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Big Brother Is Watching You (Sort Of)

I practice in California, which, like most (but not all) states has a service by which I can review my patients’ controlled-substance prescriptions.  “Controlled” substances are those drugs with a high potential for abuse, such as narcotic pain meds (e.g., Vicodin, Norco, OxyContin) or benzodiazepines (e.g., Xanax, Valium, Klonopin).  The thinking is that if we can follow patients who use high amounts of these drugs, we can prevent substance abuse or the illicit sale of these medications on the street or black market.

Unfortunately, California’s program may be on the chopping block.  Due to budget constraints, Governor Jerry Brown is threatening to close the Bureau of Narcotic Enforcement (BNE), the agency which tracks pharmacy data.  At present, the program is being supported by grant money—which could run out at any time—and there’s only one full-time staff member managing it.  Thus, while other states (even Florida, despite the opposition of Governor Rick Scott) are scrambling to implement programs like this one, it’s a travesty that we in California might lose ours.

Physicians (and the DEA) argue that these programs are valuable for detecting “doctor shoppers”—i.e., those who go from office to office trying to obtain Rx’es for powerful opioids with street value or addictive potential.  Some have even argued that there should be a nationwide database, which could help us identify people involved in interstate drug-smuggling rings like the famous “OxyContin Express” between rural Appalachia and Florida.

But I would say that the drug-monitoring programs should be preserved for an entirely different reason: namely, that they help to improve patient care.  I frequently check the prescription histories of my patients.  I’m not “playing detective,” seeking to bust a patient who might be abusing or selling their pills.  Rather, I do it to get a more accurate picture of a patient’s recent history.  Patients may come to me, for example, with complaints of anxiety while the database shows they’re already taking large amounts of Xanax or Ativan, occasionally from multiple providers.  Similarly, I might see high doses of pain medications, which (if prescribed & taken legitimately) cues me in to the possibility that pain management may be an important aspect of treating their psychiatric concerns, or vice versa.

I see no reason whatsoever that this system couldn’t be extended to non-controlled medications.  In fact, it’s just a logical extension of what’s already possible.  Most of my patients don’t recognize that I can call every single pharmacy in town and ask for a list of all their medications.  All I need is the patient’s name and birthdate.  Of course, there’s no way in the world I would do this, because I don’t have enough time to call every pharmacy in town.  So instead, I rely largely on what the patient tells me.  But sometimes there’s a huge discrepancy between what patients say they’re taking and what the pharmacy actually dispenses, owing to confusion, forgetfulness, language barriers, or deliberate obfuscation.

So why don’t we have a centralized, comprehensive database of patient med lists?

Some would argue it’s a matter of privacy.  Patients might not want to disclose that they’re taking Viagra or Propecia or an STD treatment (or methadone—for some reasons patients frequently omit that opioid).  But that argument doesn’t hold much water, because in practice, as I wrote above, I could, in theory, call every pharmacy in one’s town (or state) and find that out.

Another argument is that it would be too complicated to gather data from multiple pharmacies and correlate medication lists with patient names.  I don’t buy this argument either.  Consider “data mining.”  This widespread practice allows pharmaceutical companies to get incredibly detailed descriptions of all medications prescribed by each licensed doctor.  The key difference here, of course, is that the data are linked to doctors, not to patients, so patient privacy is not a concern.  (The privacy of patients is sacred, that of doctors, not so much; the Supreme Court even said so.)  Nevertheless, when my Latuda representative knows exactly how much Abilify, Seroquel, and Zyprexa I’ve prescribed in the last 6 months, and knows more about my practice than I do (unless I’ve decided to opt out of this system), then a comprehensive database is clearly feasible.

Finally, some would argue that a database would be far too expensive, given the costs of collecting data, hiring people to manage it, etc.  Maybe if it’s run by government bureaucrats, yes, but I believe this argument is out of touch with the times.  Why can’t we find some out-of-work Silicon Valley engineers, give them a small grant, and ask them to build a database that would collect info from pharmacy chains across the state, along with patient names & birthdates, which could be searched through an online portal by any verified physician?  And set it up so that it’s updated in real time.  Maintenance would probably require just a few people, tops.

Not only does such a proposal sound eminently doable, it actually sounds like it might be easy (and maybe even fun) to create.  If a group of code warriors & college dropouts can set up microblogging platforms, social networking sites, and online payment sites, fueled by nothing more than enthusiasm and Mountain Dew, then a statewide prescription database could be a piece of cake.

Alas, there are just too many hurdles to overcome.  Although it may seem easy to an IT professional, and may seem like just plain good medicine to a doc like me, history has a way of showing that what makes the best sense just doesn’t happen (especially when government agencies are involved).  Until this changes, I’ll keep bothering my local pharmacists by phone to get the information that would be nice to have at my fingertips already.

