Posts Tagged ‘prescription monitoring programs’

Idle Time and Our New PMP

 

 

 

 

 

 

Usually I stay busy when I work at the opioid treatment program (OTP). Every August, however, things slow down. We see fewer people presenting for admission. I don’t know why this is, but I’ve seen it happen every year for the past seventeen years I’ve worked at OTPs.

This August was no exception. Our admissions dropped down significantly, giving me chunks of time that I otherwise dedicate to doing intake admission histories and physicals. My new challenge was staying busy.

My staff knows I must be kept busy. Otherwise, I tend to Get In To Things.

For example, once when we were slow, I went on a fact-finding mission about why our toilets have no blue dye in the water. Blue dye reduces the risk of adulterated urine obtained for drug screens, yet we had no blue dye. As it turned out, the answer to my question was: it’s complicated. Our toilets have a bladder system that holds water instead of storing water in the back of the tank…well, that’s not important. But it wasn’t under my control to fix, and I only managed to interrupt people with more pressing work to do.

Another time when I wasn’t busy, I wanted to know why there were five WTA vans in our parking lot at the same time. WTA is the transport service that picks up our Medicaid patients to bring them to the OTP for treatment. We’ve asked them to stagger their arrival time, so that we don’t have multiple vans disgorging five to eight people arriving to dose at the same time. This causes a delay in dosing for all of the patients, and no one likes that – not the patients, staff or our dosing nurses.

Apparently, our request to WTA was a river too wide, a mountain too high. I can’t remember the last morning when I’ve arrived at work at 7am when there were fewer than three WTA vans. Their drivers chat amiably amongst themselves while tempers flare because of dosing delays due to a clump of patients arriving all at the same time.

I know I can be annoying when I’m not kept busy, so yesterday I kept going to the lobby to ask if anyone needed to see me. I got to see five or six people this way, a good use of time.

During the other free time, I looked at patients on our state’s new prescription monitoring program.

While I recognize I’m never good with new technology, I have some complaints about our new system.

Last week, I settled in on a Thursday evening to look at the reports of the office-based buprenorphine patients I had scheduled to see in my private office the next day. Every time I entered the patient’s first name, last name, and date of birth, I got an error message.

When technology fails to work for me, I become enraged. Many times, it turns out to be my own fault, which enrages me all the more. But this time, the new system clearly wasn’t working.

There was a phone number listed on the web site to call for problems. Since it was after hours, I expected a machine, but a human answered. I told him of my problems, and he said, “Try entering just the first three letters of the first and last name, and check the boxes that indicate partial name.”

I did so, and it worked. My short-term problem was fixed. However, feeling a little crotchety with this delay, I asked him how any provider could know it only works with the first three letters of first and last name, unless they made the effort to call the help number.

He said as long as it worked, it was good enough. In my mind, I pictured all those “There, I fixed it” photo memes often seen on the internet. I grumbled a little more, but ended with a thank you. To be fair, since then, the system has been working with the full names again.

On our old system, we could adjust our search to allow for an error in the date of birth. That is, we could select the exact date, or options for one to two years surrounding this date. You’d be surprised how many times the date of birth is recorded wrong in our charts or by the pharmacy. With this new system, the date of birth data entry must be entered exactly by the pharmacy and by the physician searching the system.

I also don’t care for the first page of this report, dedicated to overdose death risk and MME of the patient. MME stands for morphine milligram equivalents. This gives an “overdose score” which may be helpful to some prescribers.

But it annoys me, since it gives big scores to patients who are only filling prescriptions for buprenorphine products. Buprenorphine isn’t translatable into MME numbers, and MMEs were never meant for this purpose. In the fine print, the MME score for patients on buprenorphine is zero, but there’s still a high overdose score. This glitch doesn’t cause any harm so far as I can see…except for the annoyance it causes. I want my patients to get credit for being on buprenorphine, arguably one of the safest opioids in existence.

