States require opioid prescribers to check for 'doctor shopping'

This article originally appeared in Stateline, an initiative of the Pew Charitable Trusts.

For more than a decade, doctors, dentists and nurse practitioners have liberally prescribed opioid painkillers despite mounting evidence that people were becoming addicted and overdosing on the powerful pain medications.  

Now, in the face of a drug overdose epidemic that killed more than 28,000 people in 2014, a handful of states are insisting that health professionals do a little research before they write another prescription for highly addictive drugs like Percocet, Vicodin and OxyContin.

“We in the health care profession had a lot of years to police ourselves and clean this up, and we didn’t do it,” Kentucky physician Greg Jones, an anti-addiction specialist, said in an online training course he gives doctors in his state. “So the public got fed up with people dying from prescription drug abuse and they got together and they passed some laws and put some rules in place.”

By tapping into a database of opioid painkillers and other federally controlled substances dispensed in the state, physicians can check patients’ opioid medication history, as well as their use of other combinations of potentially harmful drugs, such as sedatives and muscle relaxants, to determine whether they are at risk of addiction or overdose death.

Prescribers also can determine whether patients are already receiving painkillers or other controlled substances from other sources, a practice known as doctor shopping. Patients with this type of history are at high risk for addiction and overdose and may be selling drugs illicitly.

In 2012, Kentucky became the first state to require doctors and other prescribers to search patients’ prescription drug histories on an electronic database called a prescription drug monitoring program (PDMP) before prescribing opioid painkillers, sedatives or other potentially harmful and addictive drugs.

Sixteen states have enacted similar laws, and experts, including the U.S. Centers for Disease Control and Prevention and the White House Office of National Drug Control Policy, are encouraging other states to do the same thing. 

Maryland Gov. Larry Hogan, a Republican, signed a law in April that requires certain prescribers to use the state’s monitoring system, and a similar bill is moving through the Legislature in California.

Prescribers can be required to check PDMP databases in 29 states, depending on conditions that vary from state to state, according to the National Alliance for Model State Drug Laws.

Although the American Medical Association supports physician use of drug tracking systems to identify potential addiction and drug diversion to the black market, state medical societies have argued against mandatory requirements they say interfere with the practice of medicine. Patients’ privacy and legitimate pain needs, they say, could be jeopardized by requiring busy physicians to investigate potential patient abuse of pain medications.

Despite these objections from some in the medical profession, more states are imposing the requirements. “Comprehensive mandates are the single most effective thing states have done to curb opioid prescribing, and it seems to have an almost instantaneous effect,” said John Eadie, who has evaluated state programs at Brandeis University’s Prescription Drug Monitoring Program Center of Excellence in Massachusetts.

In states where physicians are required to use monitoring systems, overall opioid prescribing has plummeted, as have drug-related hospitalizations and overdose deaths, Eadie said. States also are seeing a rise in addiction treatment as more doctors refer patients to treatment after discovering they are taking painkillers from multiple sources and are likely addicted to them.

In Kentucky, hydrocodone (Vicodin) prescribing dropped 13 percent, oxycodone (Percocet) dropped 12 percent, oxymorphone (Opana) dropped 36 percent and tramadol (Ultram) dropped 12 percent between 2012 and 2013, the first year the law was implemented, according to an analysis by the University of Kentucky’s College of Pharmacy.

Since the law was passed, overdose hospitalizations declined 26 percent, and prescription opioid deaths dropped 25 percent, the first reduction in nearly a decade, according to a March 2016 report by Shatterproof, a national advocacy organization that promotes prevention and treatment of drug addiction.

In another effort to stem overprescribing of opioid painkillers, which is widely blamed for the current epidemic, the CDC in March took the unprecedented step of issuing national opioid prescribing guidelines. Along with patient education, urine drug testing and abuse-deterrent formulations of pain pills, the federal agency recommended prescribers check prescription databases before prescribing to reduce the risk of opioid overdose and addiction.

Vastly underused

Prescription drug monitoring systems have existed in paper form since the 1930s, and every state except Missouri has some type of system. But the rules governing who has access, how quickly pharmacies must enter dispensing data, and which medications are included vary widely from state to state. 

(The creation of a prescription drug monitoring system in Missouri has been blocked by a small group of legislators, led by state Sen. Rob Schaaf, a Republican and a doctor, who argue that allowing the government to keep prescription records violates patient privacy rights. In March, the opioid-plagued county of St. Louis adopted an ordinance to create a monitoring system, and advocates and some lawmakers continue to press for a statewide program.)

