Posts Tagged ‘prescription monitoring program’

New Data from State Prescription Monitoring Program

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North Carolina’s Health and Human Services published a most interesting data set recently: http://www.ncdhhs.gov/divisions/mhddsas/ncdcu/Prescription-Rates-by-County

This interactive map shows information, by county, of the prescribing rates for opioids, benzodiazepines, and stimulants for the years 2012 through 2015. It also includes the average morphine milligram equivalents, or MMEs.

This data was gleaned from my state’s prescription monitoring program, called the North Carolina Controlled Substance Reporting System, abbreviated NC CSRS.

Quantifying MMEs, sometimes also called MEDDs, for morphine equivalent daily dose, is a way to quantify the potency of the opioids being prescribed. For example, since fentanyl is so potent that it’s prescribed in micrograms rather than milligrams, a prescription of 10mg of fentanyl would be very different than a prescription of 10mg of hydrocodone. So using MMEs, prescribed opioids are “translated” into the potency of that dose if it were morphine.

This data is important, since the risk of opioid overdose death risk increases when patients are prescribed higher MMEs. The Centers for Disease Control and Prevention (CDC) has said MME doses higher than 50mg per day should be used with great caution, since doses above this cut off are associated with higher risk of opioid overdose death.

I looked at my own county first, and found some puzzling data. For 2015, Wilkes County was fifteenth out of one hundred counties for the number of opioid pills prescribed per resident. The table said county residents were prescribed one hundred and two opioid pain pills per resident, giving an average of 1.3 opioid prescriptions per resident.

But when I looked at the 2012 data, Wilkes County averaged eighty-two pills per resident, giving an average of 1.1 opioid prescriptions per resident. In other words, the data showed more pills are being prescribed in 2015 than in 2012.

That’s disheartening.

A new pain clinic opened in late 2014, which could explain some of this data. Also, since this is data collected by the patient’s county of residence, perhaps county residents travel to physicians in other counties for prescriptions, and then bring them to Wilkes County to fill.

Then I looked at the MME, the abbreviation for morphine milligram equivalents.

Wilkes County was number one out of one hundred NC counties for highest total morphine milligram equivalents. That says our county’s residents are prescribed more opioid firepower per capita than any other county in the state.

Really? This data doesn’t feel right to me. My impression from the new patients I admit to the opioid treatment program is that area physicians are prescribing lower doses than in the past.

So I started thinking…the opioid addiction treatment program where I work has been growing, accepting more patients, and our census is a little higher than one year ago. But data from my opioid treatment program is not part of the prescription monitoring data, because we must adhere to a higher standard of confidentiality, given the stigma attached to medication-assisted treatment of opioid use disorders.

Except for the office-based buprenorphine patients. At present, they are not protected by higher levels of confidentiality and their data is part of the prescription monitoring program. I only have thirteen patients in that program in Wilkes County, but the pain clinic also prescribes much buprenorphine, for both pain and addiction.

Buprenorphine is an odd drug, since it is a partial opioid agonist with a ceiling effect at 16-24mg per day.

The American Society of Addiction Medicine published a paper giving instructions about how to calculate MME for methadone and buprenorphine. Their position paper on this issue (http://www.asam.org/docs/default-source/public-policy-statements/public-policy-statement-on-morphine-equivalent-units-morphine-milligram-equivalents.pdf?sfvrsn=0 ) says,

  1. When used for the treatment of addiction, methadone and buprenorphine should be explicitly excluded from legislation, regulations, state medical board guidelines, and payer policies that attempt to reduce opioid overdose-related mortality by limiting milligram morphine equivalents (MME). Higher MME of these medications are necessary and clinically indicated for the effective treatment of addiction involving opioid.
  2. State medical boards should not use MME conversions of methadone or buprenorphine dosages used in addiction treatment as the basis for investigations or disciplinary actions against prescribers.

In other words, when buprenorphine is used to treat addiction, translating the dose into MMEs is misleading. I would add that given the ceiling effect of buprenorphine, a partial opioid agonist, overdose is much less likely with this drug than with full agonists for opioid-tolerance people. And really, the risk for overdose death is the purpose for collecting MME data.

My state’s prescription monitoring program does use MMEs for buprenorphine. I’ve seen it on my office-based patient reports, and it annoyed me, knowing ASAM’s position statement about this issue. But I didn’t realize using MMEs for buprenorphine could potentially skew data until now.

What if residents of my county are prescribed more buprenorphine than other counties, both because it’s being prescribed appropriately for the high incidence of opioid use disorder in the county, and also because at least one physician group prescribes buprenorphine off-label for pain?.

