Colorado Medical Society

Prescription drugs in Colorado

Friday, September 01, 2017

Nationally and in Colorado, opioid use disorders have emerged as a significant public health concern. Colorado’s prescription opioid related overdoses have quadrupled since 2000. Nearly 224,000 Coloradans misuse prescription drugs each year. For a majority of the past 15 years, Colorado’s drug overdose rate has been significantly higher than the national rate and opioid related overdoses represent a large portion of those deaths.

To combat this epidemic, Colorado legislators passed a bill in 2014 that aligned Colorado’s Prescription Drug Monitoring Program (PDMP) with best practice strategies, such as: mandating registration for prescribers and pharmacies, daily reporting of controlled substances dispensed by pharmacies, allowing prescribers to delegate access to PDMP records and giving Colorado Department of Public Health and Environment access to PDMP data to provide population-level results.

The Colorado PDMP is a secure database that collects information on schedule 2-5 controlled substance prescriptions dispensed by Colorado pharmacies. They are categorized into five classes: opioids, benzodiazepines, stimulants, sedatives and muscle relaxants.

From 2014 through 2016, opioid prescriptions in Colorado represented a majority of prescriptions dispensed, and benzodiazepines represented about a quarter of all prescriptions. In 2016, the number of opioid prescriptions per recipient ranged from one to 184 (median=1.0; mean=3.8), and the number of opioid prescriptions per patient increased with age.

The information captured in the PDMP is useful in monitoring prescribing practices and patient behaviors that are associated with increased risk of overdose. According to the U.S. Centers for Disease Control and Prevention (CDC), potential risk factors for prescription drug misuse include high-dose prescribing, multiple provider episodes, long duration opioids, and overlapping opioid and benzodiazepine prescriptions. Understanding these risk factors and using the PDMP to assess them may help providers better assist their patients in pain management while protecting their health and safety.

Risk factors for prescription drug misuse

Patients receiving high dosage prescriptions

Morphine is considered the standard measure for managing pain and is used as a reference for calculating opioid prescription doses. In 2014, the Colorado Quad-Regulator Boards of Dental, Medical, Nursing and Pharmacy suggested limiting dosages to less than 120 mg morphine equivalents (MME) per day to reduce negative outcomes, and in 2016, the CDC’s prescribing guidelines recommended opioid dosages not exceed 90 MME per day. Although there is variability regarding safe dosage thresholds, assessing dosage can help identify problematic prescribing practices and patients who may be at risk for substance use disorders.

Multiple provider episodes (MPEs)

The use of multiple prescribers and pharmacies is associated with high-risk, drug-related behaviors and adverse events. The number of prescribers and pharmacies a patient visits is often used as a proxy measure for “doctor shopping.” The CDC defines MPE as receiving opioid prescriptions from five or more prescribers and pharmacies in a six-month period.

Patients prescribed long-acting/extended release (LA/ER) opioids who were opioid-naïve

Opioid naïve patients may be more vulnerable to adverse effects of LA/ER opioids such as respiratory depression and overdose. For this metric, opioid naïve refers to patients who did not fill an opioid prescription in the previous 60 days. Time-scheduled opioids are associated with greater total average daily dosages and increased risk for long term use.

Patients with overlapping prescriptions

Both benzodiazepines and opioids are central nervous system depressants that can compromise the respiratory system. Benzodiazepines enhance the effects of opioids, so concurrent use can increase the risk of adverse events. This indicator measures the duration of overlapping prescriptions. Longer duration of overlapping prescriptions may raise concerns of potential drug interactions and resulting side effects.

In the wake of the opioid overdose epidemic, the PDMP has been identified as a promising practice to address prescription drug misuse and associated adverse health outcomes. However, safe prescribing of opioids should take a balanced approach and help preserve access to medications for the management of care and patient expectations while also decreasing the misuse and diversion of controlled substances. Use of the PDMP demonstrates Colorado’s efforts to improve the health of Coloradans through coordinated state and local efforts. For additional resources, including local data, please reference the following websites or contact the Prescription Drug Overdose Prevention Unit.