Jan 24, 2006 By: Andis Robeznieks Modernhealthcare.com

While some talk about an upcoming golden age of medicine where interoperable electronic medical-record systems allow doctors to share patient information and deliver the best healthcare as efficiently as possible, one use for collecting and sharing patient information continues to create controversy: state prescription-monitoring programs that electronically track the dispensing of narcotic medications.

Supporters see prescription-monitoring programs as a tool that warns physicians about patients who “doctor shop” and go from clinic to clinic presenting real, exaggerated or fake symptoms in order to obtain multiple prescriptions of powerful pain killers. While others fear that information stored in the electronic databases could be used by law enforcement officials with no medical training to go on fishing expeditions and harass physicians who are appropriately prescribing opioids to patients with a legitimate need for them.

Currently, 28 states have prescription-monitoring programs or are in the process of implementing one, according to the U.S. Drug Enforcement Administration. Vermont is poised to become the next state to join the list, and a bill to develop a program there that has the endorsement of the Vermont Medical Society was recently approved by the state Senate and is now before the state House.

State medical societies generally prefer that prescription-monitoring programs fall under the control of the state health department rather than under law enforcement, and Vermont is no exception. According to VMS Executive Vice President Paul Harrington, the organization had a seat at the negotiating table with the commissioner of health and the director of public safety and had a major role in drafting the bill before the Legislature.

“The society was concerned with law-enforcement access to the database without it first being reviewed by medical peers to determine whether there was an issue that was appropriate for law enforcement to review,” Harrington said.

“The bill, as it’s been further amended with proposals put forward by the medical society, is one that we support.” Harrington said it will be up to the Vermont Medical Practice Board to determine whether law enforcement should have access, although the health commissioner could provide access if it’s felt there is an immediate threat being posed.

Nevertheless, only law-enforcement officials who have received training will be allowed access under these narrow circumstances, Harrington said, adding that “We wanted to make sure that the legislation had as its purpose patient care.”

If everything goes according to schedule, Harrington said that — with the help of a $350,000 grant — the database should be operational by Jan. 1, 2007, and will provide physicians Web-based access to a patient’s narcotic-prescription history. He added that the burden of inputting the data will be left mostly to pharmacists and not physicians. While some talk about an upcoming golden age of medicine where interoperable electronic medical-record systems allow doctors to share patient information and deliver the best healthcare as efficiently as possible, one use for collecting and sharing patient information continues to create controversy: state prescription-monitoring programs that electronically track the dispensing of narcotic medications.

Supporters see prescription-monitoring programs as a tool that warns physicians about patients who “doctor shop” and go from clinic to clinic presenting real, exaggerated or fake symptoms in order to obtain multiple prescriptions of powerful pain killers. While others fear that information stored in the electronic databases could be used by law enforcement officials with no medical training to go on fishing expeditions and harass physicians who are appropriately prescribing opioids to patients with a legitimate need for them.

Currently, 28 states have prescription-monitoring programs or are in the process of implementing one, according to the U.S. Drug Enforcement Administration. Vermont is poised to become the next state to join the list, and a bill to develop a program there that has the endorsement of the Vermont Medical Society was recently approved by the state Senate and is now before the state House.

State medical societies generally prefer that prescription-monitoring programs fall under the control of the state health department rather than under law enforcement, and Vermont is no exception. According to VMS Executive Vice President Paul Harrington, the organization had a seat at the negotiating table with the commissioner of health and the director of public safety and had a major role in drafting the bill before the Legislature.

“The society was concerned with law-enforcement access to the database without it first being reviewed by medical peers to determine whether there was an issue that was appropriate for law enforcement to review,” Harrington said. “The bill, as it’s been further amended with proposals put forward by the medical society, is one that we support.”

Harrington said it will be up to the Vermont Medical Practice Board to determine whether law enforcement should have access, although the health commissioner could provide access if it’s felt there is an immediate threat being posed.

