Oklahoma lawmakers are hammering out a bill that would require doctors to check a patient’s drug history before writing a narcotic prescription. Some consider the mandatory checks critical to address a prescription drug epidemic that in 2012 led to the overdose deaths of 534 Oklahomans.
The legislative effort, led by Rep. Doug Cox, R-Grove, and Sen. A.J. Griffin, R-Guthrie, is aimed at eliminating the practice of “doctor-shopping” by patients who fill multiple prescriptions written by different physicians. The two lawmakers sat down last week with The Oklahoman’s Jaclyn Cosgrove and Warren Vieth from Oklahoma Watch to discuss negotiations.
Q: Where are we on getting a bill through the legislature to require that of doctors?
Griffin: “We have reached a compromise, we believe, with some of the other interested parties and that bill, because it’s been changed, now will go to what we call conference committee. We expect to have it out sometime in the next two weeks.”
Cox: “Physicians and practitioners had some concerns with the bill. They wanted to make sure that we didn’t put requirements on them that would take too much of their time because, as you well know, we’re short on medical providers in this state and they don’t have enough time to see the number of patients in line. So they wanted to make sure it was time efficient.”
Q: Why do you think it’s necessary to make a doctor look online every time he or she writes a prescription for narcotic drugs?
Cox: “The idea is to get physicians to pick up on patients that are drug shoppers, that are doctor shoppers, that go from doctor to doctor, emergency room to emergency room or nurse practitioners or dentists or whatever to obtain excessive narcotics for either personal use or for diversion. It’s a real problem in Oklahoma. As almost everyone knows, we have more citizens dying from prescription narcotic overdoses than we do car wrecks in this state.”
Q: Why wouldn’t they do this voluntarily?
Griffin: “That is a question we’ve asked as well. But medical physicians have a lot of pressure on their time and they see a lot of people with a lot of different types of problems. And substance abuse isn’t necessarily in their wheelhouse so to speak. So they generally don’t look at their patients as a potential substance abuser.”
Q: Dr. Cox, you still work in the emergency room on the weekends. How long does it take to check the PMP?
Cox: “Once you get used to doing it, once you have an icon on your computer screen that goes directly to the site, I would say 60 to 90 seconds. So it’s quite fast. However, being a family medicine doctor for the first 18 years of my practice life, I can relate to the small-town doctor who has taken care of Aunt Mary for ten years and he knows Aunt Mary and he knows that Aunt Mary’s knees are just bone on bone. In a small town you see Aunt Mary not only in your office, but also in the post office, the grocery store, the local café, and I’m not to worried about Aunt Mary diverting drugs. So the physicians say, ‘Why should I take the time and trouble to check the PMP on Aunt Mary?’ The other thing that physicians say is, ‘Why do I have to pay the price and be inconvenienced for the small number of doctors who routinely overprescribe?’ Unfortunately, I think that’s kind of life as we live it today. I’ve never hijacked an airplane. I’m not a terrorist. But when I go to the airport, I still have to take off my shoes, my belt, and go through a metal detector.”
Q: But don’t a lot of the patients who ultimately become doctor shoppers and overusers start out as Aunt Marys in some cases?
Griffin: “I would say that happens very frequently. You can’t tell by looking at someone if they have cancer either. And we have this belief about substance abuse that these are people that are living on the fringes of our society, that you can tell by looking that someone is a drug abuser. With prescription drug abuse, most of these individuals never set out to use an illegal drug or to misuse a legal one. It just happens because these are physically, highly addictive medications.”
Cox: “That’s true. Many of the people that become addicted are prescribed their first dose for a legitimate medical reason, either a sports injury or arthritis, but you never know which patient that first hydrocodone pill is going to make so sleepy they don’t like it, or, number two, it treats their pain and then they quit it, or, number three, who it’s going to reach out and grab and they like it so much that they later become addicted.”
Q: What’s the current legislation look like and how has it changed since it was first written?
Griffin: “Most of the changes have been in who’s going to enforce the changes of the requirements. Physicians had some concerns with that being the Bureau of Narcotics and Dangerous Drugs so it has been moved to their medical boards that supervise the appropriate specialties. That’s been the biggest change.”
Cox: “I think another important thing in the legislation is the fact that we allow the physician’s office personnel, either their receptionist or their nurse, whoever they designate, to have access to the (prescription monitoring program) website, to get on there and print off the report for the physician. So it actually takes time not from the physician, but a little bit of time of their nursing staff or office staff.”
Q: We’ve already talked to some doctors who are already doing that. There are probably some who are not aware they’re not allowed to do that.
Cox: “The other thing I did in the past not knowing it was technically illegal was to be able to show the report to the patient and say, ‘here’s your history of narcotic use and this is the reason why I’m not going to write you a prescription for a controlled narcotic.’ In the past, unbeknownst to myself and many physicians, that was not allowed under the law. We changed the law to make sure the physician can share that with the patient and, importantly, we have relieved the physician or provider….of any liability where the patient may come back and say, ‘I’m going to sue you because you’re calling me a drug seeker or because you report me as a drug seeker.’”
