Association of Electronic Prescribing of Controlled Substances With Opioid Prescribing Rates

In this study, we aim to build on the existing research by analyzing the association of the adoption of EPCS [electronic prescribing of controlled substances] with opioid prescribing across the United States. We specifically examine trends in the adoption and use of EPCS and 2 measures of opioid prescribing across the United States from 2010 to 2018. In doing so, we aim to provide policy makers, prescribers, and patients with evidence of the association of the use of EPCS with the opioid epidemic. [..]

[..] We used data from annual reports published by Surescripts, a near-monopoly supplier of electronic prescribing, to measure the proportion of controlled substances prescribed using EPCS (hereafter referred to as “EPCS use”) by state. Owing to their high market share, Surescripts’ data on EPCS is likely to represent almost all use of EPCS. [..] Using publicly available data, we categorized states based on whether they had a mandate for EPCS in effect, had passed a mandate but it was not yet in effect, or had not yet taken legal action toward a mandate as of the end of the study period.

[..] In addition, we included the status of 4 related opioid policies, which all aimed at reducing opioid overuse and were likely to correlate to EPCS mandates and use, from the Prescription Drug Abuse Policy System: (1) prescription drug monitoring programs, (2) pain management clinic laws, (3) direct dispensing of controlled substances laws, and (4) opioid prescribing guidelines for acute emergency care.

[..] Our data included observations on 50 states and the District of Columbia over 9 years, yielding a total of 459 observations. In 2018, the population-weighted percent of opioids prescribed using EPCS was 27%, up from 0% as of 2013. Meanwhile, national rates of opioid prescriptions have decreased from 78 prescriptions per 100 persons in 2013 to 53 in 2018. Over the same period, there was a decrease from 64 071 MME per 100 persons in 2013 to 40 906 MME per 100 persons in 2018, representing 36% of the 2013 level.

[..] Opioid prescriptions decreased nationally by a mean of 28.7 (95% CI, 22%-35%) opioid prescriptions per 100 persons but varied by state, with the largest decrease of 98 opioid prescriptions per 100 persons (117% of the national average) in Alabama and an increase of 34 prescriptions per 100 persons in Alaska (41% of the national average) between 2013 and 2018. There was a small, positive association between the change in EPCS use and the change in opioid prescriptions over this period (Spearman rank correlation = 0.26), meaning that states with higher EPCS use had smaller decreases in opioid use. The mean decrease in MME across states was 25 299 (37.1% of the national average) and ranged from decreases of 62 407 MME per 100 persons in Tennessee (91.5% of the national average) to 10 087 in Nebraska (14.8% of the national average). The Spearman rank correlation between change in EPCS use and change in MME was −0.002.

[..] In multivariable regression models, we observed that a 10-percentage-point increase in EPCS use was associated with an increase in opioid prescriptions of 2.0 prescriptions per 100 persons (95% CI, 1.3-2.8), which represents a 2.5% increase from the mean levels in 2013. The same increase in EPCS use was associated with a small increase in MME of 0.8% (95% CI, 0.06%-1.5%) from the mean level in 2013, which is equivalent to 565.9 MME (95% CI, 41.8-1090.0). We did not observe an association between EPCS and lower opioid prescribing (ie, a beneficial association) in models that adjusted the outcome variable by the states’ baseline rates and observed an association between EPCS use and greater opioid prescribing in 1 model.

[..] In the robustness check examining whether EPCS use was associated with MME per prescription (rather than per person), we observed that greater EPCS use was associated with lower MME per prescription, such that a 10-percentage-point increase in EPCS use was associated with a decrease of 19 MME (95% CI, 12-27 MME) from a baseline of 838 in 2013. In the final robustness check, we did not observe a statistically significant association between mandatory PDMP checking and EPCS use when estimating opioid prescriptions per 100 persons. However, we did observe an association between mandatory PDMP checking and EPCS use when estimating MME per person, such that states without mandatory PDMP checking observed an increase in MME per person, while states with mandatory PDMP checking did not.

[..] On its own, EPCS’s primary benefits may be to make it harder to alter paper prescriptions or otherwise commit fraud. But this type of fraud is likely a small part of overall prescribing rates, so that this function alone may have a limited effect. A second potential benefit of EPCS is to facilitate the use of default or recommended doses, which may explain our finding that EPCS use was associated with lower MME per prescription. Beyond these functions, EPCS itself may not directly dissuade prescribers from prescribing opioids. Instead, it may, in fact, make it simpler to place an order for a controlled substance because, relative to a paper-based workflow for prescribing controlled substances, EPCS is more similar to the electronic process used to write other prescriptions. This dynamic may have resulted in the small increase in prescribing rates we observed.

[..] To provide maximum benefit, EPCS must facilitate the use of data from PDMPs and other external sources through interoperable data exchange and make it easier for clinicians to understand the data in a certain context. EPCS should simplify the process of providing accurate and usable data to PDMPs and showing PDMP data to prescribers through effective clinical decision support. Despite the intuitive appeal of robust information sharing and automated decision support, the literature on both topics indicates that achieving benefit from these technologies depends on the specific context of their implementation and use. Similarly, successfully reducing opioid prescribing through EPCS use likely depends on factors related its implementation.

Since 2015, public policy on EPCS has progressed rapidly, such that most states have passed laws mandating its use, and the federal government has mandated its use for Medicare Part D drugs. Our data indicate that EPCS use has not performed as expected and that mandates may be a necessary but insufficient step toward decreasing opioid prescribing. For policy makers, this points to a need to ensure that relevant incentives exist to use the data and that factors related to how EPCS is implemented facilitate its effective use.”

Full article, Everson J, Cheng AK, Patrick SW et al. JAMA Network Open 2020.12.21