Monday, May 20, 2013

Critique of Prescription Drug Monitoring Programs--Charlie Jose

Since the 1990s, Opioid-related overdose deaths have increased dramatically in the United States (Paulozzi, 2006). In Massachusetts alone, opioid-related overdose deaths have exceeded motor vehicle crash-related deaths since 2005 (CDC, 2011). Many factors have contributed to this increased mortality, which include: new drug use patterns, greater heroin availability, more potent heroin composition, as well as increased abuse of prescription medications (Shah, 2008).
Numerous strategies exist to reduce the rate of opioid-related overdose deaths, as well as opioid-related harm. In Canada, established safe injection facilities, where drug users can use pre-obtained drugs under supervision, have reduced mortality in drug-using populations (Marshall, 2011). Prescription Drug Monitoring Programs (PDMPs) have been established in numerous states to reduce prescription drug diversion and the act of “doctor shopping” by drug users seeking access to opioids (Office of NDCP, 2011). While PDMPs are useful in reducing use of non-prescribed medications, there is no data to support their efficacy in reducing overdose-related deaths and harm (Paulozzi, 2011).

Overview of Critique: Isolation and Hopelessness Caused by Prescription Drug Monitoring Programs (PDMPs)
This critique will address the vast limitations of PDMPs. While these programs can minimize access to prescription opioids, many skeptics criticize the role PDMPs play in reducing opioid-related overdoses and harm (Green, 2011). Particularly, this approach does not address social and behavioral considerations sensitive to drug users, which have the most effect on reducing mortality.
Although PDMPs generate databases help physicians identify risky patients likely to abuse opioids, the resulting actions taken by physicians contributes to the social stigmas and labels that can fuel drug use. When physicians deny drug-seeking patients in clinical settings, psychological reactance triggered by the authority of physicians can lead to worse health outcomes. As PDMPs place interventional control with health care professionals and not the drug users themselves, this strategy diminishes a patient’s sense of self-efficacy.
Overall, PDMPs instill a sense of anger and hopelessness among drug users. These individuals most often need more support than the average citizen. For this reason, PDMPs are not effective in reducing opioid-related overdose and harm.

Adding a Label to a Heavily Stigmatized Population
In some states, law enforcement can become involved with PDMPs. This can lead to sanctioning for drug seeking patients that highlight the illegality of “drug shopping.” Simply put, this adds a negative label to an already heavily stigmatized population.  National campaigns and community-based programs teach society from a young age to avoid drugs, creating a societal norm that drug users are “bad people.” This has created a social stigma surrounding drug users, who do not adhere to the social norms of living a drug-free lifestyle and further become ostracized from society (Goffman, 1963). In the case of opioid use, growing stigma in receiving medical treatment affects the receipt and access of health care (Latkin, 2013). In some cases, stigma can lead to worse health outcomes, such as severe depression and isolation of drug users during treatment (Cornford, 2012).
PDMPs enable health care professionals to negatively label drug users as deviants of common societal norms, as supported by Labeling Theory (Mead, 1934). Patients seeking prescriptions are already dealing with the stigma of being a drug user, now they are branded and labeled as criminals in the clinical setting. Drug users are left with no choice but to believe they are in fact criminals, which embellishes their existing social stigma. This malicious cycle defeats the original purpose of PDMPs to reduce opioid-related harm, as depression caused by stigmas and labels can lead to even more drug use (Chen, 2013).
Both stigmas and labels affect the overall well being of an individual. Specifically, the negative nature of these elements diminishes the self-esteem of drug users. According to the Hierarchy of Human Needs, depressed individuals who lack self-esteem neglect the value of their personal health (Maslow, 1943). In the case of drug users, being healthy is defined by society as abstaining from drug use altogether. Maslow cites that lower levels of human needs, such as the desire for respect, positive recognition, and confidence, must be satiated before an individual can even start considering the importance of health. Since society does not condone drug use, confidence and self-respect become impossible to attain.  The idea of being healthy and free from drug use far surpasses the daily concerns of opioid users. As a result, these individuals turn to drugs in order to cope with the negative attitudes and feelings caused by societal stigmas and labels. Drugs provide validation when society (through the implementation of PDMPs) rejects drug users for their deviation from cultural norms.

