic tool that nudges doctors with helpful insights directly in their clinical workflow. One of the apps on IllumiCare’s platform checks a patient’s history for controlled substance prescriptions. Every opioid filled in a clinic or a local drugstore is reported to the state prescription drug monitoring program (PDMP) database, creating a single source within each state of every opioid prescription filled.

Most U.S. states, in no small part because of the opioid crisis, legally require providers to consult the state’s PDMP database before writing a new opioid prescription. The IllumiCare app quickly checks the patient’s opioid prescribing history and injects that information into the clinical workflow. “If the patient has a history of filling prescriptions for a controlled substance, it will surface this information automatically to the clinical user,” says LaBorde.

Normally the clinician might log into a website or look in the EMR to find the information they need, but the intent here is to make it easier to do the right thing for the patient.

“Our app is utilized thousands of times a day all over the country, and that gives us insight into the data,” LaBorde says. “We know what medications are prescribed for patients and how often clinicians are checking the PDMP database.”

And through the knowledge this app provides about the drugs prescribed and the information providers are looking for, it offers insight into how the opioid crisis is changing.

What the data says

LaBorde has two pieces of key data, and a hypothesis based on his analysis. First, the data.

IllumiCare observes that providers are checking the state PDMP databases, and through examining the app’s users and install base, LaBorde notes that the population of those providers has stayed constant. “From late 2019 to now, there’s been a 64% increase in the number of provider checks of the state database,” he says. “That is a proxy measure for outpatient opioid prescribing.”

Physicians are required to check the PDMP before they write a new prescription, so this increase indicates that, unfortunately, more people are being prescribed opioids today than pre-COVID-19, LaBorde says.

The second key data point is the use of overdose rescue drugs.

Naloxone, well known by its brand name Narcan®, is given to patients who present with an overdose. “You don’t want to see an increase in use of this,” says LaBorde. But according to IllumiCare’s data, health systems’ use of naloxone increased 16% from February 2020 through January 2021. “That tells me that not only is opioid usage going up, so are the total number of overdoses,” says LaBorde.

The numbers aren’t as simple as they first appear. Interesting factors to take into account are elective surgeries and emergency department (ED) visits. Elective surgeries are a huge driver of initial opioid prescriptions, since patients often deal with pain in their aftermath. “Opioid prescriptions by health systems showed an enormous dip in March, April, and May, when many health systems stopped doing elective procedures,” he says.

But overall prescriptions went back up after that. Elective surgeries, however, were not fully back in swing, as organizations limited procedures out of caution. Also, ED visits were still down even in late 2020.

“A lot of people had, and still have, a hesitancy to go to the ED because of COVID,” says LaBorde. “So when I said there was a 16% increase in Narcan use, I ruled out every surgical patient and said let’s eliminate these populations and see what’s happening with the rest of the medical world.”

With fewer elective surgeries and limited ED visits, the prescriptions for opioids should have been limited, LaBorde thought. “My takeaway and hypothesis is that COVID has caused a huge mental strain,” he says. “It doesn’t surprise me at all that people would turn to a drug that has been abused for mental health reasons.”

The increases in prescriptions and overdoses as tracked by the IllumiCare app support this hypothesis. “If you look at the chart of overall use, it looks like things are unchanged from pre-COVID,” says LaBorde. “Those surgical cases involved were a baseline of appropriately prescribed opioid use. But remove that population, and that’s where you see this troublesome increase.”

Acting on the data

So looking at these numbers, what do we do with them? And how do we address opioid over-prescribing in the age of COVID-19? LaBorde suggests that the data offers an opportunity for greater awareness and sensitivity among providers.

“Clinicians can appreciate that any patient could be really struggling with mental health issues during this horrible crisis,” he says. “That may be the underlying reason why they’re there. For people to see the doctor today, they have to overcome a bit of hesitancy and may be desperate to reach out.”

Remarkably, even almost a year into the crisis, surgeries and ED volumes are down as much as 15% to 20%. Even primary care physicians may not see their patients as often, as many patients are still shying away from entering medical facilities to avoid the coronavirus.

“What I see is we have a population struggling,” says LaBorde. “The problem hasn’t magically gone away. We understand why we’re focusing so much energy on COVID, but other crises continue to need our attention.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.