Nevertheless, only law-enforcement officials who have received training will be allowed access under these narrow circumstances, Harrington said, adding that “We wanted to make sure that the legislation had as its purpose patient care.”

If everything goes according to schedule, Harrington said that — with the help of a $350,000 grant — the database should be operational by Jan. 1, 2007, and will provide physicians Web-based access to a patient’s narcotic-prescription history. He added that the burden of inputting the data will be left mostly to pharmacists and not physicians.

Improved patient care Harrington predicted that prescription monitoring will be of particular use to emergency-department physicians who treat patients they are unfamiliar with and that the program will lead to improved patient care.

The Vermont bill was based on Kentucky’s program, but was significantly amended, Harrington said, and it follows current national trends.

“There has been recognition on the federal level that the primary focus should be on patient treatment and the secondary focus should be on law enforcement,” Harrington said. “Vermont’s bill represents the evolution that has taken place on the federal level.”

Of course, one consequence of a state starting a prescription-monitoring program is that it sends doctor shoppers across the border to a state that doesn’t have one. A goal of the National All Schedules Prescription Electronic Reporting Act, or NASPER, that was signed into law by President Bush on Aug. 11, 2005, is to create electronic databases where information can be shared between providers on different sides of state lines.

Since 1999, NASPER has been championed by the 3,300-member American Society of Interventional Pain Physicians and its founder and Chief Executive Officer Laxmaiah Manchikanti, M.D., who has offices in Paducah, Ky., and Marion, Ill.

Although NASPER included authorization for Congress to spend up to $60 million on state prescription-monitoring programs though 2010, Manchikanti said supporters will have to fight for funding and a lobbying effort has already started to include $15 million for the grant program in the fiscal 2007 budget. The Vermont grant will come from an existing program under the U.S. Justice Department’s jurisdiction, while NASPER will be under HHS control.

Manchikanti added that, under NASPER, a physician will need patient consent to access their prescription history in the electronic database. If a patient refuses, the physician can refuse to prescribe the pain medication, and Manchikanti said this has only happened twice in his practice.

He said NASPER was necessary because state laws can be ineffective for doctors. Although Kentucky’s program is often cited as a model for other states to follow and recently underwent improvements, Manchikanti said the information in the database is still usually 2 to 3 weeks old.

That said, it’s still better than Illinois — despite the fact that Illinois has had a program in place since 1999. “We have a heck of a lot of difficulty finding out anything in Illinois,” he said.

Manchikanti said critics who complain that prescription monitoring causes a chilling effect on physicians’ opioid prescribing have no proof to back their claim. “Actually, it makes them more comfortable and more willing to prescribe to a patient who really needs it,” he said.

One of those critics, American Academy of Pain Medicine President Scott Fishman, M.D., said studies show that the programs create a “substitute effect.”

“If you put up a barrier to prescribing a Schedule 2 opioid, they will prescribe a Schedule 3,” said Fishman, professor and chief of the Division of Pain Medicine at the University of California, Davis. ‘Anything but opiods’ Siobhan Reynolds, president of the Pain Relief Network advocacy group, called this the “anything but opioids” style of practicing medicine.

“Individuals who get less-efficacious medicine have had their doctor-patient relationship interfered with,” Reynolds said. “It also stigmatizes people who are in pain and that offends me. I also feel doctors are way too accepting of law enforcement’s intrusion into medicine.”

Fishman, however, acknowledged that most of the studies involving prescription monitoring are more than 20 years old, but he recently received a Robert Woods Johnson Foundation grant to study the impact of California’s prescription-monitoring program.

“The American Academy of Pain Medicine — which I’m president of — is very supportive of prescription-monitoring programs in order to keep opioids safe,” Fishman said. “A good electronic prescription-monitoring program can help everybody: law enforcement, patients and physicians. But, if done inappropriately, it can cause harm on all fronts.”

