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Big Brother Is Watching You (Sort Of)

February 17, 2012

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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Curbing Prescription Addiction

April 21, 2011

It should come as no surprise to anyone that prescription drug abuse is a serious problem.  As if we needed any reminder, a flurry of articles recently hit the press, showing just how serious the problem is.  Opioids (narcotic pain medications like Vicodin, Oxycontin, methadone, etc) are the most widely prescribed drugs in America, according to IMS and to a recent survey by the National Institute on Drug Abuse (NIDA), and prescriptions can lead to misuse, abuse, and dependence.

Predictably, the government plans to get involved.  As the New York Times reported earlier this week, the Obama administration wants to create legislation “requiring doctors to undergo training” before being permitted to prescribe opioid pain meds.

Hearing “government” and “training” in the same sentence doesn’t exactly inspire confidence.  What will the “training” consist of?   An online seminar?  A paper-and-pencil exam from the DEA?  A separate section on “managing pain patients” in our Board Certification exams?

[And didn’t we do this already?  As a matter of fact, yes, we did:  Back in 2000, JCAHO (the “Joint Commission” which accredits healthcare organizations) required doctors to undergo training to recognize and treat pain disorders.  Back then, we were told that we weren’t treating pain often enough.  Maybe the pendulum has swung too far in the other direction?  Maybe we’ve done our job too well?]

With respect to the prevention of opioid abuse, I agree it’s a good idea for doctors to recognize the warning signs of addiction, to implement monitoring procedures (like random urine tests and treatment contracts), to deny early refills, and to inquire about other risk factors for abuse.  Sadly, many doctors don’t take these measures and need encouragement to do so.  But something tells me that simply providing government-mandated “prescriber education” won’t fix the problem.

In my opinion, there are two other important issues to be addressed before this “training” will prove to be useful.

The first is to get rid of existing inefficiencies.  The truth is, most doctors already know the proper steps for prescribing potentially abusable opioids to pain patients.  Some clinics (particularly pain clinics) follow these steps with all patients, simply as a matter of course.  But in most treatment settings these steps are difficult to take.  Regular urine monitoring is cumbersome and intrusive (although relatively inexpensive); generating a treatment contract takes time (although it’s arguably the most important “paperwork” of the appointment); and reviewing a patient’s full medication history is a challenge.  Moreover, most of our non-patient-care resources and personnel are devoted to billing and data entry, rather than in these ancillary services that, in the long run, are far more important to cost-effective patient care.

[A side note: many states provide a “prescription drug monitoring” service to permit doctors to view prescriptions for controlled substances that any patient has filled in that state.  However—at least in California—the application process takes 3-6 months, the data are typically delayed about 2-3 months, it does not include non-controlled drugs, and not all pharmacies participate.  It still blows my mind that for the last 10-15 years it has been easier to purchase airplane tickets online or to send computer files halfway around the globe than to determine whether the patient sitting in my office has filled a prescription for OxyContin in the last 90 days.  Simply improving the existing technology would be the most immediately beneficial step.]

The second—and, in my opinion, more important—item is for doctors to understand what is the goal of treatment.  Not just “relief of pain,” but when (if at all) can the treatment be said to be complete?  I’ve written about this before (see “When Does Treatment End?”), and I’m convinced it’s an important question not just in the treatment of pain but in the management of all conditions, even those we consider “chronic.”  I believe that all prescribers need to ask themselves, “How long will the patient need this medication?” and engage the patient in this discussion, too.

I frequently see patients who have been prescribed opioid pain medications, or benzodiazepines or stimulants (not to mention SSRIs or other psychiatric meds), who have no idea how long they’ll need to take them.  They just “got a script.”  And because these medications are highly reinforcing (they relieve pain or anxiety, and sometimes have a pleasant psychoactive effect as well), they’ll continue to ask for more.  Why shouldn’t they, since they were never told they should stop?

In any treatment setting, the patient and doctor should have a mutual understanding of the goals and likely duration of treatment.  This plan can (and should) be flexible, but it should always have some realistic end point.  Moreover, we should always measure our progress relative to that goal, rather than “kicking the can down the road” and letting someone else deal with the discontinuation of care later.  I don’t think doctors should be in the business of denying care to patients, but if we’ve already had the discussion of when treatment might end, the issue of “no” has already been raised, and the patient understands this.

How would this minimize the abuse of addictive medication?  For one thing, it would limit access to the drug because we, a priori, are refusing to provide an endless supply.  In turn, this helps the patient recognize that everything is being prescribed for a particular purpose, whether for the transient relief of post-op pain or the longer-term management of cancer pain.  If and when other symptoms emerge, they need to be discussed and treated separately—or a more comprehensive treatment plan should be developed, if the evolving symptoms fit a characteristic pattern.

I know this is a tall order, and these suggestions may be hard to implement in many of the places where narcotic prescribing is common (ERs, urgent care clinics, etc).  But they are important measures to take.  We need to take the steps we know we should take (rather than wait for the government to tell us to do so—because we know how that will turn out).  And we need to think about patients as people with the power to heal, and plan for the healing process to take place, rather than give knee-jerk reactions (i.e., prescriptions) for symptoms.  If we do this, patients will be less likely to take matters into their own hands and “self-medicate,” and the outcome of treatment will be better for all.


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