Opening new fronts in the war on opioids

He didn’t look like an addict. The 50-year-old suburbanite sitting in Dr. Charles Cutler’s Norristown exam room was a husband, a father and a long-time patient. When he asked for an opioid prescription to deal with his pain, Cutler had no reason to doubt his sincerity. But because of a new state law that took effect last summer, Cutler was legally obligated to look up his patient’s records on Pennsylvania’s new, online prescription drug monitoring program, or PDMP. Upon doing so, he was surprised to see that the man had recently filled an opioid prescription from another doctor. When Cutler asked what happened to those pills, the patient admitted that he doubled up on them. “Then I knew we had a problem,” Cutler recalled thinking.

Cutler isn’t just an internist; he’s president of the Pennsylvania Medical Society. His organization and many others advocated for creating the PDMP, which was proposed as Act 191 and signed into law by Gov. Tom Wolf in 2014. Overseen by the Pennsylvania Department of Health, PDMP attempts to curb opioid abuse by flagging pill seekers who go from doctor to doctor asking for prescriptions to feed their addictions. Now, prescriptions for everything from oxycodone to codeine must be entered into the PDMP when they are filled. Physicians are also required to check the PDMP before writing prescriptions for new patients or writing new prescriptions for existing patients.

PDMP is statewide, superseding regional systems such as the HealthShare Exchange of Southeastern PA and the Keystone Health Information Exchange in central Pennsylvania. It’s also interstate, widening the scope to New Jersey and Ohio. “Patients who shop for controlled substances will go anywhere,” said Mike Evans, a clinical investigator and associate vice president of strategy and innovation for Geisinger Health System. “Think you’ll just slip over the border and get a scrip? Not anymore.”

In September, more legislation further tightened restrictions on opioid prescriptions. Act 122 limits the quantities of opioids that can be prescribed by emergency room and urgent care physicians to seven days. Act 126 put restrictions on opioid prescriptions for minors. Further legislation is expected; Wolf has repeatedly stated that combating opioid abuse is a central piece of his agenda.

Creating the PDMP was a first step, although not a particularly innovative one. Pennsylvania was the 49th state to enact such a database. Nevertheless, the PDMP was a significant step forward in enlisting the medical community in the fight against pharmaceutical addiction. Its effectiveness has allowed advocates to ask the freighted question of whether an alliance between government and physicians can really curb opioid abuse, or if this is a case of government overstepping its jurisdiction by legislating how and what physicians prescribe.

Dr. Mike Lynch said yes to both questions. As medical director of the Pittsburgh Poison Center and an emergency physician at University of Pittsburgh Medical Center, Lynch has seen many pill seekers and many patients with acute injuries that necessitate using opioids for pain management. While the PDMP is a good tool, Lynch said, he will always rely on his medical judgment. For example, Lynch won’t deny opioid pain management to a patient with a broken bone just because there are previous opioid prescriptions in the PDMP. “What the ER staff and I like about the PDMP is that when I’m making decisions to responsibly prescribe opioids, I can have objective, factual information at my disposal,” he said.

On the other hand, patients can have opioid addictions, past or present, that aren’t documented in the PDMP or anywhere else. Title 42, a federal regulation authorized by the Drug Abuse Prevention, Treatment, and Rehabilitation Act of 1979, protects the confidentiality of patients’ records, including their diagnosis and treatment for drug abuse. “In case of a car accident or other trauma, a physician may give a patient opioids and accidentally restart an addiction or put a patient at risk for that,” said Evans, who, in addition to his other roles, is co-director of Geisinger’s Center for Pharmacy Innovation and Outcomes. Evans would like to repeal and replace that law.

Doing that would certainly help pharmacists, who form another line of defense in the war on opioid abuse. Pat Epple, CEO of the Pennsylvania Pharmacists Association, advocated for the creation of Pennsylvania’s PDMP. “We’d seen it work in many other states,” Epple said. “Any tool we have to fight prescription abuse is a tool we want.”