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11 Responses to Big Brother Is Watching You (Sort Of)

  1. yep, the reason is people (especially men in power with mistresses) don’t want their Viagra and STD scripts known to the cops — but those scummy drug addicts aren’t people like us so we can monitor them.

  2. aek says:

    Are all dispensed medications on this database, Steve? Are any dispensing pharmacies not included (VA, perhaps)? I think it could enhance or replace the medication reconciliation procedures and enhance coordination of care. To me, it’s attractive to use on the patient’s presentation to an ED, urgent care, clinic, office visit, nursing home, rehab and home care. It would allow duplicate/conflicting meds to be identified across all drug classes. The only additional info you would need is the patient’s self report of OTCs, supplements and non FDA regulated substances. Helping patients use a reliable website such as Drugs.com to enter those and bring print outs for you could be an adjunct to care.

    Underlying your post seems to be a default view that patients are devious and that drug tracking is done to find illicit use. But I see this as a basic safety feature. Patients and prescribers all get confused over drug names and indications. For example, I took Zanaflex for an acute back injury and reported it to another provider during an appointment. I actually used the generic name, tizanidine, but because he didn’t recognize it, I then gave him the brand name. It was transcribed by several nurses and physicians as Xanaflex, Xanax, and Valium (!?!) – all documenting during that visit (I won’t say what academic medical center that was because it could be any of them).

    Patients don’t – and can’t know – all of the various brand names, generic names, derivations and variations. A drug database that could list both the dispensed drugs and known drug-drug and drug-food interactions, would be an incredible boon to physicians and patients.

    The caveat I would have about using this is twofold: one that it be completely separate from the prying eyes of third party payers and marketers. (ha! fantasy)

    The other is that it wouldn’t be used as a tool to punish patients. Discrepancies in and of themselves are not evidence of malfeasance, noncompliance or patient shenanigans.

    • stevebMD says:

      aek,

      I agree with everything you write. And thanks for emphasizing that the main purpose would not be to identify “devious” patients, because even honest patients and competent providers can get their medications confused.

      However, your last two paragraphs summarize why this idea will never be implemented. Information could (and would) be used against patients, in the form of higher premiums or refusal of coverage for certain procedures, and it would only be a matter of time before pharmacies or drug companies started targeting patients on insulin, for example, with advertisements for glucose meters, cookbooks, and new diabetes medications. And yes, as you point out, docs may use this information against patients, too, instead of recognizing that the discrepancies may simply be a result of human error.

      • Jackie says:

        I’m a wee bit confused about your and aek’s concerns about third-party payers, e.g. insurance companies, Medicare, Medicaid, etc.

        Don’t these entities already have complete drug information on most people (those of us trying to get legitimate healthcare, not those trying to stockpile drugs), given that most policies and programs come with prescription drug coverage now?

      • stevebMD says:

        Not necessarily. If I prescribe a medication to you, you’re not obligated to use your prescription drug coverage to pay for it, so the insurance won’t “know” that you take it. (Of course, this is not the case for the VA or Kaiser, where everything’s done in-house.)

        This is something that I think we should take advantage of more frequently. Patients are probably happier to pay $4.00 out of pocket for a prescription from the Walmart or Target low-price generics list, than to wait for my office to obtain prior authorization from the insurance company simply because their nonsensical formulary covers generic Prozac but not generic Celexa. (And even then, the patient might be asked to pay a $10 or $30 copay!) In fact, it can be relatively inexpensive (except for doctors’ cash fees) to get routine psychiatric care completely “under the radar” of your insurance company.

  3. Jackie says:

    “Most of my patients don’t recognize that I can call every single pharmacy in town and ask for a list of all their medications. All I need is the patient’s name and birthdate.”

    How does the pharmacy know that the patient in question actually is your patient -or, indeed, anyone’s patient? What’s to stop a doctor going on a fishing expedition to dig up information on a neighbor, an accountant, a love interest, rival, etc.? Do the pharmacies even check that you’re a doctor at all before revealing this information?

    I think that doctors should have to obtain informed consent before being able to call pharmacies like this for (non-controlled substances) medication lists. I think it’s particularly important that the medical and pharmaceutical records of those who have sought psychiatric care not be open to any doctor (or anyone playing a doctor) who calls Walgreens.

    It seems strange to me that this isn’t covered in HIPAA or some other law.

    • stevebMD says:

      Jackie,

      Excellent points, all of which I’ve questioned myself. While I agree with you that only a patient’s health care provider should be authorized to view his/her record, I’m not sure how I feel about requiring informed consent. As I wrote above, sometimes the information I get from other sources is invaluable for the psychiatric care of my patients.

      The “doctor impersonation” issue is something no one ever talks about, and is ripe for abuse. As you accurately point out, anyone can call Walgreens, say they’re “Doctor Smith” and ask for the medication records of their spouse, lover, coworker, etc. Similarly, if you know my license # and DEA # (both of which are printed on any prescription I write, or can be found with just a few minutes of sleuthing online) you can call up Walgreens, pretend to be me, and order yourself a prescription for an antibiotic, an antidepressant, or (in some cases) a benzodiazepine. And I’ll never know about it. [By the way, this is illegal. I am NOT condoning this action here, just pointing out how easy it is.]

