The woman who showed up in the emergency room of Boston Medical Center with a life-threatening apparent overdose of painkillers was contrite. She promised to follow a plan to ease her pain with medications that did not contain opioids, the principal ingredient of prescription drugs including oxycodone and fentanyl whose vast increase in use has led to an epidemic of overdoses.
Then she went across town and got another doctor to prescribe them anyway.
This kind of “doctor-shopping” by patients addicted to opioids is one of the primary reasons drug overdoses have become the leading cause of injury death in the Unites States. There were nearly 17,000 fatal overdoses of pain medications in 2011, the last year for which the figure is available, according to the Centers for Disease Control—more than from heroin and cocaine combined, and triple the number in 1990.
Yet 12 years after the launch of a federal program that encouraged states to share information about patients’ prescription histories, there remains no single national database to thwart doctor-shopping. Meanwhile, the various prescription drug monitoring programs in separate states follow a patchwork of different rules—including whether or not doctors are even required to check them before prescribing opioids to patients.
The safety net is even patchier for veterans, whose rates of opioid overdose are double the national average. The Veterans Administration medical system, the nation’s largest hospital network, serving nearly nine million people, only last year agreed to report its patients’ prescription histories to state registries or check prescriptions from outside providers. But the process is voluntary; VA doctors are not required to follow any of the safeguards.
“If you don’t use the system, you’re not going to detect misuse,” says Melissa Weimer, an assistant professor of medicine at Oregon Health and Science University and medical director at the substance-abuse treatment center CODA Inc.
Weimer is an advocate of sharing prescription information across state lines through so-called prescription drug monitoring programs, known as PDMPs. Many states have adopted PDMPs in the last few years in response to the overdose crisis and now every state except Missouri have or plan to develop a monitoring program. But the rules differ widely.
In many cases, registration by doctors is voluntary. Even among states that require doctors to sign-up and use the PDMPs, only a handful mandate that they check the prescription histories of every patient. Efforts to make that mandatory have largely failed after opposition from medical groups. In Oklahoma, which has the nation’s fifth-highest drug overdose mortality rate, a state House bill to require that doctors check the registry was defeated in late May after medical associations said it would be burdensome and legislators called it regulatory overreach.
“As soon as you start talking about databases and tracking people and tracking prescribers, there’s pushback,” says Daniel Alford, director of the Safe and Competent Opioid Prescribing Education program at the Boston University School of Medicine, who treated that woman in the emergency room. He says doctors ask themselves, “‘Do I want the feds monitoring my prescribing patterns?’”
The paperwork doctors are required to file under the current laws doesn’t have to be submitted by providers in most states for as long as seven days, and often takes another week or two to show up in the prescription monitoring system.
“If you’re an ER physician, that’s not going to do you any good if the patient you’re seeing has just been to another emergency room that day, getting more of the same drugs,” says Heather Gray, legislative attorney for the National Alliance for Model State Drug Laws, a federally-funded nonprofit research organization.
Then there is human error. Misspelled names or missing middle initials can make patients disappear in the shared databases.
“It starts to frustrate you to the point where you question whether you want to invest time in looking at this as opposed to doing other things,” says Alford.
But the biggest drawback is that many of the PDMPs don’t talk to each other, meaning that a doctor in Georgia, for example, may not know that a patient seeking a prescription for oxycodone received a similar one in Oklahoma the week before.
“It’s a huge problem that I don’t have access to data from doctors and pharmacies in other states,” says Joanna Starrels, an assistant professor at Albert Einstein College of Medicine and Montefiore Medical Center. Starrels published research in the Journal of General Internal Medicine showing that doctors are often lax in monitoring potentially addictive opioids. It's a pressing concern: her own practice in the New York City borough of the Bronx is within easy reach of New Jersey and Connecticut.
Tired of waiting for a national prescription database, groups of states and a pharmacists’ association have created three of their own. But not all states are members, those that are don’t always border one another, and each PDMP works differently.
That’s because each state has different rules about what information is collected, how it’s organized, and who can see it. In some states, for example, law-enforcement agencies can have access to prescription information in cases that they’re actively investigating, while in others, such as Vermont, they need to get subpoenas.
The vast increase in the number of opioid overdoses, and its cost—estimated by the Centers for Disease Control at about $56 billion in healthcare and law-enforcement expenses and lost productivity—has started to create momentum for improvement.
Several states have tightened the rules about reporting prescriptions, including shortening the deadlines for doing it, and making registration by doctors mandatory.
The governors of five of the six New England states are collaborating on a regional interstate PMDP to foil doctor-shopping. (The sixth, Republican Paul LePage of Maine, has said he’d rather use law enforcement to confront the problem.)
And under a pilot project in Ohio, physicians can now check their patients’ prescription histories not just in their own state, but in neighboring Illinois and Indiana.
A new proposal, by the Prescription Drug Monitoring Program Center of Excellence at Brandeis University, calls for also making prescription histories available to medical insurers, including prescriptions they now can’t see—the ones obtained outside of patients’ health plans for potentially unscrupulous purposes. This is likely to provoke privacy concerns, especially as states differ on whether sharing prescription information violates the federal Health Insurance Portability and Accountability Act (HIPAA), which protects patient records. Wisconsin, for example, has determined that healthcare providers can disclose prescription information without the patient's consent if required by state law, while California says it cannot be divulged to anyone other than prescribers unless part of a criminal investigation. Oregon, meanwhile, requires that patients be informed about the process.
All of this potential for confusion is one reason that for many doctors on the front lines, the most effective measure would be a national registry.
“There should be one database that all providers report to,” Starrels says. “I understand there are privacy concerns with that, but you could get around some of those by allowing access to certain data only to local prescribers, or perhaps requiring patients’ permission. But if I’m seeing a patient who just moved here from California and reports being prescribed oxycontin for the past three years, I should be able to check that.”
Even if such a system existed, however, “and was miraculous and worked without any problems, and all the states talked to each other, it still wouldn’t solve the problem,” Weimer says. “Maybe you would detect the most egregious doctor-shoppers, which would be great, but then you’d have a lot of doctors who don’t know what to do with the information, or a lack of access to addiction services, or persistent pain that isn’t treated.”
On top of that, says Peter Kreiner, principal investigator at the Brandeis center, people who become dependent on opioids have proven extraordinarily resourceful.
“As some of the smarter people doing this behavior realize what’s being implemented,” Kreiner says, “they’d probably come up with new ways around it.”