New prescription monitoring draws complaints
Beginning Wednesday, pharmacists, doctors and other prescribers will be able to see all controlled-substance drugs that individual patients are getting through prescriptions anywhere in the state. But already, the state's new Prescription Monitoring Program, an effort to cut down overdoses and deaths from prescription drugs, is running into trouble, mostly about who pays for it.
Seattle Times health reporter
Understanding the new Prescription Monitoring Program
Who can access patients' prescription records?
• Any prescriber or dispenser holding a Drug Enforcement Administration license, including pharmacists, physicians, physician assistants, osteopathic physicians, osteopathic physician assistants, naturopaths, podiatric physicians, dentists, nurse practitioners, optometrists and veterinarians.
• In addition, "authorized practitioners" of the Department of Social and Health Services and the Health Care Authority regarding Medicaid program recipients, the director or designee of the Department of Labor and Industries regarding workers' compensation claimants, and the director or designee of the Department of Corrections.
What medications will the state database include? All controlled substances on the state's controlled-substances list from Schedules II through V.
The program's website: doh.wa.gov/hsqa/PMP/default.htm
Since October, pharmacies around the state have been sending information into a giant computer database, detailing every prescription they've dispensed for controlled substances. That means every pain pill and patch, every anti-anxiety medication, every sleeping pill — listed by the patient's name.
Beginning Wednesday, pharmacists, doctors and other prescribers will be able to see all such drugs a patient is getting anywhere in the state, even if the person pays with cash.
The state's new Prescription Monitoring Program (PMP) will list all the doctors prescribing the pills and will even spit out a color-coded map showing every place the patient got drugs.
The program, created by the Legislature in 2007 but only recently funded by the U.S. Department of Justice, is a response to troubling numbers of overdoses and deaths from prescription drugs.
Proponents say it will enable doctors, as well as officials from state programs that pay for health care such as Medicaid and workers' compensation, to spotlight patients who are "doctor shopping" to get multiple pain-drug prescriptions, and also help cut down on accidental overdoses.
Not even out of the gate, the program is running into trouble.
It's not that doctors and pharmacists hate it — on the contrary, many lobbied for such a program and supported the 2007 bill. But they were assured, with a provision in the law, that they wouldn't have to pay for it.
Now, the Department of Justice has warned the state not to expect ongoing funding. So state health officials came to lawmakers last month to ask them to rescind the provision banning provider fees — and ran into a hailstorm of opposition.
One after another, pharmacists, physicians, osteopathic physicians and dentists, among others, lined up on the "con" side. At first glance, the opposition, like the fees, doesn't seem noteworthy.
The program is estimated to cost $530,000 per year, Department of Health Secretary Mary Selecky told lawmakers. More than 52,000 dispensers and prescribers would pay those costs — in other words, yearly fees of $11 to $15.
Such a program depends on the wholehearted support of providers, who are not required to access the information. Don't they see enough value in it to pay the paltry fees?
At the heart of such seeming truculence, some believe, is an identity crisis that has engulfed prescription-monitoring programs here and around the country from the start.
With origins in law enforcement, PMPs are caught in a "tug of war," often seen as a tool of police rather than an important component of patient safety, laments Dr. Gregory Terman, a University of Washington pain specialist.
Many programs, like Washington's, are primarily funded by law enforcement. National news and local discussions often contain references to "pill mills" and "catching doctor shoppers," Terman notes.
Several states originally barred health providers from accessing the database, and at least one still does.
In Oregon, it took 10 years to pass a similar program, in part because of concerns that patients with mental-health or substance-abuse issues would end up in jail rather than in treatment programs, said Lisa Millet, who oversees the program.
For these programs to work, says Millet, doctors and other providers must be engaged. "If health-care providers who need the system don't support it, it probably won't be useful to them," she says. "This thing needs to be owned by the people who use it."
Access to data
In Washington, officials from the state's workers' compensation program, Medicaid, the Department of Corrections and the Department of Social and Health Services can access the information. So can police and prosecutors in a specific investigation.
Unlike programs in some states, such as Oregon, Washington's allows licensing boards to use the information to discipline doctors.
