Does Plan to Require Tougher Controls on Painkillers Go Too Far?

Andrew Kitchenman | January 23, 2014 | Health Care
Medical examiners say doctors may be hesitant to prescribe drugs, leading to unnecessary suffering

Dr. Paul Jordan and Kevin Walsh of the state Board of Medical Examiners air concerns about proposal for tighter monitoring to prevent abuse of prescriptions for painkillers.
Proposed tighter monitoring of opioids and other dangerous drugs has doctors and others worried that it may result in unnecessary suffering for patients who really need the powerful painkillers.

Those concerns were front and center at a recent meeting of the State Board of Medical Examiners, whose members raised concerns about requiring all doctors who prescribe potentially addictive painkillers to check on whether their patient has already gotten the drugs from another source.

Prescribers would be required to show that they’ve checked the Prescription Monitoring Program (PMP), a database that tracks all prescriptions of controlled dangerous substances such as opioids.

Supporters of the mandate say the concerns are overblown and that tougher steps are necessary to deal with the state’s prescription drug-abuse crisis.

The issue has been in the public eye since July, when the State Commission of Investigation released a report that found some doctors had been bilking Medicaid by wrongfully handing out prescriptions for opioids that found their way onto the black market.

The SCI report recommended that “at a minimum,” the top 30 percent of prescribers of controlled substances be required to access the PMP before prescribing these drugs to make sure patients aren’t repeatedly seeking the drugs from different prescribers.

The task force’s report quoted regulators and law-enforcement officials who said the State Board of Medical Examiners’ actions have been “weak and infrequent.”

Since then, other proposals to require PMP participation from all prescribers of dangerous drugs have been advanced by legislators and by members of a state task force studying heroin and other opiate use by young people. The task force, launched by the Governor’s Council on Alcoholism and Drug Abuse, made a similar recommendation in a report it completed in the fall, according to task force chairman Frank L. Greenagel Jr.

A pair of bills, S-3063 and A-4393,
introduced in the last legislative session also would have required prescribers of controlled substances and pharmacists to check the PMP before issuing prescriptions. While the bills weren’t passed before the end of the session, debate is expected to continue in the new session.

Board of Medical Examiners member Kevin Walsh, a physician assistant, said he became concerned about the proposal after discussing it with emergency room doctors. He would like to see any new requirement imposed only on doctors who are likely to see patients seeking illegal prescriptions, such as pain-management doctors.

On the other hand, emergency room doctors “just see this as another thing that ‘s going to take added time, that’s going to slow down the process of seeing patients,” Walsh said at the January 8 board meeting. He cited the example of a doctor who worked in Pennsylvania and saw doctors avoid prescribing appropriate pain relievers because of the difficulty documenting that they had checked records of the patients’ prescriptions.

“You started to see a decrease in pain medication being given, even for people who appropriately should have been given stronger pain medication” but were instead given over-the-counter pain relievers, Walsh said.

Walsh suggested requiring prescribers to check the PMP if they are prescribing more than a specified number of tablets. He said emergency doctors rarely prescribe more than 20 tablets of an opioid, while patients seeking illegal prescriptions want 60, 80 or 120 tablets.

“In a way, I would say it’s a good idea – I would say that the pain management (specialists) should be checking the PMP, without a doubt,” Walsh said.

Board member Karen Criss, a certified nurse midwife, said she was concerned about the possibility of swinging back toward a tendency to undertreat patients’ pain symptoms.

“My biggest concern is that we get back to where we were a decade ago, when doctors were then reluctant to treat the truly chronic pain patients,” said Criss, recalling that the board received complaints at that time about doctors failing to treat legitimate pain. “They just wouldn’t do it because, you know, they just didn’t want to be subject to investigation.”

Criss said the state must get a handle on prescription-drug abuse, but it shouldn’t repeat previous mistakes.

Dr. Paul Jordan, another board member, referred to patients with severe conditions – giving the example of an 80-year-old with a fractured shoulder — being denied appropriate pain relief.

“The more things you introduce into the process, the slower the process works,” Jordan said, referring to emergency-department responses.

Board staff and committee members will now weigh whether to endorse the legislation. Board members noted that they generally support efforts to combat prescription drug abuse, but said they are concerned about the impact of the new requirements placed on prescribers.

Greenagel noted that some states already require prescribers and pharmacists to check versions of the PMP.

“I think it makes perfect sense,” to add the requirement in New Jersey, Greenagel said yesterday. “A lot of professionals in these professional groups are going to oppose it because it leads to extra work.”

But in the long run, Greenagel said, they will likely find the added requirements to be like seatbelt laws – an insignificant inconvenience that leads to real public health benefits.

Sen. Joseph F. Vitale (D-Middlesex) has called for comprehensive legislation addressing drug prevention, treatment and recovery.