Prescription monitoring system has potential to curb abuse, but program is widely under-utilized
YAVAPAI COUNTY - It's no secret that the abuse of prescription drugs has risen to a deadly level.
A new federal study by the office of National Drug Control Policy entitled Epidemic: Responding to America's Prescription Drug Abuse Crisis indicates that, nationwide, the per person use of prescription opioids (synthetic or semi-synthetic opiates), a classification that includes some of the most powerful medications available, increased by more than 400 percent from 1997 to 2007. Opiate overdoses, once almost always attributed to heroin, "are now increasingly due to abuse of prescription painkillers," such as oxycontin, percodan, vicodin and others.
The April 2011 report also states that prescription painkillers are now "the second-most abused category of drugs after marijuana, and the second leading cause of accidental death in the U.S. after car accidents."
In Arizona, drug overdose deaths are at an all-time high. More than 1,100 people died from drug-related incidents in 2009, doubling the 543 such cases in 1999. And in Yavapai County, 10 deaths were attributed to drugs in 1999 compared to 46 such deaths in 2009.
"I strongly believe that increase is from prescription drugs," said Marilee Fowler, executive director of MATForce, Yavapai County's drug prevention coalition. "I've talked to kids who are addicted and they tell me that to get off it is horrible, harder to kick than heroin."
The dangers of these substances are insidious, according to Sgt. James Gregory, director of PANT (Partners Against Narcotic Trafficking), the countywide drug law enforcement task force.
"People think it's not as bad as regular street drugs because it came from a doctor," Gregory said. "That's wrong."
So wrong, in fact, that as many as a dozen overdose deaths in the Yavapai County have been at least tentatively attributed to the abuse of prescription drugs in the past several months.
In one of those deaths, that of a 21-year-old woman, investigation by the Cottonwood Police Department indicated that a suspect involved in selling the drugs to the victim had received prescriptions for painkillers from at least six doctors, and had filled those prescriptions at two different pharmacies.
The federal report identifies four areas - education, monitoring, proper disposal and enforcement - in which officials and the public can combat the growing problem.
Of those four, monitoring the distribution of the drugs for signs of abuse may have the best chance of combating the problem by reducing supplies.
Arizona is one of 33 states that has a prescription monitoring program in place but, according to Dean Wright, prescription monitoring program director of the Arizona Board of Pharmacy, only 11-12 percent of pharmacists and prescribing practitioners access the CSPMP (controlled substance prescription monitoring program) database while determining what medications to prescribe and dispense.
"We've got practitioners adding to the database constantly," Wright said, adding that the system has accumulated 33 million records since its inception in 2007, with additional records added at a rate of about 1,500 per day. "But the only time a practitioner is required to use the database (to research a patient's prescription history) is when they get involved in medical marijuana."
MATForce's Fowler thinks that more diligent use of the system would have a great effect on the availability of the drugs for abuse. "We have an awesome system that's barely being used," she said.
When a dispensing practitioner or pharmacist supplies a controlled substance to a patient, that doctor or pharmacist must enter the patient's ID, as well as the type and amount of the drug, into the CSPMP database. The pharmacist also enters the identity of the prescribing doctor. The result, then, is an easily searched log of who is getting the drugs and who is prescribing and dispensing them. Authorities, in the course of an active investigation, can unearth evidence against a suspect who may be "doctor-shopping" for painkillers, either for excessive personal use or in search of profit. They can also determine if a doctor is over-prescribing.
Doctors can access the system and see what medications a patient has recently received, and pharmacists can use it to see the prescription history of the customer in front of them.
Dr. Leon Cattolico of Cottonwood has been on a bit of a mission of late, trying to educate doctors and pharmacists alike to the benefits of the program.
"If a physician is treating patients with pain medications, he should be using this," Cattolico said at a recent MATForce gathering, citing a couple of examples that he found while doing research on his own patients.
One man, whom Cattolico said he promptly dropped as a patient, had filled three 90-day prescriptions for a pain medication within three weeks.
The problem, he said, is that pharmacists in some of the big chain stores were unable to use access the system for research, even though those same businesses met the letter of the law in reporting prescriptions they had filled.