Q: Last year Oklahoma pharmacies filled nearly 10 million prescriptions for narcotics. As your bill was originally written, it would have required doctors to check that PMP every time they write one. As it’s currently written how often would they have to do that?
Griffin: “With each new prescription and refill and then at least once a year.”
Q: So out of those 10 million prescriptions, how many of those would that cover?
Cox: “Basically, between prescriptions and refills, it’s going to essentially cover all controlled narcotics. And physicians reached that compromise basically in exchange for moving the enforcement from the Bureau of Narcotics and Dangerous Drugs to the licensing agencies.”
Q: Do you see this as an opportunity for intervention for these folks who are addicted and may not even realize that they are having a problem with abusing them?
Griffin: “I certainly do, having come from a substance-abuse background. The difference with these individuals is, if you decide you’re going to do cocaine, you know that it’s not good for you. You know that it’s illegal and you’ve decided to take that risk. But individuals are using prescription drugs. It’s a medication. So you don’t have to worry about the criminal element initially. It takes them down a path they never intended to go down.”
Cox: “I think Sen. Griffin said it very well when she said you can’t tell by looking who has a narcotic problem. I think as physicians become more used to using the PMP, they’re going to be surprised at some of the people they pick up. They’re going to be disappointed in some of the people that they pick up. It’s kind of sad about the fact that addiction can affect everyone, regardless of how rich, how poor or what color you are. And physicians will see that, ‘hey, this is a worthwhile instrument to help me.’”
Griffin: “Addiction in our state and other mental illnesses still have such a stigma. Those two things go hand in hand. We need to treat this like the medical issue that it is.”
Q: Where are we in getting those people treatment? Having the resources available?
Cox: “We’re short. We’re short on beds for treatment. We’re short on counselors for treatment. It’s very difficult unless you are independently wealthy or have very good insurance to get adequate treatment for narcotic addiction. I think not just in Oklahoma, but pretty much nationwide. So, we’re trying to attack the root of the problem. Sadly, I think all physicians practice with one overriding motivation; to help people. But, unfortunately, behind every person who’s obtaining prescription narcotics is a physician’s signature on a prescription.”
Q: Why wouldn’t the narcotics bureau continue to enforce these restrictions? Why did you decide to move those over?
Cox: “There was some concern with the ability of the bureau of narcotics and dangerous drugs to fine physicians up to $2,000 for each patient that they failed to check the PMP, that the bureau would use that as a revenue-raising measure and physicians just felt more comfortable having the licensure bureau in charge of enforcement. And there’s some feeling that the licensure bureau can approach physicians if they feel that they’re prescribing excessively, educate that physician, and turn their prescribing habits around before they get further in trouble and lose their licensure.”
Griffin: “It helps reinforce that this is an issue of proper medical practice, not necessarily criminal behavior, both with the patient and the physician.”
Cox: “I think the end goal is to educate and motivate physicians to check on patients and, in one sense, to check on their own prescribing habits. We control our own destiny as physicians and it’s an educational tool rather than a punishment tool.”
Griffin: “Other important changes we’ve made in the last couple of years include allowing the PMP to be part of the Department of Mental Health-approach toward prevention across the state. They can share information, not about specific patients, but about the frequency of those prescriptions, if we have hot spots in the state that we may need to beef up our prevention efforts or intervention efforts and make sure we have plenty of treatment available.”
Q: Doctor, do you run a PMP check routinely when you write narcotics prescription?
Cox: “Yes I do. Probably more so as an emergency physician. I would say emergency physicians have a better habit of checking it because we don’t know our patients. I will tell you that had it been available when I was a primary care physician I probably would not have because I knew those patients and probably, like most physicians, was maybe a little bit gullible. We tend to trust humanity. Unfortunately, being a full-time emergency room physician, sometimes you get a little jaded outlook on life. It’s kind of like being a police officer.”
Q: How often do you detect what appear to be cases of doctor shopping or overuse?
Cox: “I would say I have concerns raised at least once a shift, sometimes more, and again, I practice in a small town of 5,000. More often than I first thought. It’s kind of disappointing.”
Q: What’s the bill number in case people want to contact their lawmaker about it?
Griffin: “It will be S.B. 1820.”
Q: Anything else to add?
Cox: “We talk a lot about the problems of narcotics addiction and the problems in Oklahoma. But I don’t think we should lose sight of the fact that Oklahoma has done a very good job of addressing this problem. We were one of the first states to have a prescription monitoring program and we actually have one of the best ones in the country. We were one of the first states to go live with our PMP, meaning that if I pull a patient’s name up on a computer, if they’ve had a prescription filled in the last 10 minutes, it will be on the computer website. The bill also encourages us to share data with other states. That is a huge plus. For instance, I practice in far northeast Oklahoma where many of the patients that I see may get their prescriptions filled in Arkansas, Kansas or Missouri. Those presently don’t show up on our website, but in the future there will be interstate cooperation.”
Griffin: “What I would leave everyone with is this is an issue that’s touched many Oklahoma families and if you do suspect that someone in your family has a problem of abusing prescription drugs I definitely encourage you to seek treatment, to look for help before it’s too late.”