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'Pill mill' crackdown linked to fewer painkiller overdose deaths in Florida

December 21, 2015

A crackdown on Florida's "pill mills" - clinics dispensing large quantities of prescription painkillers often for cash-only and without proper medical examinations - appears to have dramatically reduced the number of overdose deaths in the state from these drugs and may have also led to a drop in heroin overdose deaths, new research suggests.

The Johns Hopkins Bloomberg School of Public Health researchers, publishing their findings Dec. 21 in the American Journal of Public Health, say an estimated 1,029 fewer people in Florida lost their lives to prescription painkiller overdoses over a 34-month period than would have had the state not taken aim at pill mills. Florida passed new laws in 2010 and 2011 establishing oversight over pain clinics and restricting the dispensing of opioids there, while major drug law enforcement initiatives arrested and prosecuted those operating them.

The researchers also found substantially fewer deaths in Florida from overdoses involving either prescription painkillers or heroin during 2011 and 2012, a finding that calls into question claims that reducing prescription painkiller diversion will increase overall heroin use. Rates of prescription painkiller addiction are at historic highs and a portion of those abusing these medications have switched to heroin, which can be cheaper and, in some cases, easier to obtain. Other research has found that four out of five new heroin users first used prescription painkillers. What could be happening in Florida, they say, is that with less access to prescription painkillers, fewer people may be developing an addiction, which in turn may prevent people from later transitioning to heroin.

"Florida's focus on these pill mills seems to have been an effective way to reduce overdose deaths in the state," says study leader Alene Kennedy-Hendricks, PhD, an assistant scientist in the Bloomberg School's Department of Health Policy and Management. "An added benefit of Florida's increased oversight of unethical businesses and providers dispensing large quantities of narcotics may be that they may have prevented new cases of heroin addiction from developing as well. Other states should consider restrictions on pill mills as one potential way to reduce prescription painkiller overdose deaths."

In 2010, of the top 100 physicians purchasing the most oxycodone in the United States, 90 were in Florida. Much of the dispensing was done in cash-only pill mills where standard medical practices were rarely followed.

For the study, Kennedy-Hendricks and her colleagues compared Florida, before and after the implementation of pill mill laws, with North Carolina, a state with similar trends of prescription painkiller overdose death rates before 2010 and with no new restrictions on pill mills during the study period. They analyzed data on 11,721 Florida deaths and 3,787 North Carolina deaths between 2003 and 2012 in which an opioid (either a prescription painkiller or heroin) was identified as the primary cause of death.

They examined changes in trends in death rates in North Carolina and pre-2010 trends in Florida to predict how many deaths were likely to have occurred in Florida had there not been this effort to rein in pill mills. Over the nearly three years, they estimated that 1,029 lives were saved in Florida, and the number of estimated lives saved grew dramatically each year as new measures were instituted to reduce pill mill operations in the state. From March 2010 until December of that year, the prescription painkiller overdose death rate in Florida was 7.4 percent lower than would have been expected absent Florida's interventions, 20.1 percent lower in 2011 and 34.5 percent lower in 2012.

Heroin overdose mortality rates rose in each state at the beginning of 2011, but North Carolina's rate of heroin overdose deaths increased much more rapidly than Florida's rates. North Carolina's rate continued to rise, increasing four-fold from early 2011 to late 2012. In contrast, Florida's rate of increase in heroin overdose mortality rates during this period was substantially lower.

Previous research has also found that since 2010, Florida has seen substantial reductions in oxycodone-prescribing physicians, opioid prescribing and the diversion of prescription painkillers to people for whom they are not prescribed.

"This study underscores that the sharp rise in prescription opioid overdose deaths has become a public health epidemic that is driven, in part, by major criminal enterprises," says co-author Daniel Webster, ScD, MPH, a professor of health policy and management at the Bloomberg School. "Our new study demonstrates that the right laws and strategic enforcement can prevent addiction and save many lives."

Expanding distribution of naloxone (a drug that can reverse the effects of an overdose) and implementing evidence-based, medication-assisted treatment programs for opioid use disorders may also reduce overdose deaths, the researchers say.
"Opioid overdose deaths and Florida's crackdown on pill mills" was written by Alene Kennedy-Hendricks, PhD; Matthew Richey, PhD; Emma E. "Beth" McGinty, PhD, MS; Elizabeth A. Stuart, PhD; Colleen L. Barry, PhD, MPP; and Daniel W. Webster, ScD, MPH.

This study was funded by an unrestricted research grant from AIG, Inc.

Johns Hopkins University Bloomberg School of Public Health

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