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Keeping painkillers from addicts
Pharmacists and providers start using prescription monitoring program

06/11/15
By Ryan Lessard news@hippopress.com



A program meant to help prescribers and pharmacists synchronize care and identify so-called doctor shoppers — addicts getting painkillers from multiple providers — has been operating since last fall. Experts say it’s working well, but tracking statewide numbers for doctor shopping will be a trickier affair.

 
Bumps in the road
David Strang is an emergency room doctor at Franklin Regional Hospital and the chair of the Prescription Monitoring Advisory Council. He says barring a few technical difficulties, virtually all pharmacists are up and running with software that allows them to upload their dispensing data on a regular basis. But getting providers — which can include doctors, physician's assistants, and other medical practitioners with the ability to prescribe — registered has been a different story.
“Right now, we're dealing with a lot of people who waited until the last minute to get this done,” Strang said.
He said the state's roughly 5,000 providers need to register in the PMP system by June 30 or risk losing their licenses. However, though they are required to register, current state law does not mandate that prescribers actually use the program before writing a prescription. So a doctor at a pain clinic could conceivably prescribe oxycodone to a patient without even checking the patient’s past prescribing patterns. 
If a provider demonstrates a pattern of writing prescriptions when they should know better, the offending prescriber's licensing board could enforce corrective action or revoke their license. But Strang said defining the threshold for offense and subsequent penalties are up to the individual boards.
“We’ve got to get as many people as we can to the program and get them utilizing it for a period of time, and then we can do some comparison studies and say, 'Yeah, it's working' or 'It's not being utilized as much as we'd like it to be,'” Strang said.
 
Data restrictions
But those studies won’t shed light on how much doctor shopping is being reduced statewide.
That’s because, unlike the tracking system for pseudoephedrine, which is meant to help catch meth cooks, the PMP is not primarily for law enforcement.
“If I see a patient in the emergency room and they're insisting that they need a narcotic or an opiate ... for their whatever pain, and I go to check their prescription profile in the [PMP] and I see a lot of emergency room visits, a number of different doctors in a very short period of time for the same opiate medication, that's going to make me very concerned,” Strang said.
He said he would have a conversation with the patient and try to direct them to addiction treatment services and would not prescribe the drug. Similarly, pharmacists seeing the same info would likely not dispense the drug.
What this means, however, is the system is not designed to automatically detect or flag potential doctor shoppers. Nor are providers expected to track these individuals. So aggregate data on doctor shopping may be difficult to obtain.
Since law enforcement isn’t being notified and the system doesn't track doctor shopping automatically, it will be difficult to accurately measure how well the program is working at curbing the number of addicts abusing the system. But Strang says there may be a few tools available to shed light on the big picture.
“There is the ability to run reports to see how many different providers different patients are using and [if] that decreased over time,” Strang said. “You can even run a report saying 'How many patients in the state are using more than five providers in a month for controlled substances? What's the rate after a year and a half?' So that would be a metric that we could use to [measure effectiveness].”
Ultimately, Strang believes data will reveal the opiate addiction problem is bigger than anyone expected.
“Having some figures that identify the size and scope of the problem would be very helpful,” Strang said.
 
What’s working
Besides a relative lack of information, Strang says the system has been working as it's supposed to.
“I think it's going very well,” he said.
When the program launched last October, pharmacists had already uploaded six months’ worth of past data. They’re currently uploading ongoing data on a weekly basis.
Each suspicious case is handled individually by providers, and law enforcement may not ever get involved.
That's just fine for pharmacists like Tom Wilmot, the co-owner of Granite State Pharmacy in Concord. He said he was nervous the PMP would mean more unfunded work for him and his peers, but Wilmot is particularly glad all the weekly uploads are automatic.
“It's just for us to use with our own professional judgment,” Wilmot said. “The government said it was here to help us and, in this case, it looks like it's true.”
He said his pharmacy has not encountered any doctor shoppers so far.
“That was a nice surprise,” Wilmot said. “You don't know until you know. We lucked out that all the patients we were dealing with were playing the way they were supposed to.”
Wilmot suspects most doctor shoppers avoid small, independent pharmacies like his in order to remain anonymous.
If Wilmot were to encounter a doctor shopper in the future, he said he's free to use his discretion.
“They gave us no instructions,” Wilmot said. “Personally, if I came across something, it would change whether I was going to dispense the medicine or not.”
That’s a good sign, according to Strang.
“This is what the PMP is designed to do, is to alert practitioners that they may be duplicating the work and prescription habits of another prescriber that they otherwise would not be aware of,” Strang said.
 
Going forward
When New Hampshire became the 49th state to adopt a prescription monitoring program through 2012 legislation, it did so with the statutory prohibition on taxpayer dollars going toward the program. A year later, it was awarded a $400,000 grant from the federal Bureau of Justice Assistance, and it officially launched last October.
How to fund the program in the long term is still an open question. The initial $400,000 grant is set to expire next spring. A new grant application for $500,000 for 18 months was just submitted to the BJA. 
The New Hampshire PMP will soon link to the PMPs of neighboring states. Strang and others on the advisory council hope New Hampshire will eventually be linked to even more states, like Florida, where Granite Staters frequently vacation or migrate in the winter. 
 
As seen in the June 11, 2015 issue of the Hippo.





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