For more than a decade, doctors, dentists and nurse practitioners liberally prescribed opioid painkillers even as evidence mounted that people were becoming addicted and overdosing on the powerful and addictive pain medications.
“We in the health-care profession had a lot of years to police ourselves and clean this up, and we didn’t do it,” Greg Jones, an addiction specialist, says in an online training course he gives fellow doctors in his home state of Kentucky. “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 prescriptions for opioid painkillers and other federally controlled substances, physicians in Kentucky can check patients’ use of opioids and of 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 “doctor shopping” — receiving painkillers or other controlled substances from several sources at once. Such patients 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 and other addictive drugs.
Sixteen states — including, as of last month, Maryland — have enacted similar laws, and national experts, including the Centers for Disease Control and Prevention and the White House Office of National Drug Control Policy, are encouraging others to do the same.
The American Medical Association supports physician use of drug-tracking systems to identify potential addiction and the diversion of drugs into the black market. But some state medical societies have argued against mandatory measures that they say interfere with the practice of medicine. Patients' privacy and need to ease pain, they say, could be jeopardized by requiring physicians to investigate potential abuse of pain medications.
Despite such objections, 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 probably 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, the CDC in March issued national opioid prescribing guidelines. The guidelines are not compulsory, but CDC recommendations are influential. Along with patient education, the testing of urine samples to detect drug abuse and the use of opioids formulated to deter abuse, the federal agency recommended that prescribers check prescription databases to reduce the risk of overdose and addiction.
Monitoring systems for prescription drugs have existed 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.
A diagnostic tool
In Kentucky, doctors and some patients complained about the requirement when it was adopted, said Van Ingram, Kentucky’s director of drug control policy. 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.”
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 David Hopkins, director of the database. “The cocktail” of these three drugs, 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.
The number of people receiving the components of the cocktail has dropped 30 percent since the law took effect, Hopkins said, and the number of doctor shoppers has dropped 52 percent.
Kentucky’s rules, which were developed by the state Board of Medical Licensure, allow doctors to have a delegate 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 for physicians.
If a potential 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.
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 12 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 physicians discover people who are obtaining drugs from multiple doctors, Rodman said, they often dismiss the patients and no longer treat them.
But Jones, who heads the Kentucky Physicians Health Foundation, which supports doctors with 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.”