This mess of data on the front page, in large type, makes it harder to find what I’m looking for, which is the actual printout of all controlled substances filled by the patient, the date they are filled and the prescriber. While the front page must have that overdose score in a font of twenty-six, the actual data is printed in – I’m not making this up – in ten font.

I’m on the shady side of my fifties, and ten font is unsatisfactory to me.

We’ve also encountered another problem, which is that the patient’s name is only listed on the first page. Some of these reports can run to six or more pages, even with the ten font. It’s a real problem to figure out which sheets go with which patients. It’s not a huge problem at my home, where I’m the only person printing. But at work, my papers can get shuffled by other personnel getting their printed papers. I’ve had loose sheets with no name on them, which had to be discarded because I couldn’t tell for sure to which patient they belonged.

No system is perfect, and the new system has some improvements – I can print the page I’m viewing, rather than the two-step process of the past, when I had to select the option to create a pdf, then go back in a second step to print that pdf file. So it’s not all bad. Plus, we can search more states. Now providers can select our own state, plus all of our bordering states. We can select a total of eighteen states.

As August turned into September and then into October, my brief problem with free time resolved. We are busy again, though not as busy as we will be later in the year. Being busy is a good thing for everyone; more patients getting admitted to treatment means more people are getting their lives back. That’s always an awesome thing to observe.

And I am prevented from bothering staff members with more important things to do than figure out how to put blue dye in the toilets.

 

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The Good, the Bad, and the Ugly

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The Good

 Probuphine

Probuphine was approved by the FDA. I’ve written about this medication in several other blog posts. Probuphine is an implantable form of buprenorphine that lasts for six months. It will be suitable for buprenorphine patients who are stable at 8mg per day or less.

I think logistical problems will prevent this medication from becoming mainstream. I hear it must be implanted in a surgical suite, which makes little sense. Maybe it’s more involved than I realize, but I had been under the impression it could be done in an office setting, like Norplant.

I’ve also read that the physician must purchase and store the Probuphine implant, which adds financial risk and DEA scrutiny to a buprenorphine physician’s already crowded schedule.

As I’ve said before, I predict Probuphine will be administered at a few specialty centers, but isn’t likely to be done by most mainstream addiction medicine doctors. Still, it’s another option that hopefully will work well for patients on less than 8mg per day.

Watch your language

The field of Addiction Medicine is pushing for non-stigmatizing language to be used by treatment professionals. Words are important, and some words carry hidden and pejorative meaning in the general public.

For example, I’ve always cringed when I hear the term “dirty” or “clean” urine drug screen. I have to quash my desire to be sarcastic towards the speaker. The proper terms are “positive,” meaning a substance was found in the urine, or “negative,” meaning a given substance wasn’t found in the urine. Addiction Medicine gurus continue to emphasize the importance of using proper clinical terms. I enthusiastically agree with their efforts.

Now experts in the field want to get rid of the term “addict” and “opioid addiction.” They want to replace those words with terms such as “person with opioid use disorder,” and “opioid use disorder,” respectively.

I understand the reason behind these recommendations, and I agree with them, but it’s going to be tough to replace a two-syllable word with a ten-syllable phrase.

Besides, when I say the word “addict,” I suspect I mean something very different than the average person using the word. In my mind, the word “addict” has come to mean “person with the disease of addiction who is probably more likeable and interesting than an average person.”  But then, I chose to spend my career treating these people, so of course I think that way.

Contrast that to an average person in the community, to whom the word “addict” means a bum in the gutter with a needle hanging out of his arm. Most of the time, people are surprised when then encounter real addicts, or to use the new term, people with an opioid use disorder. Because since anyone can develop opioid use disorder, these people usually don’t look different from the rest of us.

Government Support for Addiction Treatment

When the President of the United States endorses medication-assisted therapies, we have arrived. That’s old news now, since he has been discussing MAT in some of his addresses since last year, as a way of addressing the opioid overdose epidemic. But now the promised money is starting to become available.

