Stronger oversight for prescription pain pills recommended

June 25, 2014 by Rose Hoban, Brandeis University
Rate of unintentional rx/medication overdose by county, 1999-2012. Credit: N.C. Injury & Violence Prevention Branch, Division of Public Health

Say you go to the dentist and need to have a root canal. As you leave, the dentist writes a prescription for a opioid pain reliever such as Vicodin or Percocet.

When you arrive at the pharmacist to fill your prescription, what you probably don't know is that your name and will be entered into a database of people in North Carolina who receive controlled substances. Doctors are encouraged to check the database before writing a prescription and pharmacists are supposed to check it to see that the medications they're distributing haven't been given too often to a specific person.

That database is to help identify people who might be "doctor shopping" for pain medication, arriving at one doctor's office and emergency department after another in an effort to collect enough pills for their abuse or perhaps for sale.

This year, Senate lawmakers are pushing a bill to strengthen the controlled substances reporting system by putting some money toward connecting North Carolina's system with that of other states; by requiring doctors, nurses, dentists and podiatrists who can prescribe narcotics to take continuing-education courses on prescription-drug abuse; and by mandating the creation of provider guidelines for prescribing opioids.

According to Sen. Ben Clark (D-Hoke, Cumberland), co-sponsor of the bill, a big impetus for looking at the issue was a series of articles in the Fayetteville Observer that looked at the high rate of opioid use in North Carolina.

"It was hitting hard in some communities where you have military populations, as a result of them being assigned over in Iraq and Afghanistan, and them being prescribed these medications and … coming back having developed tendencies for these particular substances," Clark said.

At least 792 people in North Carolina unintentionally overdosed from opioids in 2012, according to the state Department of Health and Human Services' Injury and Violence Prevention Branch.

Guidance strong enough?

A law passed by the General Assembly last year requires pharmacists to enter into the CSRS information on who picks up narcotic within three business days of dispensing the medications, and they're "encouraged" to do it within 24 hours.

But there's no requirement for doctors, dentists or pharmacists to check the system before writing a prescription, something that caused concern among the sponsors.

"The guidelines that are currently in place for the state are incredibly weak next to national standards for what guidelines should look like," said legislative Program Evaluation Division staffer Sean Hamel during a presentation to lawmakers earlier this month.

When firm guidelines are in place, he said, state medical boards take appropriate actions against doctors who violate them.

Lawmakers are concerned that physicians don't check the system for patients who ask for opioid pain relievers, and that some of those patients could be trying to collect as many prescriptions from as many providers as possible.

According to a study conducted by the Program Evaluation Division, North Carolina's CSRS is underused. In 2012, doctors and pharmacists in the state used the system less than 6 percent of the time they wrote or filled a prescription.

Last year's law allowed anyone working in a doctor's office to have access to the system. But physicians have resisted any requirement that they check the database.

And they're not alone. People who advocate for better oversight of prescription drugs agree that requiring doctors to check for every prescription will cause more problems than it solves.

"They've found in other states that the more regulation you have making checking mandatory, the more prescribers tend to stay away," said Fred Brason, who helped start Project Lazarus, a program that seeks to reduce the number of opioid deaths. "If they know they're being watched over, [doctors] won't see pain patients."

Unintentional prescription and opioid drug abuse deaths, by year in N.C. 1999-2011. Credit: NC DHHS Division of Public Health, Injury and Violence Prevention Branch

"And there's no way to effectively police that anyway," he argued.

"We don't want to create a problem by trying to fix a problem," Brason said.

Requiring education

Bill co-sponsors Clark and Sen. Fletcher Hartsell (R-Concord) said they would also like to see a requirement that physicians and other opioid prescribers complete continuing education on best practices for prescribing.

Physicians have resisted that too.

According to Sandra Brown, a physician from Concord who sat in on the meeting, physicians already have to take hundreds of hours of continuing medical education to maintain licensure.

She said doctors already know when they're writing a prescription for "legitimate and when we're writing for legal dope."

Brown argued that some doctors, in particular emergency-department physicians, will dispense a prescription for opioids because they are under pressure to avoid poor patient-satisfaction scores, something used increasingly by hospitals to determine doctor compensation and even continued employment.

She argued that there are doctors who run "pill mills" and others who write prescriptions for narcotics because they're afraid.

"If you all want to get on top of this problem, you have to change my behavior," Brown said. "And when I say 'my,' [I mean] you have to change behavior at the level of the individual physician."

Under protocols developed by Project Lazarus and being rolled out across the state, emergency-room doctors only write for two or three days' worth of medications, instead of, say, for 30 days.

Those same protocols advise dentists to only write for a few days' worth of narcotics, instead of reflexively writing for 30 or 60 pills, most of which end up sitting in a medicine cabinet and tempting a family member with a drug problem.

Brason said disseminating the protocols is more effective than creating regulations.

"We're changing physician behavior one on one, face to face, at the local level, with community doctors speaking to community doctors," he said.

"We're at close to 50 percent of the doctors and pharmacists signed up," Brason said. "At the rate we're growing, by the end of the year we'll be at the 65 percent level, about right."

Brason noted that about a third of physicians rarely write prescriptions for narcotics, if at all.

He said that by the end of 2015, Project Lazarus protocols will be implemented statewide for all Medicaid patients.

But senators were reluctant to take the continuing-education piece out of the bill.

"Unfortunately, the enemy of the perfect is the good," Hartsell said. "I think what we have is good, and I'm committed that we'll address the issues of [continuing medical education] as best we can."

"The I talk to are absolutely supportive of this bill going forward," said Sen. Jeff Tarte (R-Cornelius), whose wife is a pediatrician. "This is imperative that we move forward on this."

Best practice

The bill also includes language ordering that the CSRS share information with the Prescription Drug Monitoring Program Center of Excellence at Brandeis University in Massachusetts. The program collects data from individual states, spreads information on best practices and can help states predict areas where prescription-drug abuse might be a growing problem.

"We know from experience in the state of Massachusetts, which we've been working with for several years, that the rate of doctor-shopping or multiple-provider episodes going on in a county can be a high-level predictor of how many overdoses and deaths they may experience in emergency rooms and in the morgue," said John Eadie, the director of the center.

He said states using their data can compare with other states, look at trends and learn from what other states have done.

For instance, Eadie said, many states are now requiring that reporting be done within 24 hours of dispensing from the pharmacy.

He said the data are useful to medical and licensing boards in sanctioning providers who are overprescribing.

"It can also help guide efforts to interdict heroin before it become a major problem by providing early warning in areas that have high levels of prescription-drug abuse and which become a target for heroin trafficking," Eadie said.

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