Technology Presents Legislative Opportunity to Crack Down on Opioid Abuse
Legislative Affairs Feature — May 2017
Tex Med. 2017;113(5):35-43.
By Joey Berlin
Sometimes, McKinney emergency physician Carrie de Moor, MD, runs into patients who she later realizes are worthy of Academy Awards.
"They're real good," she says — that is, they're good at deceiving practitioners about their nonexistent need for prescription painkillers.
Years ago, Dr. de Moor was working in an emergency department (ED) in El Paso when a patient came through who said he had been in a car accident and had severe back and neck pain. The patient, who said he was traveling through from out of town, was "very believable" and "seemed like a normal person," Dr. de Moor said. But she soon heard the truth from the pharmacy where the patient was supposed to fill his prescription: He had hit "every ED in the city" angling for prescriptions.
"[I'm thinking], 'You deserve an Oscar' sometimes. Some of these people are really good actors, with the stories they come up with," Dr. de Moor said. "If they're coming in, it's not for us to say, 'You're a liar' or 'You didn't do that.'"
Master thespians feigning pain in physician offices don't get golden statues, but sometimes they come away with what they really wanted: pain medication that dangerously feeds their addiction. While the number of opioid prescriptions has dropped both in Texas and nationally over the past few years, opioid abuse, drug diversion, and "doctor-shopping" remain major concerns at both the state and national levels. Most tragically, opioid overdose deaths continue to climb.
The Texas Medical Association is committed to curbing the abuse and diversion of prescription drugs and supports using the state's new prescription drug monitoring program (PDMP), PMP Aware, as a vital part of a technology-based solution to the opioid crisis.
However, TMA doesn't believe a mandate for physicians to check the PDMP every time they write a prescription for a controlled substance is a practical, effective piece of that solution — despite the popularity of similar mandates in other states and the Texas Sunset Advisory Commission's recommendation for one.
"I think that as long as we are using technology to advance the cause of trying to prevent doctor-shopping, and trying to prevent the overutilization by patients who get these prescription narcotics, and targeting geographic hot spots, I think we're working in the right direction," said anesthesiologist Ray Callas, MD, chair of TMA's Council on Legislation. "And we have the technology in hand to do just this without a mandate to check every prescription."
Prescriptions Down, But Deaths on the Rise
According to studies cited by the Centers for Disease Control and Prevention (CDC), almost 2 million Americans abused or were dependent on prescription opioids in 2014, and as many as one in four people who receive prescription opioids long-term for noncancer pain in a primary care setting struggle with addiction. Prescription opioid misuse results in the treatment of more than 1,000 people in EDs each day.
The number of opioid pain-reliever prescriptions in Texas is dropping, according to CDC data. In 2012, scrips for opioid pain relievers in Texas fell by 10 percent, and prescriptions for benzodiazepines dropped by 21 percent. For 2012, Texas had 74.5 opioid painkiller prescriptions per 100 people, below the national average of 82.5, and 29.8 benzodiazepine prescriptions per 100 people, also below the national average of 37.6.
Recent data also show that after years of increases, the number of opioid prescriptions has dropped nationally. In May 2016, The New York Times reported two data companies had reported declines in opioid prescribing. IMS Health found opioid prescriptions had declined 12 percent nationally since peaking in 2012, while Symphony Health found a decline of 18 percent in that time frame. The number of opioid prescriptions fell in 49 states, including Texas, since 2013, according to the IMS data.
However, national opioid death rates continue to climb, CDC data show. From 2014 to 2015, drug overdose deaths increased by 11.4 percent, and the death rate from synthetic opioids other than methadone increased by 72 percent.
"Whenever I run into people like this, it's whenever I look at their medication list and they're on Vicodin, they're on Stadol, they're on nose sprays, they're on MS Contin, Xanax," Dr. Callas said. "I look at it, and I'm shocked to see these patients on all these different types of drugs. To me, it just confirms that we have to do a better job, all of us who even touch a patient's life, to try to improve the delivery of health care and go a different direction than just [using] narcotics."
The Times noted the surge of heroin overdose deaths in recent years has experts saying the drop in opioid prescriptions is "at best a half victory." Heroin is a popular alternative for addicts who can no longer get their hands on prescription painkillers.