Available grant money fueled plans for new, collaborative opioid use disorder treatment programs in our state…

One primary care low-cost clinic just started working with their local opioid treatment center to provide needed primary care to patients in that OTP. Referrals should flow both ways, with the OTP sending patients to the medical clinic for needed healthcare, and the medical clinic will detect opioid use disorders in their patients, and refer them for treatment at the OTP.

An exciting initiative to connect people involved with the criminal justice system with appropriate medication-assisted treatment is in the planning phase. With this program, prisoners being released and people under parole and probation will be evaluated by addiction medicine doctors. Where appropriate, they will be offered methadone, buprenorphine, or naltrexone, to better treat their illness, and they will get increased counseling.

Prescription Monitoring Programs Work!

I had a few spare hours last week, and was able to look at around 125 of my 450 OTP patients. I discovered only one patient with some questionable findings, and she’s scheduled to talk with me this week.

What a change from 2007, when over 20% of all my OTP patients had serious prescriptions for opioids, benzodiazepines, and/or stimulants. These were prescriptions about which I knew nothing. Patients had filled prescriptions and there was no way for me to know about it, until our prescription monitoring program came online in mid-2007.By the time I got access late in the year, I found data indicating over a fifth of our patients were filling prescriptions that could harm them with the methadone I was prescribing.

Over the last nine years, our system has improved, making it ever easier and more accurate.

The Bad

All Use of Methadone is Toxic?

Perhaps in response to my blog post that was critical of the medical examiners in North Carolina, a medical examiner called me.

My complaint in the June 5, 2016 blog is that any patient who dies while on methadone maintenance is said to have died from methadone toxicity, regardless of clinical information.

This doctor and I had a cordial yet frustrating conversation. The physician introduced himself and said he was calling me because he had promised to do so after I spoke with him last year about a patient of mine who had died. When we last spoke, the toxicology results had just been sent off. He called yesterday to tell me that the level of methadone in this patient was toxic, and that along with the cocaine found in her system, he was reporting cause of death as “Methadone toxicity, cocaine toxicity.” I already knew this from reading incident report data, but I didn’t interrupt him. I was hoping he would give me additional information, but he didn’t.

When he was done, I informed him, again, that she had dosed at 130mg of methadone for months in the several years prior to her death. At her request, we started a slow taper. She came down on her dose by 5mg every couple of weeks, and she had been dosing at 60mg for several weeks prior to her death. I asked him how, with that information, could he still say she died from methadone toxicity?

He didn’t have an answer, and just repeatedly said her methadone level was “toxic.” He read the level to me, and I told him that I have patients with trough levels  higher than that.  I told him toxic for an opioid-naïve patient may be just what one of my patients needs for stabilization.

I don’t think he ever heard what I was saying. He never got off the topic of drug levels, and implied perhaps she could have obtained methadone from another source.

I suppose this is possible, but unlikely. For this patient to have overdosed on methadone, she would have had to gotten a supply of the medication from another source. I know she didn’t get a prescription for it, since I checked the state prescription monitoring database. And why would she buy illicit methadone off the street when she could just ask to go back up on her dose if she were in withdrawal?

I appreciate that this doctor took the time to call me. He didn’t have to do that, and it probably wasn’t an easy conversation for him. I don’t doubt he’s conscientious at his job.

I only wish he could have heard what I was saying.

What I heard him was saying was more of the same: the medical examiners will base their decision about cause of death on the methadone level, and will not consider any clinical information from me, or presumably from any another other opioid treatment program physician, if a patient dies under my care.

This increases the risk of being a doctor at an opioid treatment program. Because no matter how cautious we are, we treat a group of people who die at higher rates than age-matched controls. Nearly all of our patients smoke cigarettes. Of course they can die from methadone overdose, but they also die at higher rates from cancer, heart disease, liver failure, and other medical problems created from a life time of drug use, including nicotine.

But we now know in advance that methadone will be blamed no matter what. And that’s bad news

The Ugly

Heroin Comes to Town

Last week, several people who should know and have no reason to lie told me heroin can be bought in Wilkes County. I am really sad to hear this.