Fishman added that NASPER is advertised as a physician tool, “But it smells like a mousetrap.” ‘Monitoring inevitable’ Improved patient care Harrington predicted that prescription monitoring will be of particular use to emergency-department physicians who treat patients they are unfamiliar with and that the program will lead to improved patient care. The Vermont bill was based on Kentucky’s program, but was significantly amended, Harrington said, and it follows current national trends.

“There has been recognition on the federal level that the primary focus should be on patient treatment and the secondary focus should be on law enforcement,” Harrington said. “Vermont’s bill represents the evolution that has taken place on the federal level.”

Of course, one consequence of a state starting a prescription-monitoring program is that it sends doctor shoppers across the border to a state that doesn’t have one. A goal of the National All Schedules Prescription Electronic Reporting Act, or NASPER, that was signed into law by President Bush on Aug. 11, 2005, is to create electronic databases where information can be shared between providers on different sides of state lines.

Since 1999, NASPER has been championed by the 3,300-member American Society of Interventional Pain Physicians and its founder and Chief Executive Officer Laxmaiah Manchikanti, M.D., who has offices in Paducah, Ky., and Marion, Ill.

Although NASPER included authorization for Congress to spend up to $60 million on state prescription-monitoring programs though 2010, Manchikanti said supporters will have to fight for funding and a lobbying effort has already started to include $15 million for the grant program in the fiscal 2007 budget. The Vermont grant will come from an existing program under the U.S. Justice Department’s jurisdiction, while NASPER will be under HHS control.

Manchikanti added that, under NASPER, a physician will need patient consent to access their prescription history in the electronic database. If a patient refuses, the physician can refuse to prescribe the pain medication, and Manchikanti said this has only happened twice in his practice.

He said NASPER was necessary because state laws can be ineffective for doctors. Although Kentucky’s program is often cited as a model for other states to follow and recently underwent improvements, Manchikanti said the information in the database is still usually 2 to 3 weeks old.

That said, it’s still better than Illinois — despite the fact that Illinois has had a program in place since 1999.

“We have a heck of a lot of difficulty finding out anything in Illinois,” he said.

Manchikanti said critics who complain that prescription monitoring causes a chilling effect on physicians’ opioid prescribing have no proof to back their claim. “Actually, it makes them more comfortable and more willing to prescribe to a patient who really needs it,” he said.

One of those critics, American Academy of Pain Medicine President Scott Fishman, M.D., said studies show that the programs create a “substitute effect.” “If you put up a barrier to prescribing a Schedule 2 opioid, they will prescribe a Schedule 3,” said Fishman, professor and chief of the Division of Pain Medicine at the University of California, Davis.

‘Anything but opiods’ Siobhan Reynolds, president of the Pain Relief Network advocacy group, called this the “anything but opioids” style of practicing medicine.

“Individuals who get less-efficacious medicine have had their doctor-patient relationship interfered with,” Reynolds said. “It also stigmatizes people who are in pain and that offends me. I also feel doctors are way too accepting of law enforcement’s intrusion into medicine.”

Fishman, however, acknowledged that most of the studies involving prescription monitoring are more than 20 years old, but he recently received a Robert Woods Johnson Foundation grant to study the impact of California’s prescription-monitoring program.

“The American Academy of Pain Medicine — which I’m president of — is very supportive of prescription-monitoring programs in order to keep opioids safe,” Fishman said. “A good electronic prescription-monitoring program can help everybody: law enforcement, patients and physicians. But, if done inappropriately, it can cause harm on all fronts.”

Fishman added that NASPER is advertised as a physician tool, “But it smells like a mousetrap.” ‘Monitoring inevitable.’

He also said that “prescription monitoring is inevitable,” so he hopes his study will be completed early enough to serve as a guide for states that are looking to develop a program with a NASPER grant. “Currently, we’ve worsened our two public-health crises,” Fishman said. “We’ve not made advances in stopping drug abuse and we’ve harassed patients who are in pain — which is completely unacceptable.”