Last December, CDC's National Center for Health Statistics released a report identifying the drugs most often involved in overdose deaths in the United States from 2010 to 2014. (See "The Deadliest Drugs.") From 2012 to 2014, heroin ranked first, overtaking oxycodone, which topped the list in both 2010 and 2011. Heroin deaths increased every year examined in the report, culminating in the drug's involvement in 10,863 deaths in 2014, 23.1 percent of all drug overdose deaths that year. In 2010, just over 3,000 drug overdose deaths involved heroin, less than one-third of the 2014 total.
"It's going up almost linearly, year by year. It has not peaked, [while] opioid prescribing has gone down dramatically," said Mesquite pain management specialist C.M. Schade, MD, a director emeritus at the Texas Pain Society (TPS). "So we're at least five years after the peak of the [opioid-prescribing] problem. People are still dying, but it's not being driven by our scrips."
The New PDMP and TMA's Solutions
Encouraging technological progress the state has made on prescription monitoring is at the center of TMA's recommendations to the legislature to address doctor-shopping and opioid diversion.
On Sept. 1, 2016, the state's new PDMP officially went live after its transfer from the Texas Department of Public Safety to the Texas State Board of Pharmacy (TSBP). Gay Dodson, executive director of the pharmacy board, says almost every comment TSBP has received about the new PDMP compares it favorably to the old version. She says between the launch in September and last January, the PDMP had more than 46,000 registered users and tracked about 16.8 million prescriptions.
"What we're finding out is, everybody had such a bad taste in their mouth about the old system because it took longer and it wasn't really easy," Ms. Dodson said. "It was three screens wide, and you couldn't sort on the screen; you had to download it to sort it to really look at the information. And this one, it's all on one page, everything you need to see, one screen. And you can sort it directly on the screen however you want." (See TMA's new how-to video on the revamped PDMP.)
The data capabilities of the new PDMP are at the center of TMA's recommendations to the legislature to address opioid abuse. Those recommendations include:
- Requiring registration with the PDMP for all prescribers and pharmacists to coincide with the issuances and renewals of their professional licenses;
- Requiring all prescriber licensing boards to furnish to TSBP the information the board will need to automatically enroll all prescribers in the PDMP;
- Giving TSBP the explicit authority to issue "push-out" notification alerts to physicians and pharmacies when evidence of drug diversion or doctor-shopping emerges; and
- A requirement for all prescriber licensing boards to develop and post opioid-prescribing guidelines on their websites.
Current law requires pharmacies to send prescription information "not later than the seventh day" after filling it. That lag time is a concern to both TMA and Ms. Dodson. TMA supports a change in the proposed TSBP sunset bill to require reporting prescription information no later than the next business day after filling.
"I think that's much better than every seven days," Ms. Dodson said, "because the way it is now, somebody could doctor-shop or pharmacy-shop for seven days, and the other pharmacies wouldn't know. Or the other doctors wouldn't know that they've gone and gotten drugs at 50 other pharmacies during that one week."
TSBP has already begun issuing its first push notifications, Ms. Dodson says. Although the pharmacy board's sunset bill asks the legislature for explicit authority to do so, she says TSBP's attorney believes the board doesn't need that legislative sign-off. The board uses criteria starting with patients who have five physicians, five pharmacies, and five different controlled-substance prescriptions, and "different measures within there," Ms. Dodson says. The push-out system generates emails to physicians that don't name the patient suspected of drug diversion. Instead, the emails let physicians know they might want to log in to the PDMP to check out something suspicious.
TMA also recommends providing TSBP with data from the Automation of Reports and Consolidated Orders System (ARCOS), the U.S. Drug Enforcement Agency's (DEA's) wholesaler drug delivery tracking system. Comparing its own delivery and dispensing data with ARCOS data could assist the board in nailing down geographic locations of drug diversion and doctor-shopping.
Dr. Schade says using both PDMP and ARCOS data is one component of a crucial piece of the equation: enforcement. Right now, drug manufacturers sell their pharmaceuticals to wholesale distributors and report those sales to ARCOS, which also receives reports from the distributors when they sell drugs to pharmacies. Pharmacies report their sales to the PDMP, but the pharmacy board only receives data from ARCOS by individual request, and often the board receives that information extremely slowly. The sunset staff report on the pharmacy board recommends requiring that wholesale distributors report sales of controlled substances directly to the pharmacy board, a step TMA and TPS advocate.
If that becomes reality, TSBP would have the same data as ARCOS and could compare it to the PDMP reports the board gets from pharmacies. "And if there's a difference," Dr. Schade said, "they've got to investigate."
