The State of Washington has finally instituted a Prescription Monitoring Program. This program will allow physicians and other practitioners who prescribe controlled substances, and pharmacists who dispense them, the ability to find out what controlled substances have been prescribed to a patient, by whom, and which pharmacies have filled these prescriptions. The database is strictly confidential and allows physicians, health care practitioners, and pharmacists who are registered with the program to utilize it. Other utilizers are the State medical boards and the DEA. The database includes the names of all patients who obtained a controlled substance from a pharmacy, what controlled substances were dispensed, the medication strengths and quantities, and the names of the prescribers and the pharmacies who filled them. Utilizers can obtain this information online only after registering with the State of Washington and by using a secret password. No one else can access this, including office staff.
Why is this a tremendously valuable new tool for pain management physicians? There are unfortunately a growing number of “patients” who are only interested in acquiring controlled substances like opioids, sedatives, and amphetamines to sell on the black market. The name for this practice is “diversion”. The black market value of most of these drugs is many times the cost of acquiring them legally. The profit margin can be tremendous if the patient/diverter has insurance to cover the costs of drug acquisition when obtained with a doctor’s prescription. As the street value of these drugs escalates, the determination of diverters to acquire these drugs escalates as well. For example, a rough estimate of the street value of Oxycontin is about $1 per milligram. An 80 mg tablet might fetch $80 on the street. The potential for huge profits is obvious. These drugs are often sold to teens and twentysomethings who naively suppose that it would provide a great high at a party. The incidence of overdose deaths in this high-risk group is increasing as the abuse of these prescription drugs increases.
A common practice of diverters is “doctor shopping”. A diverter will go to many physicians presenting with a pain complaint or a set of symptoms that would lead to a diagnosis for which a controlled substance is the treatment (back pain, headaches, ADHD, panic disorder). The diverter will go to different pharmacies to avoid being detected by the alert pharmacists who are on the lookout for diverters. Before now, a physician or pharmacists had no way of doing a background check of present or new patients to detect for diversion. The new Prescription Monitoring Program now allows us to do the background checks that will greatly assist us in finding diverters.
Unlike people who develop addictions to medications and who demonstrate aberrant drug behaviors like frequent requests for early refills, unauthorized drug dose escalation, claims of lost prescriptions, and flunked urine drug screens, the smart diverter may behave like the model patient. He/she may follow all the opioid agreement rules, pass all the urine drug tests, and act appropriately during all physician encounters. He/she may also have a significant knowledge about medications and attempt to steer the unsuspecting physician to prescribe the diverter’s drug of choice. The addict is much easier to recognize than the smart diverter. The smart diverter may in fact not use any drugs except just before the next doctor visit in order to pass the urine drug screen.
The Prescription Monitoring Program will greatly assist physicians and pharmacists by creating transparency of the diverters’ actual behaviors. Most diverters are not smart enough to have multiple IDs that would help to escape detection from this program. The advantage has finally swung to prescribers and pharmacists who use this program. The program is just now getting under way. It may take several months to screen everyone in a practice. Some physicians may choose to screen selected patients whom they see as possible diverters based on demographic information (younger males and females), payment methods (cash payment for medications), and a gut sense of who is trying to con you.
Many physicians who might be willing to treat chronic pain patients are reluctant to do so since we have all been conned by someone at sometime. The fear of being conned again has created an adversarial relationship between physicians and chronic pain patients where the majority of opioid users have a legitimate need for these medications that are the mainstay of treatment for most pain conditions. Most pain patients have had to suffer the humiliation of being treated as if they were either an addict or a potential diverter. The utilization of this program will hopefully serve to allay these fears of being conned since it provides the prescriber or pharmacist with a very effective tool to detect diversion. This will serve to increase trust between physicians and pain patients who consistently follow the rules and pass the urine drug screens.
In my practice, I have other methods for weeding out new patients who may be diverters. I require that all new patients provide past medical records of their treatments, including x-ray and MRI reports, surgery or invasive procedure reports, past medication trials and effects, and sometimes, a call to the previous physicians when there are unanswered questions or concerns. I let new patients know that I will not prescribe a controlled substance on the first visit even if they are running out. I require they pass a urine drug screen, read and sign an opioid agreement and informed consent form when opioids may be prescribed. These requirements are usually too much work for most diverters who don’t want to work too hard or wait too long to get their next prescription. They prefer to find the easy prescriber who is not screening for diversion. The use of the Prescription Monitoring Program will allow me to screen out diverters more effectively. I welcome this program as a valuable new tool for the treatment of chronic pain.