That said, her organization did push back against some of the PDMP’s initial components, saying that they placed an unfair burden on pharmacists. For example, the original law mandated that pharmacists update the PDMP in real time, as prescriptions were being fulfilled. PPA pushed for a 72-hour timeline so pharmacists could phase in the system. “There was a lot of debate and discussion about that,” Epple said. “Real time is expensive and costly. The next business day is as close as we can get – that’s where the majority of pharmacists are now.”

Her group also wanted to limit government intrusion on how pharmacists make decisions. “We wanted to preserve pharmacists’ rights to execute their judgment in the fulfilling of prescriptions,” Epple said. “Our members know the red flags of drug seekers: new customers, paying cash, exorbitant amounts of pills and odd combinations of them.”

What do medical providers do when those red flags are raised? Are they required to call law enforcement or recommend some kind of treatment? “There isn’t a mandated protocol – and shouldn’t be,” Lynch said. “How we use the PDMP information remains in the hands of individual providers. The culture of medicine has shifted to being very conscious in understanding the power of opioid medications. We certainly educate our patients about their potential addictiveness. But it also is not our intention to leave pain untreated.”

That’s especially problematic for chronic pain, Cutler said. “Pennsylvania Medical Society recognizes the need for better treatment options for people with chronic pain,” he said. In his practice, Cutler uses evidence-based treatments as a first line of treatments for chronic pain. If those prove ineffective, Cutler talks to patients about acupuncture, chiropractic and physical therapy.

But those treatments, while proven to be at least somewhat effective, can become cost-prohibitive for patients because most insurance plans don’t cover them or only allow a certain number of sessions. The federal government can lead the charge in changing that. “The largest health care provider is Medicare and Medicaid, so government can play a role in covering more services like physical therapy,” Cutler said. “Commercial insurers would likely follow suit. If it provides an option to opioids, why not try it?”

Epple wants more to be done to stop people from getting started – or restarted – on opioids. “There has been overprescribing of opioid products in the past,” she said. “I’m not pointing fingers, but it has to slow down. And then we have to provide resources for people who are already addicted.”

That’s the biggest hazard of the PDMP: cutting off prescriptions without having readily available treatment options for opioid addicts. Government can lead the way there, too. “One good way to facilitate treatment that people can afford is to have it reimbursed by Medicaid and Medicare,” Lynch said. “Affordable, accessible addiction treatment is our most urgent concern for the short term.”

Lynch repeated what every medical provider knows: When prescriptions or money to fill them runs out, opioid addicts often turn to heroin, which is less expensive and more readily available. Heroin usage in Pennsylvania is at epidemic proportions. In 2014, the Centers for Disease Control and Prevention ranked the state eighth in drug overdose deaths. Overdose deaths rose 23.4 percent in 2015 and heroin played a role in 55 percent of those deaths. The problem is statewide: 59 of Pennsylvania’s 67 counties reported heroin as the main cause of overdose fatalities.

State and federal government agencies have legalized and trained first responders to use naloxone, the drug that can counteract an opioid overdose. But getting addicts help before they overdose is the overarching goal. To that end, Wolf designated $20.4 million to create 45 new drug treatment centers throughout Pennsylvania. When and where they will be built has yet to be announced.

Geisinger isn’t waiting. In 2017, the health care system will open three new addiction medical centers. “We have a shortage of outpatient treatment centers for patients who are addicts,” Evans said. “It is a chronic disease. We need to help patients manage it on a day-to-day basis wherever they are.”

Why don’t more health care systems have extensive drug treatment centers? Cutler said it’s a matter of insurance reimbursements, which the government could also change. The Affordable Care Act mandated that insurance companies cover annual mammograms and other services. It could do the same with addiction, Cutler said. But one hurdle in doing that is the stigma of addiction. For example, Americans rally around efforts to raise awareness and funds for all kinds of cancer, Alzheimer’s disease, Parkinson’s disease and many others, but not addiction. Cutler said the medical community is equally to blame. “Almost every major university and medical school has a cancer center that cares for patients and does research into new cancer-fighting treatments,” he said. “Why don’t we have that for addiction?” ■