  4. Deer raiding the bird feeder says:

    All of this stuff makes me terribly sorry that I ever sought psychiatric care. Soon, I will not be able to “pass for normal” with various cover stories. I already got the “she’s an axe murderer” reactions when I married into another family, and it took my husband’s children a few months before they felt it was safe to leave their children around me, even when my husband was right there. I can see that in a few years, I will be getting that reaction from many more, once it gets out in my small town. Mentally ill people (not talking depression and anxiety disorders here) will be more and more isolated over time. All that has to happen is a small mistake – a social worker leaves her laptop on a chair at the cafe, or some jerk hacks the data and puts it on the internet for all to see. All these mistaken Bipolar II diagnoses, which hopefully you will write about this, make people think that all people with bipolar are horrible people. The stigma seems worse now for serious mental disorders than it was 20 years ago.

    • Mara says:

      😦 Sorry you’ve faced so much stigma. I wish that some people would not be labeled with a mental illness and could instead be labeled as assholes. You’re right. Some of these people aren’t very mentally ill…they’re just messed up people who were given a BD II diagnosis or some other thing.

      I remember hearing Robert Downey Jr. saying that the rumors of his bipolar disorder are false. He was diagnosed with bipolar disorder, but the doctors who thought that diagnosed him when he was still addicted to cocaine. He didn’t feel you could reasonably judge whether a person is bipolar or not if they are high on cocaine, so he does not give their diagnosis any credibility. Doctors may be getting diagnosis happy.

  5. Anonymouus says:

    You better believe! There is course “Good and Evil” and many times, I thank goodness, Walgreens is the only place my prescriptions are handled. Yes, my pricey, full coverage insurance, keeps trying to mail “animal drugs” at a cheaper price to my home…?, but sometimes, psych drugs are a little more specific to your mental disorder and are not on the veterinarian chart for sheep. Because they have everything for my family, they can see drug interactions that MDs may no know.

    I appreciate that I keep my MD informed of everything I take and what I can not take, and that the nice lady at Walgreen’s always takes more time than MDs to inform me. So be careful what you ask for unless you need a boatload of oxycontin.

  6. minder says:

    Well, I’m both a clinician and a programmer with expertise in web database systems.

    1) So lets say someone such as me builds such a thing, and we put all our Rx eggs in this one technological basket.

    Who owns the basket?

    All sorts of implications and ramifications follow from that. I mean, if you could go back in time and determine who got to define all mental illnesses for most of the Western world, would your choice have been a committee of the APA? We are at exactly that choice point with electronic medical records. We’d better pick very deliberately and carefully who gets to own the basket, because we’re going to be stuck with whatever we choose for a really long time.

    2) You say that because you are entitled to request certain information by phone, that therefore there is no privacy issue with collecting that data into a database that can be accessed by any “verified” doctor (or person who has a verified doctor’s login, but I digress.) That is false. That is like saying because you are entitled to know your patients’ names, it’s not a privacy issue for you to write patients’ names on the outside of their (paper) charts: the privacy issue resides in how you propose to dispose of the data, not in whether you get to have it in the first place.

    In this case, putting information which previously was only available via phone call that would return only a single patient’s prescriptions, into a vast collection with many other people’s data, exposes that data to a whole new classes of risks: (1) It becomes a tantalizing target for compromise and theft, in the same way online retailers’ databases of credit card numbers are targets — it’s barely economically viable for most crooks to steal CC numbers one by one, but if they can make off with a few million at one go, the ROI is much more attractive to them. (2) There are whole new classes of computer bugs to which such as system is heir; for instance, while a pharmacy tech answering the phone won’t accidentally read you dozens of other patients’ records, over-returning due to insufficient delimitation of a query is a highly plausible and common bug in databases. Indeed, the fact that a system might be induced to express such a bug is itself a vector of criminal attack (the “injection” attacks).

    (If like many non-programmers, you are thinking, “well, yes, but those are *bugs*, they’re *accidents*, we don’t mean to have them there and would work to remove them, an in any event they’re probably rare, I commend to you the “RISKS Digest” archive.)

    It may surprise you to lear that I’m a strong supporter of the idea of a centralized databases for psychiatric prescriptions for reasons that have to do with continuity of care. But I think it’s perfectly reasonable for any informed consumer of MH services to blanche at the prospect. This has the possibility of going hideously wrong; this has privacy ramifications which they are wise to be concerned about.

    There are some very hard problems — most of them social and political and policy — which would need to be solved if this weren’t to be instituted in some way(s) which were enormously detrimental. We have to take these risks seriously, and address them directly — and be prepared to refuse to proceed unless and until they can be addressed adequately.

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