In general, state databases have been used effectively by law enforcement to track down so-called pill mills, where doctors indiscriminately prescribe opioid medications for cash. And a substantial number of pharmacists have consulted them before filling a prescription. But a relatively small percentage of medical professionals are signing on to the systems to detect patients who are at risk for addiction or overdose.

In most states, health care professionals who prescribe at least one controlled medication are encouraged to use PDMPs, but only on a voluntary basis. As a result, the typical state program in 2012 had only 35 percent of doctors signed up for access, according to the center at Brandeis. In 2014, 53 percent of doctors were signed up to one of the programs, according to a survey by Lainie Rutkow, an associate professor of public health at Johns Hopkins.

Most states require prescribers to obtain access to PDMPs and use them at their discretion when they suspect a patient is at high risk for addiction, drug diversion or overdose, according to the National Alliance for Model State Drug Laws.

The problem with that, said Van Ingram, Kentucky’s director of drug control policy, is “people think doctors can just look at a patient and recognize this disease of addiction, and it’s not that simple.”

“People with addictions can fool their spouses, their children and their employers. They can definitely conceal the disease from their physician in a 15-minute visit.”

A diagnostic tool

In Kentucky, doctors and some patients complained about the requirement when it was first adopted, Ingram said. But these days, he said, he mostly hears doctors saying, “Wow, I treated that patient for 20 years and had no idea he had a drug problem.

“If there’s a tool out there that takes 15 seconds to use and can diagnose a disease, why wouldn’t you want to use it? To me it’s a no brainer,” Ingram said.

Before Kentucky physicians were required to check the database, patients commonly visited multiple doctors to get prescriptions for opioid painkillers, the sedative Xanax, and the muscle relaxant Soma, according to the state’s PDMP director, David Hopkins. “The cocktail,” as it’s known in Kentucky, produces a high that is similar to heroin and just as deadly. It has become much less prevalent since the law was enacted.

“We cracked down on that big time,” Hopkins said. The number of people receiving the cocktail has dropped 30 percent since the law took effect and the number of doctor shoppers has dropped 52 percent, he said.

Kentucky is also trying to curtail dangerously high doses of prescribed painkillers by flagging the database when a patient is taking medications from multiple sources that add up to the equivalent of 100 milligrams or more of morphine per day. Last year, a calculator was added to the system so doctors wouldn’t have to add up the morphine equivalents on their own.

Hopkins said the state listened to doctors’ complaints and added some commonsense exceptions after the initial rules came out. Prescribers are no longer required to check the database in emergencies or for patients in hospice, long-term care or cancer treatment. They can also skip the step if a patient was originally prescribed a pain medication by a fellow doctor in their practice and needs a refill or a different pain medicine.

Kentucky’s prescriber rules, which were developed by the state Board of Medical Licensure, allow doctors to appoint a delegate to access the drug monitoring system and review patients’ drug profiles. Doctors typically ask their assistants to run prescription drug histories on all the patients they will see the next day and add the information to their electronic medical records, said Michael Rodman, director of Kentucky’s licensure board.

If a potential drug problem is detected, prescribers can query the database to determine how other physicians in the state are addressing the pain needs of similar patients, and they can discuss an individual patient’s drug history with another prescriber, something that was forbidden under previous state privacy laws.

Another part of Kentucky’s 2012 opioid law requires prescribers to attend a certain number of free training sessions each year on addiction, pain management and use of the state’s prescription monitoring system. (Jones conducts some of those training programs.)

To increase the effectiveness of drug monitoring programs, Kentucky and other states use reciprocal agreements to allow interstate sharing of drug dispensing information for pharmacists, law enforcement and physicians in nearby states. Kentucky has agreements with at least 20 other states. New Jersey Gov. Chris Christie, a Republican, announced in April that New York had joined his state in sharing PDMP information, along with Connecticut, Delaware, Minnesota, Rhode Island, South Carolina and Virginia.

As for what happens when a physician discovers a patient is doctor shopping, Rodman said, they often dismiss patients and no longer treat them.

But Jones, who heads the Kentucky Physicians Health Foundation, which supports doctors who suffer from substance use disorders, tells doctors not to do that to patients.

“Maybe you don’t keep prescribing them 90 OxyContins with five refills,” he said, “but don’t throw them out. If you do, you’re missing an important opportunity to save a life.”