For Rhode Islanders between 15 and 44 years old, the leading cause of death is accidental drug overdose, usually involving prescription painkillers. State health leaders are calling it an epidemic. There’s growing evidence that tracking the number of pills doctors prescribe to potential abusers might ease the problem. But Rhode Island’s fledgling prescription drug monitoring program is just getting started.
The dark side of opiates
Dr. Jody Rich is an infectious disease specialist at The Miriam Hospital in Providence. He sees a lot of patients with HIV and hepatitis C. Many also struggle with addiction to opiates – painkillers like Oxycontin and Percocet. Before heading into his clinic, Rich takes a moment in his office, piled high with papers and folders, to explain why.
“Now when somebody uses opiates regularly, even in a matter of a few weeks, they can start to develop tolerance,” says Rich, “which means they need a higher dose to get the same effect, and the withdrawal phenomenon.”
He says he hears this story all the time. Someone gets injured. A doctor prescribes some painkillers. The pills work. In fact, they work really well. At first.
“They like the feeling. And then pretty soon they notice they need more and more. They start buying them from other people, or searching through medicine cabinets. And then they realize if they stop, they start going into withdrawal. Now, I’ve talked to many people about what withdrawal feels like, and you can imagine your worst flu you ever had, the most miserable you ever had, it’s 10 times worse than that.”
He says that in the throes of addiction, people will do almost anything to get more pills. And that can be pretty easy. If one doctor stops refilling a prescription, addicts might shop around for one who will, or several.
Until recently, it would have been pretty tough to detect. But now, most states now have some kind of online database where doctors can look up all of a patient’s prescriptions in one place. Rhode Island’s prescription monitoring program went live last October. But so far, the Department of Health says only about 15% of physicians and other prescribers are registered to use it. And Jodi Rich is one of them.
Demonstrating the PMP
“I’m going to start a new request…"
In the time it takes me to tell you that Rich has turned to his computer, pulled up a web site, and logged in, he’s demonstrated how the prescription monitoring program works.
“…so I need the patient’s name…and date of birth. And I look up…and it takes that long to create a history. …. and bingo. This gives the patient’s name and every opiate prescription they’ve had for whatever time I request.”
Rich says it’s easy to use, and useful. Just the other day, he says, he discovered a patient who was filling opiate prescriptions from more than one doctor – and most likely abusing the drug. Rich might confront the patient. But whether that patient will acknowledge the problem and get treatment is hard to say. If he doesn’t, the patient could end up a statistic.
“We have four to six people dying every week in this state of opiate overdose,” says Rich. “It’s really, it’s in epidemic proportions.”
Tom Clark is a researcher with the Prescription Drug Monitoring Program Center for Excellence at Brandeis University.
“There is some preliminary evidence that prescription monitoring programs are helping to reduce overdose deaths.
He says researchers need a lot more data to draw solid conclusions. But he thinks these programs are playing another important role:
“…first of all, it’s the only way we can really track the problem in terms of doctor shopping. It’s the only way we can track prescribing patterns of prescribers.”
State health officials should be able to investigate doctors who prescribe inappropriately. But doctors should be able to look up what other providers are prescribing their patients, Clark says. That’s where a prescription monitoring program comes in.
“It can alert doctors to possible addiction and abuse of controlled substances,” says Clark.
But to be most effective, Clark says the program should have some basic functionality.
“You want good accurate data. You want the data to be analyzed proactively such that the information you get is timely, and then you output that information to users that need to see that information,” Clark says.
But the problem is that not every doctor who prescribes opiates uses a prescription monitoring program. And not every program analyzes data proactively, looking for troubling patterns in the data. Clark says programs in some states like Kentucky and Oklahoma are ahead of the curve, sending out automatic reports to doctors when they spot possible trouble. But then again, Clark says, you have to get doctors to use the program.
“And the way to do that of course, you have to go out and pitch it to doctors, you have to make it known,” Clark says. “That takes a good deal of work, it takes manpower, and it’s time consuming.”
