When Cody Wiberg, the executive director of the Minnesota Board of Pharmacy, visited his dentist’s office a while back, he asked her whether she’d signed up for the state’s Prescription Monitoring Program, which tracks controlled substances prescribed to Minnesotans, from Adderall to prescription opioid painkillers and benzodiazepines, and some other non-controlled drugs.
It occurred to him to ask because the pharmacy board, which runs the program, had recently identified a patient who’d visited dozens of dentists around the state, possibly seeking addictive prescription drugs.
The dentist hadn’t signed up yet, but said she would. When Wiberg went back for a checkup six months later, though, the dentist confessed she still hadn’t gotten to it. She’d forgotten.
Soon, forgetting won’t be an option for many medical providers. Last month, the legislature passed a law that will require more medical professionals in Minnesota to sign up for the Prescription Monitoring Program. The idea is that if more have login credentials for the database, more are likely to use the program.
The push to expand use of the database comes during something of a public health crisis: Nationwide, the number of deaths related to prescription opioids has quadrupled since 1999, according to the Centers for Disease Control. In 2000, 23 Minnesotans died of opioid pain reliever-related drug overdoses. By 2015, that number had climbed to 216, according to the Minnesota Department of Health — or nearly twice as many people as were killed by heroin overdoses.
Other states have seen reductions in opioid-related deaths when doctors and pharmacists are required to check prescription databases before dispensing drugs — but even with its new law, Minnesota still has no such mandate. Can Minnesota’s softer approach — requiring registration for the program, but not requiring that providers check the database — make a dent in the state’s opioid abuse statistics?
Minnesota’s drug monitoring program was first authorized by the legislature in 2007 and has been running since 2010. It keeps track of every prescription for legal controlled substances — schedules II through V — dispensed in Minnesota, and some non-controlled substances. It also shares data with 22 states, including all the states bordering Minnesota.
At the core of the program, at least from the perspective of a doctor or pharmacy, is an online database that allows people writing or dispensing prescriptions to see how often a patient has previously filled medications.
Here’s how it works: say there’s a patient with pain caused by cancer. They’d like to get powerful drugs to treat that pain, but first need a prescription, which means a trip to the doctor. Before prescribing the drugs — say an opioid like Vicodin — the doctor could check the prescription drug database. The doctor might notice that the patient has a number of recent past prescriptions for opioids from other providers and decide not to authorize more drugs, or at least have a conversation with the patient. But there’s no requirement that doctors check before writing the prescription.
Assuming the patient does get the prescription, the next step is to take it to a pharmacy to get it filled. A pharmacist could also — but doesn’t have to — check the database, and could refuse to fill the prescription. Many chain pharmacies have policies that specify when a pharmacist should refuse to fill a prescription, according to Wiberg. In 2014, for example, an Indiana news organization obtained a Walgreen’s checklist for filling prescriptions for powerful narcotics, which included past history and possible red flags that could indicate doctor shopping.
In any case, any time a prescription for a controlled substance or other monitored drug is filled at a pharmacy in Minnesota (with very few exceptions), it will be reported to the Prescription Monitoring Program. So almost all prescriptions find their way to the database eventually, even if doctors and pharmacists don’t check in on it before prescribing and distributing drugs.
That data give a pretty full picture of what controlled drugs are prescribed in Minnesota. By far, the most commonly prescribed drug tracked by the program last year was hydrocodone with acetaminophen, better known as Vicodin, a schedule II opioid painkiller. In 2015, there were more than 1.23 million reported prescriptions for the drug filled in Minnesota, or one for every four or so Minnesotans over the course of the year.
But legislators think the program could be stronger. That’s why, by July 1 of next year, every Minnesota health-board licensed prescriber permitted to write prescriptions for controlled substances for humans who holds a Drug Enforcement Administration registration, plus every licensed, practicing pharmacist, will be required to maintain login credentials for the Prescription Monitoring Program. Any who don’t sign up could ultimately face discipline by licensing boards, Wiberg said.
They will not, under the new changes, be required to check the database before prescribing or dispensing controlled substances.
