Everybody Hurts: Painkiller Tracking Can Stop Doctor Shopping

Imagine that after a few months of being treated for a back injury, you start to develop an addiction to painkillers. Your doctor has only prescribed a 30-day supply, so you go see another doctor who gives you a 30-day supply and then another. Now you have three times the drugs for one month’s time. And, in many states, there is nothing to stop you from continuing to pile up prescriptions.

The same goes for the doctors prescribing those drugs. There’s no easy way to track them in most states.

Dr. David Juurlink recommended a bit of reading. Last year, he and a group of researchers published a study in the Canadian Medical Association Journal called Effect of centralized network on inappropriate prescriptions for opioid analgesics and benzodiazepines. 

For the study, Juurlink and his co-authors went back and reviewed prescription records from 1993 to 1997 for senior citizens and people receiving government aid in British Columbia, programs akin to Medicare and Medicaid in the U.S. Why this period of time?

Because right in the middle of this period, in 1995, British Columbia instituted a real-time prescription drug tracking system called PharmaNet, like the one some states are now using in the U.S. Here’s how British Columbia’s Ministry of Health describes it:

PharmaNet is the province-wide network that links all B.C. pharmacies to a central set of data systems. Every prescription dispensed in B.C. is entered into PharmaNet. In 2007, over 47 million prescriptions were processed on PharmaNet and the system flagged more than 24 million potential drug interactions. PharmaNet—administered by the Ministry of Health and the College of Pharmacists of B.C.—was developed in consultation with health professionals and the public to improve prescription safety and support prescription claim processing.

So Juurlink and his colleagues wanted to see what prescribing patterns were like pre-PharmaNet and immediately after implementation. First, they had to decide what “inappropriate prescriptions” looked like. This is a bit in the eye of the beholder, of course, but they set some strict parameters. “We made it extremely strict to minimize criticism from the pain lobby,” Juurlink told me.

Here’s how they described it in the paper:

First, we identified all filled prescriptions for 30 or more tablets of an opioid analgesic or a benzodiazepine during a 5-year period (Jan. 1, 1993, to Dec. 31, 1997). We chose this number of tablets because it is a commonly prescribed quantity that should, in many instances, encompass at least 7 days of treatment. For each filled prescription, patients were followed for 7 days to ascertain whether another prescription for the same drug was filled. We defined a subsequent filled prescription as inappropriate if it was issued by a different physician and dispensed at a different pharmacy.

Think about how that definition might plug into a tracking system. Every person would have a unique identifier, the way you do right now at your doctor’s office or health insurance company. When you filled your prescription for painkillers once a month, the system would just log those prescriptions. When you filled more one prescription and then filled another less than a week later at a different pharmacy, the system would send out an alert. Either it would prevent the pharmacist from filling the prescription or it would notify state officials to alert the doctors prescribing the drugs to the behavior.

Juurlink and his colleagues looked at different doctors prescribing the drugs and patients filling the prescriptions at different pharmacies. The assumption here is that the patients are the ones being deceptive, going from doctor to doctor and loading up on painkillers. The tracking system also could track prescribers by setting an upper threshold for the amount of opioids and other drugs prescribed in a certain period.

Did the tracking system work? Yes. Just six months after PharmaNet was unveiled in July 1995, inappropriate filled prescriptions for opioids dropped by one third among patients on government aid. The drop was even bigger for benzodiazepines: nearly 50%.

Juurlink and his colleagues wrote:

These findings provide empirical evidence that centralized prescription networks can reduce inappropriate prescribing and dispensing of prescriptions by offering health care professionals real-time access to prescription data. Physicians did not have access to PharmaNet when it was first introduced; consequently, the reductions observed in our study likely reflect the availability of real-time prescription information to front-line pharmacists.

“Some people will argue, ‘Some of those prescriptions might be legitimate’” Juurlink wrote me. “That is true, and we say as much in the paper. But it is equally true before and after PharmaNet.”

Have your own idea on how to track addictive prescription drugs? Write me at askantidote@gmail.com or via Twitter @wheisel.

Image by Dawn McIlvain Stahl via Flickr