Sunday, October 9, 2016

If not, What is the Point?

California leaped to the forefront on Physician Drug Monitoring Database (PDMD) recently. Florida has had a PDMP for a bit longer, passing it in 2009, which we refer to as the Physician Drug Monitoring Program or "PDMP," The PDMP is Showing Progress. We call Florida's E-Forcse (Electronic Florida Online Reporting Controlled Substance Evaluation Program). I have written about it before, EForcse and Kasper, Cousins with a Cause

The purpose of databases is to monitor the volume of medication that a given patient receives (or has access to). There is a concern that certain patients obtain more medication than is necessary or appropriate. Generally, the concern is not with Ibuprofen, or statins, or insulin. It is focused on medications that can be dangerous in quantity (overdose) or for which there is a demand for resale on the street (diversion). In the great opioid expansion that pharmaceutical companies drove in the 1990s and 2000s, availability of, addiction to, and death from opioids exploded in America. Billions were made, and people died. 

With Florida and other states implementing the monitoring databases, the hope was to decrease the potential for overdose or diversion with medications. Any physician can easily know how much medication she or he personally is prescribing to a patient. The database allowed the physician to also know how much other doctors were simultaneously prescribing to the same patient. Information, as they say, is power. 

The real point, from some perspectives is the death rate from opioids, which was outlined in New CDC Report on Opioids in 2014. That was complimentary of Florida, Kentucky, an others. But as I noted, "despite the improvements, there is likely more that can be done. The New York and Tennessee requirements for providers to check the PDMP are perhaps the most encouraging." Both of those states demonstrated marked improvement, which was somewhat attributed to their requirement that physicians check the PDMP database before prescribing medication. Though Florida has a database, and is accumulating volumes of prescription data, there is no requirement for a physician to check it before prescribing. 

California followed, enacting a PDMP in 2011. It was given bit more memorable name, "CURES." This stands for Controlled Substance Utilization Review and Evaluation System (which would actually be CSURES, but who wants to quibble?) But California is in the news recently for taking the next step as New York and Tennessee already had. In California, WorkCompCentral recently reported the Governor Mandates PDMP. In California, starting in 2017, physicians will have to check the database before prescribing. After all, If it's Worth Having, Is it Worth Checking

So, the California legislature in 2016 legislatively required "providers to check the database before prescribing a Schedule II, III or IV drugs." This will include "most opioids except codeine- and hydrocodone-based cough suppressants." The requirement appears to be a compromise. It applies only when the physician is prescribing "to a patient for the first time." In the world of medication abuse, overdose, and diversion it might seem that the multiple prescription scenario could surface later. So, the law requires the physician to check CSURES every 4 months if these scheduled drugs remain in the patient's treatment regimen. So, "ehcck," then "check again," because things can change. 

But, California has gone even further. If a physician consults CSURES and finds the patient is already prescribed "Schedule II or III substances," the law now precludes that physician from prescribing "additional controlled substances until determining there is a legitimate medical need." That is curious language perhaps. Does it mean that the initial decision to prescribe the opioid was made without determining "legitimate medical need?" Will we be concerned with legitimacy only when there is an existing prescription discovered?

Some would argue this is merely word games. They would urge an interpretation that the "need" analysis in this scenario is specific to the "need" for multiple prescriptions. But, history has taught us that there are doctors to whom the Hippocratic oath is simply meaningless. They practice with a singular focus on how much money can be generated from people's pain and misery. And some are going to prison for it recently. 

Recent news showed one doctor jailed for prescribing painkillers to 250 patients daily. Yes, that is potentially over 57,000 patients annually. Another traded painkillers for cash and sex, and is responsible for people dying. And though some are receiving significant punishment, others seem to be receiving minimal sentences, including a doctor recently sentenced in West Virginia, a leader in overdose death. 

The Opioid overdose problem is not over. Overdose is still the leading cause of accidental death in the United States, with "47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014," according to the American Society of Addiction Medicine

The new California approach is reportedly "hailed" by the insurance community, and praised by prescription providers. One physician interviewed by WorkCompCentral said that these requirements will slow down the prescription process, requiring some introspection and caution, and thus he opines the new CSURES requirement is "something of a 'speed bump.'” 

Why do physicians prescribe pain medication? That is a bigger issue. I have written about pain and how it can be addressed. Removing opioids from the marketplace is a laudable goal in terms of the overdose and diversion issues, but pain is real. Therefore, as we focus on decreasing access to opioids, the injury and illness market must also focus on how pain can be addressed effectively, and safely. The solution is not to ignore pain or to tell patients to do so. There are injuries and conditions for which "walk it off" is simply not a solution. 

But, there is a perception that some abuse pain medication. There is also a perception in today's age of advertisement and information that there are patients who visit doctors with specific requests for mediation and other modalities. In open markets, there is a fear expressed by some doctors that they will lose patients, and therefore revenue, if they do not comply with these patient requests or demands. Some believe that this scenario plays with opioids, with patients pressuring physicians for such prescriptions. 

There are those who feel that the CSURES solution will provide physicians with a validation of saying no to a patient's request. The conclusion that this provides doctors with a "'defensive tool' when they have a patient who is pushing for an opioid," expressed by WorkCompCentral provides a sad commentary on medicine generally. It would be preferable that a doctor would do the right thing for a patient, and would deny superfluous or redundant opioid prescriptions because of the dangers and lack of necessity. But, for those who lack fortitude and honor, perhaps a "defensive tool" is required?

The California requirement is not seen as perfect, with most opposition coming from oncologists. But, the law includes exemptions from the CSURES consultation requirement. For example emergency room doctors who are dealing with urgency can focus on treatment and not check CSURES. And, prescriptions for a five-day, non-refillable, script are also not covered by the law. And, finally, the requirements do not apply to the humanitarian work of hospice programs. 

According to WorkCompCentral, California now joins "32 other states that require doctors to check drug-monitoring databases when prescribing certain controlled substance." It notes the success of this requirement in New York, Arizona, Kentucky, Tennessee and more. Forty-nine states (Missouri) require the collection of prescription data. As many as thirty-two states require physicians to consult the database before prescribing medication. But, the Pew Institute says that 16 states have this requirement.


Courtesy, Pew Institute

Florida does not require physicians to consult the database though. In recent years, some have estimated that as many as 90% of Florida physicians ignore the database. The national trend seems to be towards mandatory checking, and perhaps that is the only way to get Florida doctors to utilize this tool. The national trend seems to be towards preventing death and destruction at the hands of prescription drugs. Hopefully Florida will follow the lead of these other states and move towards a mandatory consultation. Clearly it is working elsewhere, but there is a great distance yet to go with 47,000 people dying each year?

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