Plan to Stem Prescription Drug Crisis in New York Fuels Disagreement

An ambitious plan to reverse New York’s growing prescription drug epidemic is causing a rift between legislators and health care providers, pitting a proposed computer system that would require doctors and pharmacists to meticulously scan patients’ medical history for patterns of abuse against arguments by two professional associations that increased monitoring would backfire.

New York Attorney General Eric Schneiderman’s Internet System for Tracking Overprescribing (I-STOP) bill, which is criticized by the Medical Society of the State of New York and the Pharmacists Society of the State of New York, would connect prescribers to a centralized online database that tracks frequently abused controlled substances in real time. It would help physicians avoid over-prescribing by requiring them to review patients’ prescription history before they issue a new prescription, and pharmacists to check the database for script authenticity before they dispense painkillers. It would also mandate that doctors and pharmacists report new prescriptions every time they are written and filled.

The bill is endorsed by U.S. Senator Kirsten Gillibrand, a bipartisan coalition of state and local legislators, law enforcement and medical professionals, and most recently the New York chapter of Treatment Communites of America, an association of providers serving people with substance abuse issues. New York state ranks 11th in the nation for admissions to chemical dependence programs for abuse of opioids other than heroin.

“The Attorney General’s I-STOP plan will help law enforcement and the medical community combat prescription drug abuse to prevent tragedies from happening in the future of Long Island and across the state. There is no good reason to deny doctors and pharmacists the ability to make controlled substance dispensing decisions on an immediate and real-time basis,” said Nassau County District Attorney Kathleen M. Rice in statement on the AG’s website.

Nassau and Suffolk counties are among the regions hit hardest by addiction-related crime, overdose and death, according to a recent report released by the attorney general. From 2007 to 2010, prescriptions for oxycodone (the main ingredient in OxyContin) increased 82 percent in Nassau County, and the painkiller has contributed to more deaths than any other prescription opioid there since 2006, the report says. In December, an armed robber held up a pharmacy in Seaford, demanding OxyContin and cash, and was killed along with the off-duty federal agent who tried to stop him. Last summer, a pharmacy shooting in nearby Medford made national headlines when a robber killed four people before escaping with thousands of prescription painkillers.

Statewide, painkiller prescriptions increased by six million, or from 16.6 million to 22.5 million between 2007 and 2010, according to the report. In New York City alone, nearly 900,000 oxycodone prescriptions and more than 825,000 hydrocodone prescriptions were filled in 2009, the city’s Department of Health and Mental Hygiene has reported. Prescription drug trafficking, lack of training and communication between specialists treating the same patient, and easy access to drugs facilitated by crooked doctors, street-level drug dealers, and doctor-shopping addicts are widely blamed.

Despite the scope of the crisis, the Medical Society, which represents 30,000 physicians, is opposing the bill. In a petition on its website, the group says it agrees with the goal of the legislation, but argues that mandatory patient record checking, prescription reporting, and penalties for physicians who fail to do so would create undue administrative burdens for doctors. Currently, there is no tracking of prescriptions written.

“We all agree that medications are being abused and diverted. What we’re concerned about is that if there are too many mandates or if they are too strict, it would create such a burden on physicians practices that some physicians would choose to stop prescribing,” said Frank Dowling, MD, commissioner of public health and science for the medical society and co-chair of its Committee on Addiction and Psychiatric Medicine, in a telephone interview.

“What’s missing in this discussion is that there are many patients with chronic pain and doctors are being asked to prescribe more painkillers because patients are being undertreated,” Dowling said. He noted that in some counties there are no pain specialists at all and patients often have to travel or wait for months to see one.

Dowling’s statement is supported by findings in a major Institutes of Medicine (IOM) report on chronic pain, in which researchers say acute and chronic pain affects at least 116 million Americans, not including children. For many of them, treatment is inadequate because they lack a clearly defined diagnosis of illness, such as cancer, heart disease, or physical trauma, that “legitimizes” their pain to prescribing physicians, causing them to seek alternative routes to supply medications.

On the other hand, patients who use painkillers for a non-medical purpose – for the “high” they cause - would likely become less forthcoming if physicians are required to report every prescription they write for them, making it even harder to identify and report signs of potential drug abuse. “There’s a lot of stigma in seeing a psychiatrist and getting an addiction treated. [With I-STOP] patients would be even more intimidated,” Dowling said.

Instead, he suggests the system that’s already in place should be improved. A voluntary prescription drug monitoring program run by the New York State Department of Health does exist, but is unpopular, time-consuming, and updated irregularly. It has been made accessible to physicians, though not to pharmacists, only in the last two years, and many doctors are not educated about its availability and usefulness.

Craig Burridge, executive director of the Pharmacists Society, which also opposes the new plan, explained in a telephone interview why the new system won’t work, even as he acknowledged the inadequacy of the existing one.

“The problem [with the current system] is that pharmacists don’t have access to the database. I-STOP would do that, but we don’t want it mandated,” said . “It’s not necessary for pharmacists to do the same thing that prescribers already do. It really gums up the flow at pharmacies, which are already understaffed and overburdened.”

Burridge said close to 74,000 prescriptions are written daily in New York. But the state’s current program requires pharmacists to report controlled substance they dispense just once every 45 days, and there is no mechanism for them to confirm the authenticity of prescriptions.

The pharmacists association also takes issue with proposed penalties for failing to verify prescriptions. The fines range between $500 for a first-time violation to several thousand for repeated ones.

“We commend the attorney general for trying to do something, but there is too much emphasis on enforcement and not enough on education not enough on trying to do this in an efficient way,” Burridge said. “By punishing prescribers for not doing this lookup, you could basically put a doctor or a small-town pharmacy out of business.”

Burridge noted I-STOP creates the unreasonable expectation that pharmacists should deny filling a prescription if they believe a patient’s medical record indicates he or she intends to misuse it. But identifying such signs should be the responsibility of the prescribing physician, he said.

“We feel that continuing education for doctors needs to be mandatory, because many of them graduated many years before [prescription painkillers] hit the market. When you have a doctor prescribing 60mg hydrocodone tablets with a refill to a teenage girl because she had her teeth cleaned, we really need to educate the prescriber, the patient, and the general public.”

As a pharmacist, you can’t turn down a patient who comes to the counter with a prescription anticipating a medication, Burridge said.

“The number of robberies at pharmacies is going up nationally. We don’t want to put our pharmacists and patients in more danger. We could basically be creating a hundred Medfords by cutting people off with no safety net,” he said.

While I-STOP aims to stop the prescription drug epidemic, it is unclear whether the legislation takes into account the prevalence of chronic pain in America, which both Dowling and Burridge cited as the main reason for the heavy use of painkillers nationwide.

During a recent testimony as part of the first U.S. Senate hearing on chronic pain as a public health challenge, Phillip Pizzo, dean of the Stanford University School of Medicine and chairman of the IOM committee that published the report, acknowledged the improper, but understandable, use of narcotic opioids for self-managed chronic pain.

Meanwhile, illustrating the need for tighter regulation, Schneiderman last month announced a prison sentence for a Bronx woman who was found to have forged more than 250 prescriptions for narcotics, including addictive painkillers like OxyContin and Roxicodone, between 2009 and 2011. She had created the prescriptions on paper stolen from New York City hospitals, and used them in 20 counties throughout the state. At the time of her arrest, she possessed enough prescription paper to write an additional 1,500 prescriptions.