Heroin has already invaded many small communities. It crept in after black market prescription opioids pain pills became scarce. Indeed, at my state’s yearly Addiction Medicine conference, most OTP doctors said they’ve been treating heroin use disorder for several years.

For some reason, the people I admitted to our opioid treatment program have thus far been around 98% pain pill addicts. Last week, more than half of the new patients were using heroin. One patient came to treatment because the first time he used heroin, he overdosed, nearly died, and woke up in the ambulance. That scared him enough to propel him into substance use disorder treatment.

You may question if heroin addiction is that much worse than pain pill addiction. I think it is, though I could be wrong about this. With pharmaceutical grade pain pills, the user has an idea, usually, of how strong the product is. There’s not much variation from one pill to another. But with heroin, the batch one day could have only a few percent of pure heroin, or 100% pure heroin. There’s no way to know. There’s no way to gauge how strong it is, unless the user dose a “tester shot.” This is when the user uses a small amount of the purchased heroin to see how strong it is. This tester shot is recommended by Harm Reduction Coalition as a way to reduce overdose risk.

Heroin manufacturers usually don’t care about quality control. The heroin could be cut with God knows what else. Some of these substances cause special problems, since they weren’t meant to be injected into the human body.

Quinine, for example, has been found as a contaminant. I’m not sure why it’s used to dilute heroin, but it is. Quinine can cause kidney damage, bleeding disorders, and severe allergic reactions. Some experts believe many heroin overdoses are really fatal allergic reactions to products used to cut the heroin. In the street parlance, adding substances to a drug is called “stepping on it,” meaning diluting it so it can go farther and make the seller more money.

Other regular heroin contaminants include caffeine, talcum powder, powdered milk, chalk, or flour.

Recently there’s been a tendency to include fentanyl in the heroin product, making it an even stronger opioid. This has caused many overdose deaths, particularly in the Northeast. I strongly suspect that’s what my patient with the near-fatal overdose injected.

 

 

 

 

 

 

 

 

 

Usefulness of Prescription Monitoring Programs

I ranted recently about Florida’s Governor Scott’s bizarre decision to give the axe torpedo their prescription monitoring program (see March 8th, also March 6th). Now I’d like to post a link to a thoughtful piece about how prescription monitoring can have positive effects.

This link was found on Brandeis University’s Center of Excellence. These folks do research for public policy surrounding prescription monitoring, among other things. The first URL below is for their home page; the second is for the specific article that I thought was interesting.

 http://www.pmpexcellence.org

http://www.pmpexcellence.org/sites/all/pdfs/methadone_treatment_nff_%203_2_11.pdf

Governor Scott’s Flamingo Express to Misery

Flamingo Express of Florida

All I could think was, “What can he be thinking???”

 I was reading an article about the governor of Florida and his bizarre decision to block the formation of a prescription monitoring program in his state. (1)

 Prescription monitoring programs are databases that contain lists of controlled substances a patient receives, the prescribing doctors, and the dispensing pharmacies. Usually, only approved physicians can get access to these databases. Prescription monitoring programs help prevent “doctor shopping,” which is the term describing the actions of a patient who goes from one doctor to another to get prescription pills, usually opioids, without telling the doctors about each other. Addicts do this to supply their ever-increasing tolerance for the drugs. Drug dealers do this to get pills to sell and make money.

 Forty-two states have approved the formation of prescription monitoring databases, and thirty-four states have operational databases. Florida was one of the last to approve the formation of such a program, in 2009, long after this recent wave of prescription pain pill addiction burned through the country. Now, the new Florida governor wants to cut this program out completely, before it even starts.

 How big of a deal is this?

In the latest survey, 5.3 million people in the U.S. used prescription pain pills nonmedically over the past month. This means they used them in ways not intended, or for reasons not intended by the prescriber… for example, to get high. In the last year, 2.2 million people misused these prescription pain pills for the first time. Our young people are particularly at risk; between 2002 and 2009, the percentage of 12 to 17 years olds misusing prescription opioids rose from 4.1% to 4.8%. Not all of these people will become addicted, thankfully. Some will only experiment, and be able to stop before addiction develops. Many won’t be able to stop taking pills, and will progress into the misery of addiction. Others will die of drug overdoses. (2)

 Why pick on Florida?

