When the state of Kentucky decided two years ago to require doctors to check their patients’ drug-taking histories before writing new narcotic prescriptions, some physicians were adamantly opposed.
The doctors said mandatory checks would cause them to waste valuable time and money running checks on patients with legitimate pain and anxiety problems. They said they didn’t need an online database to help them spot “doctor-shoppers” who might be obtaining prescriptions from more than one doctor.
Then, a funny thing happened.
During the first 12 months after Kentucky’s mandatory checks took effect, the volume of prescriptions began falling. Hydrocodone, down 10 percent. Oxycodone, down 12 percent. Alprazolam (Xanax), down 13 percent. All narcotics, down 9 percent.
“It’s the first drop that we’ve seen since our program was initiated in 1999,” said Dave Hopkins, administrator of the Kentucky All Schedule Prescription Electronic Reporting program. “I can tell you right now, we’ve definitely seen a reduction in doctor-shoppers.”
As Oklahoma lawmakers prepare to debate a similar proposal here, Kentucky may offer the best example of the potential impact.
Oklahoma, like Kentucky, has one of the nation’s highest rates of prescription drug abuse and overdose deaths. Last year, Oklahoma pharmacies filled nearly 10 million prescriptions for hydrocodone, oxycodone, alprazolam and other controlled dangerous substances. The previous year, 534 Oklahomans died from overdoses of prescription drugs. At least half were taking pills prescribed by their own doctors.
For years, Oklahoma doctors and their lobbyists at the Capitol have fought off proposals to require them to check the state’s online Prescription Monitoring Program before writing narcotic prescriptions. Like their counterparts in Kentucky two years ago, they argued that mandatory checks would be costly, expensive and, in most cases, unnecessary.
That might be about to change. Gov. Mary Fallin and like-minded lawmakers have been pushing to enact mandatory check legislation this year. Under a tentative deal negotiated in recent days, doctor groups have agreed to accept mandatory checks at least for the most frequently abused narcotics.
Experts familiar with the experiences of Kentucky and other states with mandatory PMP checks say it might be the single most effective strategy for curtailing prescription drug abuse.
“The mandate seems to have the biggest effect of any of the practices that we’ve seen,” said Peter Kreiner, principal investigator for the Brandeis University PDMP Center of Excellence in Waltham, Mass.
Kreiner cited studies showing that emergency room physicians who rely on their intuition tend to misjudge how many of their patients have histories of doctor-shopping activity.
“In a large proportion of cases, the physicians are wrong,” Kreiner said. “Their perceptions are not all that accurate.”
Kentucky, whose prescription drug scourge has been showcased in the television series “Justified,” was the first state to require all doctors to check an online database before writing new or refill prescriptions for Schedule II narcotics such as oxycodone and Schedule III narcotics containing hydrocodone.
Not only has Kentucky seen a significant decline in prescribing volumes since, it might be about to witness the first decline in overdose deaths in more than a decade. Although 2013 overdose data is still being tallied, Hopkins said it appears last year’s death toll might fall below the record 1,031 logged in 2012.
Other reforms contributed to the improvements, Hopkins said. Kentucky took steps to shut down high-volume “pill-mill” clinics not owned by doctors and provide more training to physicians on addiction and pain management. But mandatory checks appear to be the biggest single factor, he said.
Meanwhile, some doctors who initially opposed the requirement have changed their minds, said Stephanie Hold, director of the inspector general’s office of the Kentucky Cabinet for Health and Family Services.
“We’ve heard from some of the physicians who might have initially been reluctant to do this, but after they actually looked at some of their patients, they were shocked. They were unaware of their patients seeing other doctors,” Hold said. “They are now firm believers.”
RISING USE OF PAINKILLERS
The volume of often-abused hydrocodone and oxycodone painkillers dispensed by Oklahoma pharmacies has climbed by 51 percent and 77 percent, respectively, since 2008.
Source: Oklahoma Bureau of Narcotics and Dangerous Drugs
Kentucky’s experience appears to be corroborated by other early adopters of mandatory prescription history checks, according to data compiled by Brandeis University and Oklahoma Watch:
- Tennessee began requiring doctors to check its prescription database in April 2013. The number of opiate painkiller prescriptions fell to 1.5 million in July 2013, down 7 percent from a year earlier. The number of doctor-shoppers —people who obtained prescriptions from five or more doctors and filled them at five or more pharmacies — plunged 36 percent.
