Opportunity Missed: the Prescription Monitoring Program in Oklahoma

Prescription drug abuse is an epidemic in Oklahoma. In 2012, Oklahoma ranked first nationwide for painkiller addiction, fifth for deaths due to drug overdoses, and fifth for number of painkiller prescriptions written. Preliminary data from the Bureau of Narcotics and Dangerous Drugs indicates that 2013 saw 788 overdose deaths, 593 of which were from prescription drugs. These numbers are expected to rise as medical examiners review more data.

This session, lawmakers had the opportunity to enact effective legislation to combat prescription drug addiction in the state – and they fumbled it. Here’s the background:

Prescription drug addiction doesn’t look like stereotypical addiction.

Part of the problem is that prescription addiction doesn’t look the way most people imagine addiction looks, which makes it harder to fight. State officials estimate that in half of all casualties from prescription drug overdoses, the victims were prescribed the drug. Of those who abuse painkillers, one in five is prescribed the drug by a doctor. The vast majority of the remainder take it or are given it by a friend or relative.

This legislative session, Oklahoma lawmakers had the opportunity to enact legislation that could have significantly hobbled the ability of drug-seekers to procure prescriptions from doctors. The Prescription Monitoring Program, or PMP, has been available for physicians to use since its launch in 1991. Still hailed as one of the best in the nation, the PMP allows prescribers to check the prescription history of their patients, to see – for instance – if the patient for whom they’re considering writing a prescription for Lortab has recently obtained identical prescriptions from other doctors. For a prescribing physician, that would be a red flag.

However, last year, Oklahoma prescribers only checked the PMP for one in every six prescriptions. Doctors claim that checking the PMP takes too much time, and undermines their authority as doctors to know what’s best for their patients. Physicians’ groups said as much this spring, when negotiations stalled over a bill (SB 1820) that would have required prescribing doctors to check the PMP before writing prescriptions for Schedule II and Schedule III drugs. SB 1820 died in committee at the end of session.

Unfortunately, evidence shows that in this case, the doctors may be in the wrong. Here’s why.

Doctors want to trust patients. They shouldn’t.

Much of the pushback against requiring doctors to check the database for every qualifying prescription comes from small towns, where doctors say they know their patients and trust that they won’t abuse the drugs prescribed. However, rural counties had the highest rates of death by overdose in 2012.

Similarly, while doctors undoubtedly want to believe that they can trust their patients where addictive prescription medication is concerned, studies indicate that they should temper that impulse. An Ohio study of physician experiences with a PMP found that 40 percent of physicians surveyed altered their prescribing behaviors after they began using the state’s PMP; a similar study in California found that over three-quarters of physicians surveyed did the same. In a survey of Kentucky doctors regarding the state’s PMP, 78 percent said that they “strongly agreed” the PMP “is an excellent tool for identifying potential ‘doctor shoppers’ – patients who misrepresent information to a prescriber in an effort to obtain controlled substances.”

And Oklahoma doctors who use the PMP seem to think it’s an important tool. Inquiries from a PMP research and advocacy group out of Brandeis University found that of Oklahoma PMP users surveyed, two-thirds reported that PMP data had helped them identify patients abusing prescription medication or doctor-shopping. Furthermore, one-fifth used PMP data to refer patients to treatment, 64 percent to a pain management specialist, and one-quarter to law enforcement. Fully 71 percent of those surveyed in Oklahoma altered their prescribing behaviors based on PMP data.

Trusting patients about their use of addictive substances, it turns out, doesn’t necessarily mean practicing better medicine. And checking a database before writing a prescription can mean an addicted patient has a possibility of getting treatment.

When doctors use PMPs, they prescribe less medication

When doctors alter their prescribing behaviors, the numbers of drugs prescribed declines accordingly. According to analysis from Oklahoma Watch, states that have mandated prescriber use of PMPs have seen a significant drop in the number of prescriptions written for narcotics. Kentucky, the first state to mandate PMP checks, saw the volume of drugs prescribed drop by 10 percent. When Florida instituted tougher regulations on prescription drugs, including PMP checks, Oxycodone prescriptions fell by one-quarter. Tennessee saw similar results.

Oklahoma pharmacies last year filled 9.6 million prescriptions for controlled substances. The estimated population that year was 3.85 million. As Oklahoma Watch has noted, that’s 195 dosage units for everyone in the state. Without a doubt, that’s excessive. Doctors should be able to reign in prescribing behaviors without sacrificing patient care.

Why it matters

Prescription drug abuse is tearing Oklahoma apart; overdose is a leading cause of death for people ages 18 – 55. More people are killed by overdoses than by car accidents every year. People seeking drugs don’t get them from shady figures on street corners; they get them from their doctors. Furthermore, the saturation of prescription opiates into the general population is believed to be a key factor in the reemergence of heroin addiction in the US. Doctors are uniquely positioned to catch addiction and recommend treatment, and they shouldn’t shirk from their ability to help stem the prescription drug epidemic in Oklahoma.

Lawmakers did approve a bill this session (HB 2589) that allows transporting large volumes of morphine, oxycodone, hydrocodone, and benzodiazepines to bring drug trafficking charge. However, this law is unlikely to have much impact on the problem, since most prescription medication doesn’t come from traffickers but from friends and doctors. Another bill requiring medical examiners to report the names of overdose victims directly to the state Bureau of Narcotics and Dangerous Drugs will make it easier to track deaths. While helpful for researchers, this will do little to immediately help the living. Meanwhile, all available data say that forcing prescribing physicians to check the PMP would actually have significant impact.

Physicians have a key opportunity to protect the health of their patients, and the health of the public in general, by utilizing the PMP. To do otherwise is to duck their responsibility as health care professionals.