"The pharmacists I've spoken to so far say that corporate won't let them have access to the internet," he said. Still, he said that his efforts have had an apparent indirect effect.
"There's an underground cooperative going on right now," he said, "where if they (pharmacists) suspect something they'll call the others." That appears to extend, as well, to a willingness to call the prescribing doctor.
"In the last 30 days I've gotten calls from pharmacies I've never had calls from before," Cattolico said.
John Phillips, owner of Prescott's Goodwin Street Pharmacy, agrees that the database is a valuable tool, albeit one that could use a bit of improvement.
"The beauty is it alerts us to people who doctor-shop," Phillips said, adding that he has seen numerous examples, some extreme, of customers trying to line their pockets with profits from the sales of pills such as oxycontin, which can go for from $50 to $80 apiece. He said he has seen people fill a prescription for 240 oxycontin pills, then return two weeks later for a refill.
When a pharmacist discovers through the database that a customer has received what they perceive as too many prescriptions, he or she has the option of contacting the doctor who wrote the prescription and discussing the data.
"We call the doctor and sometimes they listen and sometimes they ignore us," Phillips said. "But I can refuse to fill a prescription for any reason."
The system can only work effectively, though, if doctors use it when prescribing controlled substances and pharmacists refer to it at the time of contact with the customer. And that can be a problem for a pharmacist faced with impatient shoppers and an often-immense workload.
Phillips, back from a recent industry convention, heard just that from some of his peers.
"They say, 'We're so inundated, we're so understaffed, we don't have time,'" Phillips said. "It's a problem for someone who's trying to fill 400 prescriptions a day."
Phillips also has a suggestion for improving the effectiveness of the system.
"I think it should be mandatory on the part of the prescriber" (to check the database for the patient's history), he said. "I think if physicians were forced to do this, it would go a long way toward fixing the problem."
Phillips has just three pharmacists in his single Prescott location, and they use the system any time they suspect that a customer is obtaining the drugs for purposes of abuse.
But it turns out to be at least partly true that pharmacists in the chain stores are cut off from the tool by corporate decisions.
Mike DeAngelis, public relations director for CVS pharmacies, said that, while the chain conforms to the legal reporting requirements in Arizona and other states that have monitoring programs, pharmacists in CVS stores do not have access to the CSPMP data in individual stores.
"They do not," he said. "The database is set up so that prescribers can consult the data before they write the prescriptions."
DeAngelis added that pharmacists are trained to recognize indicators that a customer might be trying to get the drugs for illicit reasons. CVS operates more than 130 pharmacies in Arizona.
Wright, who agrees that the chain outlets reluctance to get on board with the program "has created a problem," said he very recently had contact from CVS headquarters, where someone told him "there are discussions going on now about a possible change in policy."
Fry's management, on the other hand, wants their pharmacists to use the system wherever they see a need.
"We actively encourage our pharmacists to make good therapeutic decisions," said Crane Davis, Fry's pharmacy supervisor. "Our stores are able to use the internet and access this system. We encourage them to do so when there's any sign there may be abuse."
Fry's operates 121 pharmacies in Arizona.
Walmart representatives did not choose to answer questions on the topic, despite several efforts to contact both Arizona and national media representatives.
Walgreens media relations representative Robert Elfinger said the chain conforms to legal reporting requirements and that in-store pharmacists at Walgreen's 247 Arizona locations "can look into the database and use their professional judgment."
Safeway spokeswoman Nancy Keane declined to directly answer the question about pharmacists' access to the CSPMP database, but she did relay this statement from Sean Duffy, the head of the chain's pharmacy division: "Our pharmacists make sure they dispense the appropriate amount of each prescription to ensure its compliance with physician directives and patient safety."
In addition to Wright's efforts, MATForce is in the process of composing letters to doctors, pharmacists and corporate entities, urging them to take part in the program.
"A change in policy," a draft letter to a corporate distributor reads, "would directly result in the reduction of the abuse of prescription drugs and in turn result in saving the lives of young people in our community."