Florida is infamous for its pain clinics. As a reporter for Time Magazine pointed out, there are more pain clinics in South Florida than there are McDonald’s franchises. In 2009, 98 of the top 100 prescribers of oxycodone in the nation were all located in Florida. Altogether, these doctors prescribed 19 million dosage units of oxycodone in 2009. Estimates of the numbers of pain clinics located in South Florida vary, but most sources say between 150 and 175. (3, 4) Many of these clinics are “pill mills,” where doctors freely prescribe controlled substances with little regard to usual prescribing standards and guidelines.

 Are all these clinics pill mills?

No. Some of the pain clinics are legitimate, and their doctors follow best practice guidelines, providing quality care to patients with pain. But careful monitoring and screening for adverse events, including the development of addiction, takes time. A conscientious doctor, trying  to do a good job, isn’t going to be able to see fifty pain patients in one day.

 I’ve talked to addicts who were previously patients at these pill mills. They describe how they were shuffled through rapidly, sometimes not even seeing the doctor. Some addicts say they were asked what pills they wanted, and quickly written that prescription, with little or no conversation beyond that. That was the extent of the visit. 

But Florida’s problem doesn’t stay in Florida. Appalachian states like Kentucky, West Virginia, and North Carolina all have addicts who buy these prescription pain pills after they’re transported out of Florida. The DEA sees so many pain pills being transported from Florida to Appalachian states that they call it the “Flamingo Express.” In one of the methadone clinics where I work, I’ve noticed a peculiar upswing in the reported use of Opana, a brand name for the drug oxymorphone. It’s not a drug I’ve seen prescribed much in NC. When I ask patients where the pills come from, many say, “Florida.”

 Governors of several states, including West Virginia and Kentucky, along with congressmen from New York and Rhode Island, have sent a letter to Florida’s Governor Scott, urging him to reconsider his decision to torpedo plans for a prescription monitoring program. Since the leading cause of death in West Virginians for those under the age of 45 is drug overdose, I can see why this governor is protesting Governor Scott’s poor decision. (4)

 It’s estimated that setting up a prescription monitoring program costs about one million dollars. The Florida Prescription Drug Monitoring Program Fund, Inc., a non-profit organization dedicated to raising money for the program, says on their website that they’ve already raised at least half of that from donations. Other states have received the Harold Rogers grant money, available from the federal government to set up these monitoring databases. This leads me to question the excuse of “budget cuts” as the reason for Governor Scott’s poor decision.

 I’ve also seen internet stories that mention the governor’s fear of invasion of privacy. This is a legitimate concern, but there are ways to safeguard the information in such a database, and laws that can regulate who has access. I’m no fan of the government peering into my business, but this database is essential, given the overwhelming numbers of people struggling with pain pill addiction. For a description of the ways in which the North Carolina prescription monitoring database has helped me help my patients, please see the preceding blog entry. It’s been a lifesaver.  

  1. http://articles.sun-sentinel.com/2011-03-05/news/fl-prescription-drug-forum-20110305_1_pill-mills-prescription-drug-monitoring-program-attorney-general-pam-bondi (accessed 3/6/11)
  2. Substance Abuse and Mental Health Services Administration (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings). Rockville, MD.
  3. Thomas R. Collins, Invasion of the Pill Mills in South Florida, Time, Tuesday, Apr. 13, 2010,  Ft. Lauderdale, FL
  4.  http://manchin.senate.gov/public/index.cfm/press-releases?   ContentRecord_id=f62482b4-f6dd-4adc-8b49-1563d8fa605b&ContentType_id=ec9a1142-0ea4-4086-95b2-b1fc9cc47db5&Group_id=e3f09d56-daa7-43fd-aa8b-bd2aeb8d7777&MonthDisplay=2&YearDisplay=2011 (accessed 3/8/11)

Why are so many people addicted to prescription pain pills?