To the extent that the PMP is a drug-enforcement tool, Terman says, it will alienate not only patients but doctors, who are wary about being associated with a police effort, and worry about becoming targets themselves.
Terman predicts a relatively small percentage of prescribers will use it, in part "because doctors see PMP as thinly veiled cops looking over their shoulder," he says. "That makes me sad."
Terman, who fervently supports the program, has no doubt it's needed. A recent case in point: A patient taking pain medication had outpatient surgery. She went home, doing well, and restarted her regular medications. Including those the surgeon prescribed for pain and nausea, nine drugs had been prescribed by different doctors.
"She did not survive the night," Terman said. Because the list she'd helped compile before the surgery wasn't complete, "nobody knew all the medicines she was on."
Whether well-intentioned or abuse, fragmented prescribing is dangerous for patients, he says. "There needs to be interaction between providers to make medical care safe."
But at every meeting about funding the state program, he recalls, everyone says, "This is a great idea, this is a great idea. ... We're not paying for it."
At one meeting, someone proposed that only those who use the PMP to check a patient should have to pay. "I said we should only charge people who don't care about their patients enough to look at it," Terman retorted.
Julie Akers, a pharmacist who testified at the recent hearing, supports the program. But pharmacists, who are required to enter data, do that without reimbursement. Some must pay for data entry, she says, so for the state to tack on more expense "just doesn't make sense."
For Akers and others, an important question is whether the program will work. Prescribers, they note, aren't required to use the system.
A 2007 study of Maine's Prescription Drug Monitoring Program found it helped identify "doctor shopping" patients and didn't appear to inhibit prescribing for legitimate patients.
But a national study by a Centers for Disease Control and Prevention researcher last year found PMPs, over six years, didn't cut deaths, overdoses or consumption.
In fact, the programs may have resulted in patients simply getting more of the less-potent painkillers.
The researchers found that states with PMPs had significantly higher rates of use for hydrocodone, often prescribed as Vicodin, considered by the Drug Enforcement Administration to have relatively less abuse and dependence potential.
When the original bill for Washington's PMP was proposed, opposition centered on worries that it would hurt patients with cancer or terminal illnesses.
Will pharmacists or prescribers who spot a patient with a problem follow through? "I've never received any information on where to refer them or information to give them," Akers said.
Caleb Banta-Green, a research scientist at the UW's Alcohol and Drug Abuse Institute, fears that patients denied opiates, without effective intervention, might try to delay withdrawal by getting drugs on the street. "Use could escalate in an unpredictable way," he warns.
Chris Baumgartner, director of Washington's PMP, says the program has just completed a question-answer guide for providers to help them in the event they discover a problem with a patient.
Currently, grants fund the program until mid-2013, and a bill to lift a ban on license surcharges likely will come up again this session.
Early test drive
In the meantime, the PMP will be open for business, along with Washington's new law seeking to rein in larger doses of prescription pain medication.
Some providers, such as Dr. Daniel Brzusek, a Bellevue osteopathic physician and rehabilitation specialist, are enthusiastic about the monitoring program and ready to use it to help patients.
Brzusek, one of about 40 providers invited to test-drive the system, has already found it useful, spotting one patient's increasing doses of painkillers from another doctor. With a few taps on the keyboard, Brzusek could see how the patient had filled prescriptions at multiple pharmacies, violating an agreement with the clinic.
The program also provides a quick, easy way for him to help protect patients who don't realize they shouldn't combine "the little blue pill" with the white one, or that they're double-dosing on a medication, taking both the generic and the brand name.
"Most people don't purposely overuse medications — they just don't know any better," says Brzusek.
Brzusek, who has been treating patients in pain for many years, says the information will help him do what he needs to do to keep a patient safe: Talk to their other doctors, talk to the patient. Have drug-treatment programs on speed dial, and make sure they'll bill patients on a sliding scale.
"It's about education, rather than saying 'gotcha!' " he says. "We find this is a real great patient-safety tool — not for catching the bad guys."
Carol M. Ostrom: 206-464-2249 or email@example.com. On Twitter @costrom.
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