When there are push notices of suspected doctor-shopping, he says, the parties involved should receive notification and should monitor the situation for a set period, such as 60 days. If there's no correction of that behavior, he says, it should trigger a mandatory report to the appropriate licensing board.
"Without investigation, you don’t know anything," Dr. Schade said. "And that's what other states are doing, and that's what works."
Fighting the Mandate Trend
Every state except Missouri now has a prescription monitoring program. In 2012, according to the Center for Health Journalism, Kentucky became the first state to adopt a comprehensive requirement for prescribers to query the state's PDMP before issuing any prescriptions for opioids, and a number of others quickly followed suit. Texas physicians don't have such a mandate but are required to show they considered checking the PDMP before prescribing dangerous drugs or controlled substances. (See "Regs and Pains," September 2015 Texas Medicine, pages 51–55.)
TMA is working to prevent a burdensome physician mandate to check the PDMP every time.
Sunset commission staff included a physician PDMP mandate recommendation in its 2017 report on the Texas Medical Board (TMB), which focused in part on the board's inspection of pain management clinics. The staff report said TMB's pain management clinic inspection program "does not follow best practices — such as effective use of Prescription Monitoring Program data, or consideration of past inspection reports, or length of time since the last inspection — to maximize efficiency with limited investigatory resources."
Sunset staff recommended that the legislature require physicians and physician assistants to check the PDMP and review a patient's prescription history "before prescribing opioids, benzodiazepines, barbiturates, or carisoprodol." Under the sunset recommendations, the mandate would begin on Sept. 1, 2018, and physicians and physician assistants who fail to follow it would be subject to disciplinary actions by their respective boards. As they were filed in mid-March, Senate Bill 315 and House Bill 3040, the TMB sunset bills, would require physicians to check the PDMP before prescribing those medications. Other sunset bills include a similar mandate. The pharmacy board's sunset bills, for example, contain a requirement for pharmacists to check the PDMP before filling prescriptions on those drugs.
Stakeholders were still discussing the mandate issue at press time, with Senate Bill 316 by Juan “Chuy” Hinojosa (D-McAllen) emerging as a potential compromise measure. SB 316 would mandate a PDMP check for opioids, benzodiazepines, barbiturates, or carisoprodol, affecting Schedule II drugs on Sept. 1, 2018, and those drug classes on all schedules one year later.
TMA lobbyist Dan Finch says a mandate to check the PDMP before writing a prescription for all controlled substances would affect between 3 million and 3.5 million Texas prescriptions per month. Even if checking the PDMP takes only three minutes per prescription, applying that to 3.5 million prescriptions adds up to the equivalent of just under 20 years of additional time burden every month. Dr. Schade is one of many physicians who don’t see a PDMP mandate as beneficial, sarcastically likening it to performing a "chest x-ray on everybody that comes in the office" to battle widespread pneumonia.
"It's total window-dressing. It's worthless," he said.
The TMB sunset report recommended exempting prescribers who are writing scrips for cancer patients or for patients in a hospice setting if the prescriber includes on the prescription "the patient's diagnosis or the basis for the exemption." TMA supports these exemptions, but also believes prescriptions for patients in emergency and surgical care have equally good arguments to be exempt.
Houston emergency physician Angela Siler Fisher, MD, says she usually looks patients up in the PDMP before she prescribes take-home opiates, but not always before controlling a patient's pain in the ED. A mandate to do so, she says, "would delay time for patients to receive lifesaving emergency care by adding five minutes to every patient that I evaluate and treat with controlled substances."
"When you're seeing two to three sick patients an hour, that can add hours to nonclinical responsibilities during a 12-hour shift," she said. "It's great to have the resource when you need it, but I disagree with mandating that physicians are required to look up all patients prior to administering controlled substances. There are many instances when pain control in the ED is a priority regardless of past history," such as a femur fracture after a motor vehicle accident.
Dr. de Moor agrees that while the PDMP is a great tool to have, a mandate to check it before writing every opioid scrip would be too onerous for an ED doctor. The circumstances an emergency physician faces, "where we're having to go, go, go, go, go all the time like that, it's not really feasible to check it every time," she said. It's also not necessary, Dr. de Moor says, because the DEA is already identifying drug-diversion suspects.
"I understand the intent behind it, but it's not reasonable," Dr. de Moor said. "And if we have to do it, I'll tell you what will happen: [I expect] physicians will prescribe controlled substances for pain a whole lot less. And that will turn into our hospitals and [others] going, 'Well, why aren't you prescribing this?' [and talking about] patient satisfaction. 'Well, because I don't have time to sit here and look up every single patient and find out if they potentially might have had prescriptions before.'"