I was reading a great blog I’ve started visiting, http:addictionblog.org and came across an entry about why the U.S. has more pain pill addicts now than 10 years ago.

I couldn’t resist blathering on,  commenting on the blog. I wrote so much the software thought I was spamming. So I thought I’d repeat my comments here, on my blog.

This is an important issue. We now have an estimated 1.7 to 2 million people addicted to prescription pain pills. Many of the conditions that contributed to this wave of addiction have been changed – but not all.

Prescription opioid addiction has increased dramatically over the last decade, due to a combination of factors. First, there was the pain management movement, which emphasized the importance of adequate pain control. Of course that’s an admirable goal, but the risks of addiction were understated due to bad science and misinterpretation of limited data. Instead of a risk of addiction of about 1%, quoted by many pain management gurus, the true incidence is more like 10 – 45%, depending on which study you read.

Then against that backdrop, OxyContin was released and marketed to general practitioners and family docs with limited knowledge about how to identify and treat addiction. In general, medical schools and residencies have done a lousy job of educating doctors about proper prescribing of opioid medications, how to identify addiction, and where to refer people for treatment of their addiction.

 Then there was access to opioids via the internet, which actually seemed to be a bigger problem than it was. A small percentage of abused opioids came from the internet, but some people became addicted in that way. With the changing laws, these rogue internet pharmacies are less numerous.

States most heavily afflicted by pain pill addiction didn’t have prescription monitoring programs in place. These programs are essential tools to identify people who are getting pills from more than one doctor at a time, called “doctor shopping,” which is often an indication the person has an addiction that needs treatment. Fortunately, most states either have these programs now or are in the process of putting them into place.

But a big part of the problem is cultural. We share prescription medications, even controlled substances, with alarming frequency. Most people aged 18 – 24 who use pain pills nonmedically get them from friends or family, not from some nefarious dealer on the corner. Adolescents don’t realize how dangerous prescription pain pills are.

Anyone with pain pills in their medicine cabinet needs to lock them up to keep them safe, or dispose of medication when they are no longer needed. And we need to stop sharing our medications. It’s illegal, dangerous, and contributes to addiction.

Prescription Monitoring Programs

Most states now have electronic databases containing patient information, available to physicians, of all prescribed controlled substances, the date they were picked up at the pharmacy, and the prescribing physicians. The federal government has strongly encouraged states to form these databases to prevent patients from “doctor shopping.” The idea is that every physician will check this database before writing prescriptions for pain pills or other controlled substances, to make sure the patient in question isn’t getting pain pills from another doctor.

These programs have been incredibly helpful to me, since I treat people with addiction. Many of the patients are addicted to prescription pain pills. If a patient gets prescription opioids while I am treating them with methadone or buprenorhpine, my first step is usually to talk with them about what’s happening. If the patient is willing to give me permission to talk with the other doctor, and stop getting other opioids, the patient can usually stay in treatment with me. But if this happens more than once, I may decide it’s no longer appropriate to prescribe methadone or buprenorphine.

I’ve had some patients say that they don’t think it’s any of my business what their other prescriptions are. But I tell them that it’s only my business because they have asked me to prescribe medication to treat their addiction.

Most patients don’t fill any prescriptions without letting me know what they’re getting, but there are always a few patients who have mixed feelings about stopping their prescription opioids. Some patients are concerned that if I talk with their other doctor, they won’t be able to get more opioids from that doctor. I tell them that’s actually what I’m hoping for. It’s important to burn the bridges back to active addiction.

For now, state databases don’t connect with each other. Soon, a national prescription monitoring database may be accessible to physicians so that only one sources needs to be consulted, rather than multiple databases, for doctors who live near state borders.

I know the North Carolina prescription monitoring database has saved lives. Many people worry about their privacy with such a system, and I agree it’s a real concern, but hopefully the databases have adequate security systems to minimize risk.