Effects of Implementation and Enforcement Differences in Prescription Drug Monitoring Programs in 3 States: Connecticut, Kentucky, and Wisconsin

 

Before analyzing the outcomes of the implementation of PDMPs and related drug control policies, let’s back track to the ‘problem’ for which these public health interventions were created to address: “Drug Misuse” is commonly defined as “the use of a substance for a purpose not consistent with legal or medical guidelines” (WHO, 2006). Examples of such use include intentionally ingesting substances (controlled or not) at a dose, frequency, or time, that is inconsistent with how it has been advised that you administer it to yourself. Presumably, this activity is deemed problematic because it is thought to be associated with increased morbidity (disease) and mortality (death). For the purposes of this discussion, I will rebrand “drug misuse” as “alternative use” because the word “misuse” connotes something negative or morally wrong about such actions. This idea is presumptuous and is based on an implicit bias that using substances alternatively is automatically detrimental to one’s own health. But what if “alternative use” of substances were to mediate improved health and wellbeing? What if that were the primary aim of those agents who engage with intentional, “alternative use”. This brings us to a fundamental principle that we need to clarify with more precision: What is “harm”? Here, we will define “harm” in relation to the individual and the concepts of “morbidity” and “mortality”. Therefore we take “harm” to mean “death” or “chronic physical or psychic pain that prevents one reasonably pursuing fulfillment, growth, or happiness”. Characteristics of harm related to substance use:

Harm Mediated by Direct Use:

Example: Compulsive self administration of substance(s) at a dose and frequency that is toxic to the user, without this being the intent of the user.

Harm Mediated by Constraints on Using in an “Alternative” Way:

Example: A need to access and use substance(s) at a higher dose & frequency for a functional or harm reductive purpose is not permitted. The prohibition here renders the user vulnerable to an unmet need. This increases the likelihood that users will turn to other sources (i.e. the black market) in order to attempt to functionally meet their needs. In common discourse about alternative substance use and risk, many individuals invoke ‘harm mediated by direct use’ as a rationale to put constraints on using in any way that deviates from a the letter of a prescription or standardized best practice.