Deploying Prescription Drug Monitoring to Address the Overdose Crisis

The United States is in the midst of a historic public health crisis. Each day, well over 100 Americans die of drug overdose, driven increasingly by street opioids. In line with other “epidemics” of grave public concern, this crisis has spurred an expansion of public health surveillance. This article focuses on the principal element of this expansion—prescription drug monitoring programs (PDMPs). By collecting information on who is prescribing, dispensing, and receiving scheduled drugs, PDMPs are intended to detect—and deter—problem patients, rogue prescribers, and pharmacists who may be diverting potentially addictive and otherwise risky drugs. PDMPs are far from new, but the recent scale-up in the number, scope, funding, and legal mandates of these systems has occurred without sufficient scrutiny. The lens of public health law research has just begun to be trained on PDMPs. By integrating empirical and theoretical perspectives, this article adds to this nescient discourse. I argue that the zeal with which we have traditionally pursued supply reduction measures to address drug-related harms reflects the legal and system design of PDMPs, as well as the street-level implementation of these programs. This also explains why the success of PDMPs has been measured primarily by their impact on suppressing medication supply with little regard for truly meaningful metrics. But, when it comes to improving patient care and addressing drug-related harms, the evidence of PDMP benefit is far from clear. This article presents a narrative review of the 34 peer-reviewed studies evaluating PDMPs published since 2010. Only 11 (32%) considered any overdose outcomes. Of studies assessing overall mortality, three found PDMP deployment to be associated with reduced overdose rates, four reported a null result, and three reported PDMPs to be associated with an increase in overdoses. These findings stand to challenge the kind of unbridled enthusiasm, generous investment, and cavalier policy emphasis that has buoyed PDMPs since the onset of the overdose crisis. Given evidence of mixed impact, the unintended harms of these systems warrant urgent examination. This includes their potential role in deterring proper prescribing practices; chilling help-seeking among patients, especially those made vulnerable by a history of trauma in the healthcare settings and criminal justice involvement; further fraying the fabric of provider-patient trust; and facilitating patient transition from prescription to black market drug supplies. Original qualitative data presented here give voice to stakeholder concerns about surveillance, privacy, and pervasive monitoring by law enforcement. A special focus on privacy is especially timely in view of recent appellate decisions allowing broad warrantless disclosure of PDMP data to law enforcement. Although the perils of expansive government monitoring and predictive technologies are recognized in national security, criminal justice, and other realms, a critique of PDMPs as dragnet electronic surveillance is long overdue. At the population level, these collateral impacts can hamper much-needed surveillance and control efforts, aggravating the very problems these policies and programs were intended to ameliorate. Ultimately, however, this article is sober to the reality that PDMPs are here to stay. As I urge a more deliberate focus on privacy protections, I argue for PDMP integration with electronic health records; user-driven design that reimagines PDMPs as a care coordination, clinical decision-making, and public health prevention tool; and meaningful training on how to deploy PDMP functionality to improve individual and public health.