To get an idea of how badly buprenorphine MMEs could skew data, I went back and looked at one of my office-based patients. The NC CSRS (our state’s prescription monitoring program) gave a MME of 360mg for a buprenorphine dose of 12mg.

That’s misleading. Morphine at a daily dose of 360mg would place a patient at infinitely more risk than buprenorphine at 12mg.

Just a few days ago, I sent an email to some of the smartest people in my state, asking them to consider this issue. As I was getting ready to post this, I heard back. The NC CSRS plans to separate office-based treatment data. I’ll update readers.

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Use of Prescription Monitoring in Suboxone Patients

I enthusiastically use my state’s prescription monitoring program. This database is available only to physicians who have applied and been approved for access. It records all controlled substance prescriptions filled by a patient, the prescribing doctor, and the pharmacy where they were filled. This means it records prescriptions for opioids, benzodiazepines, anabolic steroids, most sleeping pills, and prescription stimulants. Any prescription medication with the potential to cause addiction will be listed. Medications such an antibiotics, blood pressure medication, etc, aren’t controlled substances, and aren’t list on the website. 

I use this database in several ways.

It can help me decide if a new patient is really addicted to opioids, and appropriate for treatment

If a new patient has a urine drug screen that’s negative for all the opioids, and has no record of getting prescriptions for opioids, I’ll have to see objective evidence of addiction before starting to treat him with Suboxone. But if the urine is negative, and I see monthly oxymorphone prescriptions (sometimes missed on urine drug screens) have been filled, it’s more likely this patient is appropriate for Suboxone treatment. Rarely, a misguided, misinformed person might claim to be addicted to opioids in order to be prescribed Suboxone. This happened once to me, with a patient who was addicted to Xanax, and was convinced Suboxone would cure her. I referred her to more appropriate care.

Using the database can help detect a relapse sooner

Most of the patients in my Suboxone practice (around 80%) are pill takers, not heroin users. When they relapse, it tends to be to prescription opioids, obtained from a doctor unfamiliar with their history of addiction. I check each patient on the state’s database just prior to each visit, and if there are medications on the site I didn’t know about, that will be the main topic of our visit. New medication on the database doesn’t always mean a relapse, so I need to listen to their explanation.

 When it does mean a relapse, the patient and I decide what to do next. Often, the patient decides to allow me to call the other doctor, agrees to increase her “dose” of counseling, and possibly her dose of Suboxone, if it was an opioid relapse. If there are repeated relapses, I may decide Suboxone, as an outpatient, doesn’t provide the support a patient needs. Then, I refer to another form of treatment. Usually this means to a long-term inpatient drug rehab, or to an opioid treatment center, where the patient comes to the clinic every day. Either way, I believe I’m able to address a relapse more quickly using the database.

 Frequently, Suboxone patients get prescriptions for benzodiazepines. That’s a problem for me. For a person without addiction, benzodiazepines can be helpful, mostly used short-term. But for people with addiction, they usually cause problems, sooner or later. People with a previous addiction to any drug, especially including alcohol, need to regard prescription benzodiazepines as high-risk medications.

 I try to be flexible, too. If a traumatic event has occurred in the life of a patient, I may OK benzodiazepines short-term, provided I can see the patient more often and have good communication with the doctor prescribing the benzodiazepines.

  I also have to remember the body reacts the same to a mixture of opioids and benzos, no matter why they’re taken.  Even though Suboxone is safer than methadone, it’s still not safe when mixed with benzos, when taken for any reason.

If this sounds wishy-washy, that’s because it is. So many situations arise in the lives of patients that one hard and fast rule just doesn’t exist. That’s the art of medicine.

 Is the patient filling Suboxone on time?

The database also shows me when patients are filling the Suboxone prescription. If I write a prescription today, but the patient doesn’t fill it for two weeks, what’s going on there? Has he relapsed for several weeks? Did he have a stockpile of Suboxone from a previous prescription? Was he unable to afford it until now? All these questions and their answers are important to guide treatment.

 It makes me happy.

It warms my heart to see a patient who had a long list of opioid prescriptions from multiple doctors before starting Suboxone, then after entering treatment, see only Suboxone. This occurs in the majority of my patients.

My state’s prescription monitoring program is one of the best tools to help patients that I’ve ever seen. I believe it’s saved many lives. I think it’s just as important as drug screening for my Suboxone patients. Of course, the best tool for recovery is the counseling. I prefer 12-step recovery, as that provides ongoing support even after Suboxone treatment, but any kind of counseling helps. The patients I see doing the best are the ones involved in both formal counseling, in group or individual settings, along with 12-step meetings.