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Back in May, a doctor proposed in The Hill that we need either easy inter-operability between the state run prescription drug databases (a doctor can look up what a person has already been prescribed; this is the current solution for some combination of drug shoppers and/or people who are about to have catastrophic negative drug interactions) or a national database.

http://thehill.com/blogs/congress-blog/healthcare/241243-a-national-prescription-drug-database-to-combat-opioid

One of the known problems with state prescription drug databases is they cause doctors to notice that the person in front of them already _has_ multiple opioid pain medication prescriptions. And then they don't want to write another one. You might think, but wait! That's a good thing.

Alas, the person then goes and buys heroin instead, because just refusing more does nothing to deal with the already present physical dependency.

The Boston Globe's Stat has an article which depicts this in some detail (altho it isn't presented that way).

http://www.statnews.com/2015/12/14/opioid-crisis-fueled-prescriptions-family-doctors-internists/

It's mostly, feel sorry for the poor doc who has to say no to the Person In Pain. Yes, they are in pain. That is not in doubt. Once you have a physical dependency to opioids, a primary symptom is ... pain.

The CDC has released some guidelines for providers prescribing for pain. Alas, they are attempting to reduce the new cases, rather than attempting to deal with the existing dependency problem. And the new guidelines are getting a lot of pushback from cancer groups and pain management people.

I can't help but feel that if a doctor can look at a person's records in a state prescription drug database and go, oh, look: they already have a bunch of scrip and are here looking for more and I am the doc-in-a-box, well, why can't we surf through that database and spot the people with the incipient need for Narcan? Perhaps we could send a visiting nurse or visiting social worker over to their house and start funneling them into an appropriate program (I'm sure the appropriate program is going to be highly situationally dependent, but some of these people might well have a much better life expectancy with something as straightforward as 3 days in a physical detox program followed by some outpatient cognitive therapy).

This would be a _screen_ not "practicing medicine", but of course we would want the appropriate, credentialed folk in charge. But if even this is thinking too far ahead for the privacy concerned, then shouldn't we be teaching the doctors who are saying, No I'm Not Giving You More You Have Too Much Already how to direct the drug shopper to a place to get help with the physical dependency? Otherwise, this is just gonna fuel the heroin problem.

ETA: Were you wondering which state does NOT have a PDMP? Yeah, so were we. Missouri. I don't know what you were expecting, but this is not what I was expecting.

http://www.pdmpexcellence.org/sites/all/pdfs/Use%20of%20PDMP%20data%20by%20opioid%20treatment%20programs.pdf

Neat article about how PDMPs are being used by substance abuse programs, and ideas for making things better. Goals include avoiding diversion of drugs and making sure that the person you are giving methadone to in the clinic isn't _also_ taking, oh, I dunno, benzos or Vicodin.

Excellent quotes:

"Now that patients know at admission that their prescription data will be checked, there are few instances in which such checks reveal prescriptions not disclosed to the OTP staff."

"Failure to find the prescribed medication in the patient’s urine drug screen is cause for followup."

The idea there, of course, is that if you have a prescription for opioids that you are NOT taking, then you are maybe selling them on the side, or helping someone else who is, and the treatment center would like to learn more about which it is.

"This Wilmington, Delaware OTP began reviewing patient prescription histories in 2013, a practice that the medical director described as “eye-opening.”"

Wow. I mean, I _get_ it. PDMP + regular drug testing means we _finally_ can actually figure out what is going on. We can do the "verify" part of "trust but verify". But just, wow. The most recent drug statistics, that I posted yesterday were from 2014, and it was only in _2013_ that some of these treatment programs had access to this data. We aren't going to know for a while just how much of a difference PDMPs can make in identifying who needs help and then effectively delivering that help.

It looks like there's some informal monitoring going on in some pharmacies as well.

"One correspondent praised pharmacist use of the PDMP in assisting buprenorphine (or OBOT) providers. Dispensers will sometimes alert a provider
should they discover prescriptions for controlled substances coming from multiple prescribers, or that might be contraindicated given a patient’s status in MAT."

Again, that is the kind of thing we could automate.

ETA: Virginia's program as of 2011:

https://www.dhp.virginia.gov/dhp_programs/pmp/docs/PMP_Instructions_NewVersion11-2011.pdf

There's a slide near the end with pointers to neighboring states' programs.