That doesn’t mean the data goes unused, of course. As of last year, the Legislature had authorized the board of pharmacy to begin reviewing the data, looking for patients who may be shopping around for doctors due to addiction to prescription drugs. The board now has an on-staff pharmacist who, once a month, crunches numbers to identify any patients who show signs of possible dependency.
In a typical month, Wiberg says, the board identifies between 30 and 40 people who might be doctor shopping and sends letters to prescribers and pharmacies associated with them, notifying them of potential abuse.
Another change coming to the monitoring program is that health boards in Minnesota will soon, for the first time, be able to access prescription drug monitoring data through the Board of Pharmacy in order to investigate complaints against professionals they license, Wiberg said.
The tweaks to Minnesota’s program come as federal agencies are recommending that states strengthen their prescription drug monitoring programs in response to the epidemic of prescription-opioid- and heroin-related deaths (opioid addiction is often a precursor to heroin addiction).
California became the first state to enact a prescription drug monitoring program in 1939. Now, 49 states (all but Missouri), plus the District of Columbia and Guam have systems, according to Brandeis University’s Prescription Drug Monitoring Program Training and Technical Assistance Center.
The programs vary across states, said Thomas Clark, a researcher at Brandeis’ Heller School for Social Policy and Management, who added that the most effective are well funded, and able to track potentially aberrant doctors and doctor shoppers.
In states that have some requirement that prescribers check databases, such as New York, Tennessee, Ohio and Kentucky, researchers have (unsurprisingly) seen a rapid increase in the number of searches in their databases, Clark said. Research has found, he added, that the requirement has changed prescribers’ behavior, leading to a leveling off or reduction in prescriptions of some drugs, including potentially addictive opioids and benzodiazepines.
Drug-related overdose deaths and hospitalizations have declined in states with that require prescribers to check monitoring programs, as have addiction treatment cases, the Pew Charitable Trusts reported in 2014.
Even states that require certain practitioners to check prescription drug databases do not require that they do it 100 percent of the time, Wiberg said. Instead, there are usually caveats: they must check it with new patients, after not seeing a patient for a period of time or if a patient is traveling from far away, for example.
Checking database not a requirement
So if doctors checking the database before prescribing opioids would reduce deaths, why didn’t the Legislature make it a requirement? That’s a concern for Minnesota Rep. Dave Baker (R-Willmar), House author of the bill making changes to the monitoring program.
Baker acknowledges he sees the issue through a different lens than most people. His son Dan became addicted to painkillers after he was prescribed Vicodin for back pain during his junior year at St. Thomas University. Dan died of a heroin overdose in 2011 at age 25.
Baker said not requiring use of the database was the result of compromise: many medical professionals say requiring prescribers or pharmacists to sift through database records will unduly add to their workload, compromise patient privacy or get in the way of professional judgement.
“I don’t think you need to require physicians to look at it,” said Jason Varin, an assistant professor in the department of pharmaceutical care and health system at the University of Minnesota’s College of Pharmacy. “I think what you need to do is set it up that they’re responsible to the patient … if you’re in a profession, you can’t claim ignorance.”
Each search of the online database takes between one and two minutes, Wiberg said, but that could add up at, say, a pharmacy filling 500 prescriptions in a day.
Since 2013, the earliest year data is available on the Board of Pharmacy’s website, the number of eligible medical professionals registered with the Prescription Monitoring Database has increased. In 2015, about a third of eligible Minnesota medical doctors, doctors of osteopathy and physicians assistants were signed up to use the prescription drug monitoring program. A fifth of dentists and more than 60 percent of pharmacists were registered.
“I want to get the numbers up so much higher than (a third) of doctors,” Baker said.
As the number of registered users increased, so did the number of queries into the database by registered users and people delegated, as allowed by statute, to check the program for them: While 2013 saw about 550,000, last year’s number was up to nearly 1 million. Wiberg expects that number to rise as more eligible users sign up.
“Based on what we know has happened in other states, where they did not have required registration and they moved to required registration, we do expect to see an increase in the number of queries,” Wiberg said. “The program is going to work best if the people who can use the program actually use the program.”
Most people who become addicted to prescription pain medications don’t intend to do so, Varin said.
“A lot of the people who become dependent on these drugs didn’t do so on purpose and they did so legally,” he said.