Psychological reactance fueled by physicians
Doctors serve as the key players who allow this program to actually have an effect on reducing overdose deaths and opioid-related harm. They review PDMP databases and decide whether or not they will prescribe opioids to patients.
More importantly, the way in which a physician delivers a rejection to drug seeking patients determines the effectiveness of this intervention. When a doctor denies a drug seeker in the clinic and counsels the patient about their drug use, Psychological Reactance Theory explains that being told “no” can have a worse outcome for the patient. This theory states that when a person experiences a threat to their personal freedom, they react in a way that motives them to restore their autonomy (Brehm, 1966).
Specifically, the dominance exerted by the physician, who serves as a figure of authority over the patient’s health, magnifies the psychological reactance of the message (Dillard, 2005). Denial of prescription drugs instills anger and rebellion among patients, which leads to negative health outcomes and further fuels their drug use (Blose, 2009). A doctor in a position of authority simply does not have the characteristics that give a drug user the ability to relate. Although physicians are trained in counseling as part of their medical education, drug counseling and addiction treatment takes a unique skill that requires specific training, especially in the case of opioid users (Joe, 2009).
Unfortunately, not all primary care physicians at the front lines of PDMPs receive this training, which has negative consequences in the ability for this program to achieve its goals of reduced harm. How doctors approach their patients matter in order to reduce overdose deaths, and most often, confrontation does not work (Miller, 2007).

Taking Control Away from Drug Users
The inherent design of PDMPs takes away any control that drug users have in curbing their drug use and reducing opioid-related harm. As health care professionals are the primary mode of intervention and hold the choice of providing prescription opioids to patients, control is shifted away from drug users themselves in managing their own drug use. According to the Theory of Planned Behavior, there is a trickle down effect on to the individual’s level of perceived control (Ajzen, 1991). Since control is stripped away from the drug users, they are instilled with the idea that they are helpless in controlling their own fate.
According to Edberg (2007), if someone does not have perceived power, they will be less likely to take action (where “action” in this case means controlling one’s drug use). For the extent of their drug use, drug users have been told that their addiction has taken away their control of their ability to curb their habits. Now, a health care policy has codified their lack of control. Utilization of PDMPs subliminally harps on a drug users perceived lack of control, which is harmful if society expects drug users to help themselves.
Not involving patients in the process of reducing their own drug use has negative consequences among heroin users (Cornford, 2012). Specifically, hopelessness can lead to more drug use. To get drug users to want to help themselves, they must believe that they have control. The authority of doctors serves to impede a patient’s sense of self-efficacy, which is an individual’s measure of their ability to complete tasks (Ormrod, 2006). If drug users are not instilled with the notion of control, they cannot take action to stop their own drug use.
Proposed Alternative Intervention: The Power of Overdose Education and Naloxone Distribution (OEND) Programs
Implementing Overdose Education and Naloxone Distribution (OEND) programs for drug users and bystanders is a cost-effective strategy to prevent and manage overdoses (Coffin, 2013). This strategy has even shown to reduce opioid-related deaths in some communities (Walley, 2013). As part of OEND training, participants are educated about overdose prevention, recognition, and response – critical skills required to manage an overdose situation. Participants are also given Naloxone, which counteracts the life threatening respiratory depression that causes death. Unlike PDMPs, OEND programs address behaviors and prevention strategies at the individual drug user level. OEND programs work by changing social norms to counter the isolation and depression caused by social stigmas and labels. The effectiveness of OEND programs comes from the fact that those delivering the intervention are laypersons that are more relatable to a drug user than doctors and pharmacists. Most importantly, OEND programs impart a sense of control among drug users, which develops the ownership necessary to combat his or her drug use habits. A sense of control is further spread through OEND trainees’ social networks.

Changing Social Norms
Instead of isolating drug users who may not adhere to standard social norms, society can change social norms in a way that reduces opioid-related harms. Changing the role that drug users play in society can counteract the burden that social stigmas and labels place on these individuals. Although society has set rules and patterns that are considered “normal,” individuals have the ability to change what is socially accepted as described by Social Expecations Theory (DeFleur, 1989). Rather than ostracizing drug users as criminals, which fuels their associated social stigma, OEND programs accept drug use as part of the healing process. Enrollment into OEND programs changes the way people, who may or may not be a drug user themself, view a drug user. OEND programs put laypersons on the front lines of reducing opioid-related harms, which develops a sense of familiarity with this heavily stigmatized group. Unlike national campaigns targeting drug use, these programs impart a sense of community among all members of society. Instead of labeling these people as criminals who are “below” society, OEND programs highlight that drug users are peers who also need help.
By fostering a sense of camaraderie, overdose education and even the distribution of naloxone has shown to reduce the number of deaths caused by overdose (Walley, 2013). While there are only 16 states with established OEND programs, Diffusion of Innovation shows promise for this initiative to reduce opioid-related harm.  Adoption of innovation is a process (Rogers, 1962). As more people enroll in OEND programs and reverse potential overdoses, society’s perspective about drug users can positively change. This changes comes from the confirmation of the value of OEND programs and from the developed familiarity about drug user behaviors. As more people become involved in preventing harm, the overall views of society change to extinguish the overly emphasized criminality of drug use.