ETA: More from Brandeis. This is a history of prescription monitoring, going back to paper systems.

http://www.pdmpassist.org/pdf/PPTs/LE2012/1_Giglio_HistoryofPDMPs.pdf

The New York State system was the first, in 1918, and tracked morphine, heroin and cocaine. Pharmacies were to copy to the state within 24 hours of dispensing.

On the depressing side, there's a strong indication here that just tracking shit ain't gonna get it done. OTOH, their goals were apparently somewhat different than ours. Their focus was on diversion, rather than addicts shopping for easy doctors.

Anyone thinking they are going to beat this kind of tracking using privacy as an argument is up against Roe v. Whalen. The basis was 10th amendment police powers. That is a tough one to fight.

https://en.wikipedia.org/wiki/Whalen_v._Roe

That case is way more recent than I thought it would be.

ETA: LA Times coverage of budget reversal on CURES, the California system, which when Brown came back he gutted. It is run by narcotics enforcement and funding was restored with the idea of tracking "bad docs".

http://articles.latimes.com/2013/jan/11/local/la-me-0111-rx-cures-20130111

I feel like it would be nice to enumerate the possible goals for these databases and then design some evaluations for whether those goals are reasonable. Then we can take attainable goals and have a national convo about which of those goals, if any, we want to pursue. Because right now, it looks like we've just been collecting data and ... hoping?

The Massachusetts program is run by the Department of Public Health. I feel like this is a _much_ better place to run it from, than law enforcement. Law enforcement has a tendency to squish one problem (prescription drug abuse) and cause another (now everyone goes and buys heroin on the dl). Public Health people are slower to act, but somewhat more likely to think about the consequences.

Virginia's program launched statewide in 2006:

http://www.namsdl.org/library/2FBB8C28-1C23-D4F9-74C8077AE90F20F0/

Collection is 2x a month. Seems typical (if lame).

Massachusetts program launched statewide in 2011. Shocking, right? There's a 2-3 delay in info showing up so that implies similar batching.

http://www.bizjournals.com/boston/blog/health-care/2014/08/physician-group-critiques-several-changes-to.html

That article indicates resistance to adding benzos. Apparently there were some concerns about the resiliency of the service in the face of added demand. But given the mortality of benzo + opioid that we're seeing, monitoring benzos seems sort of like a no brainer. Wouldn't you want aging mum's doc to check for a pre-existing benzo prescription before writing her script for Vicodin? Or the other way around? Aging mum might not remember to tell the doc about that script. And that's just on the safety side.

Some of the suggestions were incorporated -- Mass has automated a lot of the signup stuff. I don't know about the rest. It does seem to me that running troublesome prescribers by the licensing boards makes more sense than setting up an alternative path to license suspension/removal, but if the boards are slow/unwilling to take action . . .

ETA:

http://www.enterprisenews.com/article/20150315/News/150317518

Pressure on Baker to improve the system, because apparently Rhode Island has better real time OD monitoring than Massachusetts. Oy! Now, on the one hand, OF COURSE Rhode Island has a better handle on this. Har de har har. On the other hand, Rhode Island has better data on this!?!

Apparently, this is the downside of having this on the public health side, as opposed to the law enforcement side. *sigh*

On page three of that article, we learn that Massachusetts only moved its death records online very recently.

"Until recently, Massachusetts was one of only a handful of states still using paper death records. State officials admitted that the system was delaying access to information. In September, the state launched an online registration system, in part, to reduce how long it takes to make death data available for "surveillance and research.""

Okay, I GET New England frugal. But jeez.

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Comments

( 1 comment — Leave a comment )
ethelmay
Dec. 16th, 2015 08:37 pm (UTC)
The CDC has released some guidelines for providers prescribing for pain. Alas, they are attempting to reduce the new cases, rather than attempting to deal with the existing dependency problem.

Yup. I've just run into this, I suspect. Some years ago I'm pretty sure that either my recent tooth problem or my current back problem or both would have netted me at least a few days' worth of opioids. (And no, I didn't specifically ask, because as a middle-aged woman with a history of depression and back pain I probably fit one of the profiles for "likely drug seeker" already, and I am not about to say anything that would contribute to that image -- as well as not wanting to actually BE a drug seeker.) That just doesn't happen any longer (and I notice they're really pushing combining ibuprofen with acetaminophen despite all the evidence that acetaminophen Really, Really Does Not Work on low back pain). Given that both conditions went on/have gone on longer than I would have been comfortable taking opioids anyway, I suppose it doesn't technically matter, but geez. It's not as though ibuprofen or acetaminophen were risk-free either; you just can't get high on them.
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