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.