The Message of OEND Programs Comes from Similar People
OEND programs are comprehensive, in that they involved all people in the process of curbing overdose-related harm. Anyone can be trained through OEND programs – family members, bystanders in overdose situations, even drug users themselves. This feature allows all people to take part in managing overdose-related harm, not just physicians and pharmacists. As described by Silvia (2005), consideration of who delivers a message is important when implementing a program.
When the person relaying the message is similar and more relatable to the audience, there is less psychological reactance experienced compared to when someone estranged relays the message (Silvia, 2005). Power and influence is removed from health care professionals and disseminated to people who are familiar to a drug user. In some cases, other drug users become the messengers to their fellow drug users in reducing overdose deaths (Doe-Simkins, 2009). Family members, bystanders, and drug users are much more relatable to a typical drug user than an authoritative doctor. For this reason, OEND programs reduce the effects of psychological reactance so that drug users are less resistant to overcoming the problems caused by their opioid use.
The added bonus of increased ability to measure psychological reactance in OEND programs compared to PDMPs also allows overdose education and naloxone distribution to be more effective. As researchers have developed ways to measure the knowledge provided by OEND programs as well as the attitudes of recipients of treatment, they are able to specifically tailor how these programs can better deliver their message (Williams, 2013). This contrasts the limited data on psychological reactance data of PDMPs, since it is hard to follow patients denied of prescriptions to ask them about their personal reactions and patient satisfaction.

The Social Networks of OEND Trainees can Spread the Idea of Control

The most important lesson taught by OEND programs is that family members, bystanders, and drug users have the ability to control the fate of themselves and their loved ones using drugs. According to Prospect Theory, people take ownership of things and think they have control when they have a better sense of the risks involved (Kahneman, 1979). Therefore, it is important for society to give back ownership to drug users about their own problems and issues. By teaching trainees how to manage overdose and reduce potential opioid-related harm, OEND programs instill a sense of confidence that was otherwise taken away by society through the implementation of PDMPs (Strang, 2008). Doctors and pharmacists are no longer the gatekeepers in managing opioid-related harm. OEND programs provide buy-in to all members of society, most importantly to drug users themselves, in determining their fate. The OEND strategy gives drug users a stake in reducing opioid-related harm.
The all-inclusive nature of OEND programs compared to PDMPs also provides a powerful benefit. As noted by Social Network Theory, behaviors spread through social networks, not through individuals (Wasserman, 1994). The social circles of OEND trainees are much more expansive than doctors and pharmacists alone. Most often, the social circles of family members, bystanders, and drug users trained in OEND better reach target populations that have greatest control in reducing opioid-related harm (Walley, 2013). As individuals trained in OEND are most likely to be the support system for drug users, these programs strategically target individuals who have the most influence in the behaviors of drug users. This has a more advantageous effect than PDMPs, where health care professionals are the key players in intervention strategies.

Opioid-related overdose deaths and harm continue to be a major issue haunting the United States. Especially with the growing rate of prescription drug abuse, it is important to develop interventions that can reduce harm. While Prescription Drug Monitoring Programs have the ability to restrict access to addicting prescription drugs, this strategy contributes to the social stigmas and labels that burden drug users and that can contribute to greater use of drugs. Not only do these programs take personal control away from drug users, the messenger in PDMP interventions is not relatable to a drug user.
Overdose Education and Naloxone Distribution Programs provide social support that helps alleviate the oppression caused by societal norms. OEND programs achieve this aim by focusing on individual-level intervention and by helping combat social stereotypes associated with drug users. This alternative strategy helps develop the confidence and self-efficacy needed to help drug users help themselves.


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