Data that sunset staff analyzed from the PDMP indicated "many pain management clinics, which are required to register with the board, pose a surprisingly low level of risk."
"The data also show that most physicians and physician assistants who prescribe controlled substances most frequently are not affiliated with pain management clinics," the report said. "Accordingly, to better curb prescription drug abuse and misuse, the Medical Board’s inspections of pain management clinics should be targeted toward the highest prescribers, and the board should more effectively monitor prescribing patterns through the newly enhanced Prescription Monitoring Program."
Austin oncologist Debra Patt, MD, testified before the sunset commission to request the exemptions for cancer patients and hospice care. She says she was thankful sunset staff agreed in its final recommendations.
"As an oncologist, I love the ability to cure cancer, but sometimes I can't cure cancer," Dr. Patt said. "And then the best things that I can do for my patients are to make sure that I palliate their symptoms and improve their quality of life. And we use controlled substances in about a third of our patients to do that, so it's really important. We've seen negative repercussions from other states that have passed these important PDMP policies that haven't had exclusions."
Learning From Other States
Dr. Schade notes that with its relatively recent entry into using a PDMP, Texas is "a rookie in this ball game" compared with a number of other states. Brandeis University's Prescription Drug Monitoring Program's Training and Technical Assistance Center (TTAC), which compiles reports on the evolving practices in administering PDMPs across the nation, looked at the changes in practices in its report last December, Enhancing PDMPs: A Comparison of Changes 2010 to 2016.
The Brandeis research — which looked at the PDMP practices in every state, plus Guam, that has a PDMP — shows a number of TMA's proposals to battle drug diversion have gained popularity in other states. For example, Brandeis noted 28 PDMPs now have mandatory enrollment for dispensers and prescribers. Thirty-six PDMPs have daily or real-time data collection, and 46 PDMPs reported having the authority to send unsolicited reports to users.
Dr. Schade says research into integrating prescription drug information into a physician's regular workflow is bearing potential fruit for the future. If that can become reality, "I don't have to do a separate login. I can set my own parameters of what I'm looking for, and it will give me [an] immediate [notification] that pops up, so that I know that this is a problem patient or not a problem patient."
"We want to modernize our workflow," he said. "[Checking the patient's drug information] shouldn't be optional; it just happens. You're there, and that way it doesn't take additional time and waste resources."
Until an advancement like that one is ready and available to satisfy both physician workflow needs and calls for prescribers to keep tabs on every patient's prescription history, medicine must strike the best balance it can. The overriding issue, Dr. Fisher says, is that "it's a shame that we find ourselves, as physicians, in a position to even question the authenticity of our patient's pain when they present."
Dr. Callas says medicine is committed to coming up with a multimodal approach to treat pain, instead of a narcotic-based approach.
"This is something where children from 10, 12 years old all the way up to 70 or 80 are not only becoming addicted, but also people are dying because of this bad epidemic. Texas medicine realizes that, and we're trying to do anything and everything in our power to … try to prevent these diversions and get them help that they definitely need."
Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.
Pain Management Education From TMA
Ethics and Regulation of Pain Management, a TMA PDF publication and course, helps physicians bridge the ambiguity between underprescribing and overprescribing pain medications. After completing the course, physicians should be able to:
- Recognize that pain is a complex clinical issue, and undertreatment and overtreatment of pain are significant problems;
- Discuss the ethical challenges involved in adequately treating pain patients while minimizing the risk of substance use disorders and diversion;
- Identify the difference between substance use disorders and physiological dependence;
- List comprehensive, ethical, and appropriate pain management strategies; and
- Document appropriately when managing patients with chronic pain.
Check the PDMP, Earn MIPS Credit
Participating in PMP Aware, Texas’ prescription drug monitoring program (PDMP), can help you earn credit for Medicare’s new Quality Payment Program. Under the Merit-based Incentive Payment System (MIPS), physicians can receive credit for the Improvement Activities performance category for PDMP-related activities, including:
- Annual registration in the PDMP — must register and participate for a minimum of six months; and
- Consultation of the PDMP — consulting the PDMP prior to the issuance of a Schedule II opioid prescription lasting longer than three days (60 percent for first year or 75 percent for second year).
Learn more about the Improvement Activities performance category for MIPS.
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