By Stuart Colburn, Esq.
By Stuart Colburn, Esq.
This is the third part of a three-part series on prescription drug abuse in America. Part One explained “the problem”. Part Two identified the stakeholders involved with this epidemic. Part Three below discusses strategies for addressing prescription drug abuse.
A. Government Regulation
Prescription drug abuse and diversion is a problem requiring close interaction between public and private sectors. Stakeholders must work together using tools at their disposal in a coordinated effort to fight supply and demand. The most successful action the government can take in partnership with other stakeholders is a prescription drug monitoring program (PDMP). Some states have created their own programs with varying degrees of success. A model program includes:
A PDMP must be mandatory for either doctors or pharmacies and must be in real time. No comprehensive strategy will be successful without it. The front line suppliers (doctors who prescribe and the pharmacies who fill) will instantly know if the patient is taking prescription drugs from another source. The PDMP protects the front line suppliers from charges of creating an addict. Regulators can monitor the prescribing habits of outlier doctors for more education or oversight.
Texas, for example, recently began regulating pain management facilities. The Texas pill mill bill requires facilities and their owners to register if they derive 50% or more of its business from writing pain prescriptions. All facilities must be owned by a doctor who spends at least 33% of his time treating patients at the facility. After the pill mill bill became law, there was a 45% drop in scheduled narcotics prescribed in Houston compared with the same time the year before. Prosecutors and law enforcement successfully used the pill mill bill to crack down against doctors improperly prescribing or diverting scheduled narcotics.
The Texas pill mill bill author, Senator Williams (R-The Woodlands), successfully passed a new law in 2011 that makes it a crime for individuals, including patients and people in the industry, to divert drugs. A patient may no longer conceal a material fact when seeking or filling a prescription. Concealment of a material fact is defined as follows: “For purposes of this subsection, a material fact includes whether the person has an existing prescription for a controlled substance issued for the same period of time by another practitioner.” The addict or diverter who attempts to fill a prescription for a drug while already receiving that drug for the same time period from a different source commits a crime.
The Texas workers’ compensation system recently adopted a pharmacy closed formulary pursuant to legislation, with the goal of bringing more drug prescribing consistency in both certified workers’ compensation health care network and non-network claims. The rules adopted by the Texas Division of Workers’ Compensation allow an appeals process for claims in which a treating doctor determines and documents that a drug not included in the formulary is necessary to treat an injured employee’s compensable injury. Learn more here.
The public has an unreasonable view of the knowledge base of healthcare providers. Although every doctor graduated from medical school, knowledge itself comes from specialized training. Scheduled narcotics should only be prescribed by doctors with the requisite training and experience. Those doctors granted the additional license to prescribe scheduled narcotics would be subject to additional regulation.
Physicians should be required to check with the PDMP database before writing a prescription for dangerous drugs. Failure to comply would place the physician at risk of forfeiting his/her license to prescribe the drugs, not to mention possible lawsuits. A physician who does verify using the database should enjoy immunity from lawsuits.
Prescribers of narcotics should enter into drug contracts with their patients. Routine and random monitoring of the patient’s urine will confirm the drugs are being taken (to avoid drug diversion) and at the right levels (to avoid abuse). Violations of the drug contract should be reported to the PDMP database.
Drug dispensing by physicians does have some benefits, but also has the potential for abuse by the inevitable bad actors present in every group. Indeed, the cost to human life and dollars are staggering even if only 1% of all providers were problem dispensers. If physician dispensing is allowed, the reimbursement rate should be no higher than that of the retail pharmacy, thereby removing the profit motive to dispense more drugs or stronger, more addicting (and expensive) drugs. The physician dispenser should be allowed to bill extra for drug contracts and urine testing.
Pharmacies should be required to participate in a prescription drug monitoring program for scheduled narcotics before dispensing scheduled narcotics.
D. Pharmaceutical Companies
Drug companies should design drugs to deter abuse. Drug companies can employ manufacturing techniques, making it more difficult or impossible for drugs to be ground up into a powder.
Example: Old OxyContin vs. New OxyContin
RADARS reports that addicts seeking OxyContin on the black market are paying far less for the new tamper-resistant OxyContin, signaling that the new version is more difficult to crush, snort, and inject. Read more here.
Pharmaceutical companies should not be allowed to market scheduled narcotics for off-label use. (The most famous example is fentanyl, an end-stage cancer pain drug, marketed for low back pain.)
Public education about prescription drug abuse should be paramount on billboards and in our school systems. Every day, 7,000 young people abuse prescription narcotics for the first time. Patients who receive a prescription or scheduled narcotics should also undergo approved education and information.
Payers should implement strategies designed to identify addicts, diverts and outliers. Payers should urge policy makers to adopt PDMP and common sense laws giving regulators the information and power necessary to fight PDA. Payers have ever more increasingly sophisticated software able to perform advanced predictive modeling and performance analytics that can identify outlier doctors and possible addicts. Communication with other stakeholders early in the process, both as preventive education and proactive identification of early PDA, is essential. Use of prescription benefit managers (PBM) and drug formularies is currently available for implementation.
The problem: Each state has different laws and attitudes towards PDA complicating payers’ efforts.
Many people believe America is losing (or has lost) the war on drugs. That war is important. But PDA kills more people and causes more family destruction than all the illegal drugs. All stakeholders should be engaged in searching for, and, at times, demanding solutions to PDA. Doing nothing is not the answer.
© Copyright 2011 Stuart Colburn, Esq. Reprinted with permission.
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