- New York started requiring doctors to check its online registry in August 2013. The number of patient queries soon jumped to an average of 42,000 per day, compared to 11,000 per month before the checks became mandatory. Hydrdocodone prescriptions during the fourth quarter of 2013 were down 20 percent from a year earlier; all opiate painkillers declined 10 percent. The number of doctor-shoppers plummeted 75 percent.
- Ohio’s medical licensing boards began mandating online checks by their members in late 2011. The number of doctor queries jumped from 911,000 in 2010 to 7.3 million in 2013. Later this year, the state will begin sending all Ohio doctors a summary of their narcotic prescribing history and a tally of possible doctor-shoppers on their patient rosters.
- Oklahoma imposed mandatory PMP checks in November 2010 for one drug, methadone. The volume of methadone dispensed by state pharmacies declined by 18 percent, from 8.2 million dosage units in 2009 to 6.7 million in 2013. The number of methadone-related overdose deaths declined from 106 in 2010 to 83 in 2012.
DECLINE IN METHADONE
The amount of methadone prescribed in Oklahoma began falling after passage of a state law requiring doctors to check the Prescription Monitoring Program before writing methadone scrips. Other factors, including growing national awareness of the drug's toxicity, contributed to the decline.
Source: Oklahoma Bureau of Narcotics and Dangerous Drugs
So far, Kentucky, Tennessee and New York are the only states that have enacted comprehensive legislation to require doctors to check online databases before prescribing the most commonly abused narcotics. Ohio didn’t impose a uniform state mandate. But in 2011, it directed its licensing boards to set their own standards, which they have done.
Twelve other states, including Oklahoma, have imposed more limited requirements for online checks. In Oklahoma’s case, it applies only to methadone, which causes more than its share of overdose deaths because of its tendency to reach toxic levels in patients who take too much of it or combine it with other painkillers.
Oklahoma’s Prescription Monitoring Program was launched in 1991. It was the nation’s first computerized registry of narcotic prescriptions. The system has been expanded and improved over the years and is still considered one of the best in the country.
But it’s only effective if doctors use it, and many don’t.
Last year, Oklahoma pharmacies filled 9.6 million prescriptions for controlled dangerous substances, according to data from the Bureau of Narcotics and Dangerous Drugs. That’s a total of 595 million dosage units, enough to supply every adult and child in the state with 156 pills, patches or injections.
Pharmacists are required to log every narcotic prescription they fill within five minutes of dispensing the drug.
Prescribers — including doctors, osteopaths, physician assistants and advanced practice nurses — can check the PMP to review their patients’ drug histories before writing or refilling narcotic prescriptions. It takes a minute or two to do so.
Last year, however, prescribers ran only 1.5 million patient queries, or roughly one for every six prescriptions filled. Even allowing for the fact that one PMP check might involve more than one prescription, it is clear that Oklahoma doctors are not using the system routinely.
That could change if the Legislature enacts SB 1820, which is being rewritten to include mandatory PMP checks for commonly abused narcotics such as oxycodone and hydrocodone. If it clears a conference committee, the compromise proposal will will go the Senate and House floors for final votes sometime in May.
Ken King, executive director of the Oklahoma State Medical Association, said association officials had not examined the effects of mandatory PMP checks in states that have put them into effect.
“I heard that Kentucky was one of the first to adopt one, but we haven’t looked at those states,” he said.
King confirmed that the association is close to a final agreement with the governor’s office and key lawmakers on required PMP checks that would cover at least the most commonly abused drugs.
The full roster of controlled dangerous substances includes dozens of drugs that are not highly addictive and rarely pose overdose risks, such as hormone supplements. King said it would make sense to exclude those from the mandatory check roster.
Oklahoma doctors also want to ensure that any new legislation authorizes physician staff members to run PMP checks, he said. Existing law does not explicitly do so.
In addition, the association wants enforcement of the PMP check requirements to be shifted from the state narcotics bureau to the medical licensing boards that already oversee doctors’ professional practices.
But even if they prove helpful, PMP checks will only address one of several factors contributing to Oklahoma’s overdose crisis, he said.
“Prescribing is certainly part of the issue and something we need to look at,” King said. “But I don’t want this to lull people into a false sense of security that we’ve found some kind of silver bullet to address prescription drug abuse.”