Florida’s ‘Modest’ Reduction in Opioid Prescribing

By Pat Anson, Editor

Florida was one the first states in the country to get serious about fighting the “epidemic” of prescription drug abuse.

In 2010, a year when eight Floridians were dying every day from drug overdoses, the state started cracking down on rogue pain clinics – “pill mills” -- and began to closely monitor the number of opioid prescriptions written and filled by physicians and pharmacies.

By most accounts, the crackdown has been a success – overdose deaths dropped and over 250 pain clinics were closed. But legitimate pain patients also began to complain that they couldn’t get their prescriptions filled. Their search for a pharmacy willing to dispense opioids – a search that could take hours or days – even got a name: Florida’s “Pharmacy Crawl.”

Which makes a new study in JAMA Internal Medicine all the more surprising.

Researchers analyzed an extensive database of prescription claims and found that there was only a “modest” decline of 1.4 percent in the number of opioid prescriptions in Florida from 2010 to 2012.

The reductions were generally limited to prescribers and patients with the highest rates of opioid prescribing and use – meaning the average pain patient shouldn’t have been affected at all.

That 1.4% reduction, researchers say, was a “statistically significant” decline by some measures. But they also acknowledge that Florida’s crackdown on opioids “had no apparent effect on days’ supply per transaction or on total number of opioid prescriptions dispensed.”

That less than overwhelming finding raises questions about the effectiveness of the crackdown and, in particular, prescription drug monitoring programs (PDMPs). Almost every state has implemented a PDMP in the last few years, spending millions of dollars to track patients with electronic databases that have yet to be proven effective. 

“Our findings highlight the need for more evidence demonstrating the effect of PDMP and pill mill laws,” wrote lead author Caleb Alexander, MD, of the Johns Hopkins Bloomberg School of Public Health.

Effect on Pain Patients

So if the number of opioid prescriptions in Florida barely budged, what about all those pain patients who claim they couldn’t get a prescription filled?

"The opioid lobby and media they've influenced portray Florida's efforts as draconian. We keep hearing that pain patients in Florida have lost access to opioids.  The study's findings refute these claims," said Andrew Kolodny, MD, a prominent critic of opioid prescribing practices who is President of Physicians for Responsible Opioid Prescribing.

“Dr. Kolodny can't see the whole picture just by looking at this short term study,” says Donna Ratliff, a chronic pain patient who founded the Fight for Pain Care Action Network, a non-profit group lobbying for adequate pain care in Florida.

“Things did get draconian after the DEA fined the distributors and chain pharmacies. The media headlines stigmatized the pharmacies and doctors early on into not treating legitimate pain patients out of fear.” 

It was in 2012 that Cardinal Health, one of the nation’s largest drug wholesalers, was fined $34 million by the DEA after it failed to report suspicious orders for hydrocodone at a distribution facility in Lakeland, Florida. Shipments of controlled substances from that facility were suspended for two years.

Walgreens and CVS Pharmacy were also fined tens of millions of dollars for violating rules and regulations for dispensing controlled substances. Afterwards, both pharmacy chains began to screen patients with opioid prescriptions more carefully, and told their pharmacists not to fill them if anything appeared suspicious.

Those developments, according to Ratliff, were not fully covered during the opioid prescription study, which ended in September 2012.

“This induced the pharmacy crawl, that got worse as time went by,” she told Pain News Network.

In a recent survey of hundreds of pharmacies, drug wholesalers and physicians by the General Accounting Office (GAO), over half said DEA enforcement actions had limited their ability to supply drugs to patients. Many said they were fearful of being fined or having their licenses revoked by the DEA.

“Some pharmacies may be inappropriately delaying or denying filling prescriptions for patients with legitimate medical needs,” the GAO report states.