A work in progress
So: good, timely data; automatic reports; lots of doctors on board: those are the best practices, according to Clark and fellow researchers at Brandeis. Rhode Island’s program isn’t measuring up to those standards yet, although it’s not even a year old. Rhode Island’s Board of Pharmacy chief Catherine Cordy says doctors can at least look up a patient’s prescriptions if they decide to.
“They are able to notify us if there’s a patient they have some concern about. They can set up an alert or a notification to the Department of Health and we would follow through on that,” says Cordy. “At this point, there is nothing proactively we do to assist practitioners with individual patients who may be of concern.”
She says the department of health would like the system to be able to analyze the data proactively for troubling patterns and send unsolicited reports to doctors. It would be great, she says, if it could scan for patients who receive opiate prescriptions from five or more doctors, and who frequent several pharmacies. But that will take funding and human resources. So will integrating prescription monitoring programs with other medical records, says health department head Michael Fine.
“There’s always the hope of bringing the entire electronic environment together in a way that simplifies workflow for physicians and other providers,” says Fine, “because we have created an environment that causes more work and more stress on practitioners because of the complexity of the electronic environment.”
Rethinking the way we manage pain
Fine says physicians and other health care professionals who prescribe drugs are beginning to feel more at home in that electronic environment. And he and other department of health officials have been meeting with doctors and community members to try to increase awareness about the prescription monitoring program. But he says curbing drug abuse will take more than electronics. The way doctors manage their patients’ pain has to change.
“Part of the reason we get into this pickle is, primary care physicians, when asked to help with somebody’s chronic pain, have relatively few alternatives open to them, and want to take care of the human being.”
Alternative therapies like acupuncture or physical therapy might help, over time. But opiates work well, and they work fast. And Fine says doctors want satisfied patients.
“About 15 years ago, we widely adopted an approach that said pain was a vital sign,” says Fine. “And physicians were judged, emergency rooms and hospitals were judged on the extent to which people’s pain had been well-addressed.”
So opiate prescriptions have soared. But not every doctor understands how to prescribe them safely.
Doctors feel bullied, lack training
Jim McDonald heads Rhode Island’s Board of Medical Licensure and Discipline. He’s the one doctors find themselves in front of if they’re investigated for misconduct – say, allowing a patient too many pills at a time, or refilling prescriptions too frequently.
“When you ask how do doctors get to a place where they get in trouble, they get there very slowly. And I find they drift there. And the majority of them, when I sit down with them representing the medical board, recognize this got out of control.
But there’s something else you might not realize is happening:
“Quite frankly, something I think might surprise folks is that doctors feel bullied, or feel pressured by patients.”
Or, McDonald says, they’re swayed by a patient’s pleading.
“And they often don’t know that a patient might be pulling one over on them,” says McDonald. “That’s where something like a prescription monitoring program can be very helpful. But if you find something aberrant behavior-wise, you have to deal with it then and there, right in the office.”
The limits of a PMP
But not every doctor has been trained in how to deal with addiction, or how to confront patients. They might have access to a patient’s prescription history through the monitoring program, but that doesn’t mean they know what to do with it. And that’s one thing infectious disease and addiction specialist Dr. Jody Rich worries about.
“One concern of this is that a clinician will find out that somebody has been using opiates prescribed from another physician, and get upset with that patient and accuse them of lying and being deceitful,” says Rich. “And it would lead to an erosion of the physician-patient relationship. Namely, ‘you lied to me, I’m not going to be your doctor anymore.’ Unfortunately, that’s part of the disease of addiction.”
A prescription monitoring program can alert a doctor that a patient is doctor shopping. It can help a doctor decide to cut a patient off. But it can’t necessarily solve the problem. An addict might turn to buying pills on the street, stealing them, or switch to heroin – which gives a similar high. But proponents of prescription monitoring programs say that at least they provide some basic data, and a starting place for having those conversations with patients who might be in trouble.
Officials in charge of Rhode Island’s program say their next steps are to try to get more doctors to use it. And they’re hopeful new legislation will lead to tracking even more classes of addictive drugs.