published Sunday, March 31st, 2013

Tennessee law places doctors on front line of drug war

  • photo
    A pharmacy tech handles hydrocodone bitartrate and acetaminophen tablets, the generic version of Vicodin, at Oklahoma Hospital Discount Pharmacy in Edmond, Okla., in this file photo.
    Photo by Associated Press /Chattanooga Times Free Press.

Starting Monday, Tennessee doctors prescribing painkillers like hydrocodone, oxycodone and other controlled substances will be required to check their patients' prescription history in an online database before signing the prescription slip.

The new requirement -- which was signed into law last year -- is the state's latest effort to clamp down on Tennessee's prescription drug abuse epidemic.

But doctors are concerned that it will add a significant burden in an era of growing medical paperwork.

"It is going to be a great tool, but it is going to be time-consuming and it will be an added burden doctors haven't had in the past," said Rae Young Bond, director of the Chattanooga-Hamilton County Medical Society.

The state's Controlled Substance Monitoring Database has been around since 2006. It allowed doctors and state officials to check on patients' prescription history, but now it will require clinicians prescribing any opioid or benzodiazepine to check first.

The Tennessee Department of Health said in a news release that the new system will "ultimately benefit all Tennesseans" by adding another layer of prevention to prescription drug abuse, putting physicians on the front lines of identifying and confronting doctor shoppers.

"Just as we check for allergies before giving a medication intended to help a patient, medical professionals will now check the database to help keep these powerful medications from causing harm," Health Commissioner John Dreyzehner said in a statement.

If doctors determine a patient has deceived them to get controlled substances, they must report the information to local law enforcement within five days. They are encouraged to counsel the patient to seek treatment.

The law also allows state health officials to keep closer tabs on prescribers who may be abusing their positions. If a prescriber or dispenser has an unusually high pattern of providing controlled substances, the state will launch a formal investigation.

Tennessee has some of the highest prescription drug abuse rates in the country. In 2011, 1,062 people died from prescription drug overdoses in Tennessee, the health department reports.

Dr. Paul M. Hendricks, staff emergency physician at Memorial Hospital for 19 years, said he and other doctors have already been using the database. Emergency rooms have long been a target for doctor shoppers.

"We are busy, and if we don't do our research it is easy to be fooled. Which is one of the benefits of this database," Hendricks said. "In other states where I've worked, you were just guessing or you had to get records mailed. This gives us one broad base to check, and it's very helpful."

WHO'S AFFECTED?

All prescribers with DEA numbers who prescribe controlled substances and dispensers in practice providing direct care to patients in Tennessee, for more than 15 calendar days per year.

The new law also meant the database was restructured, creating easier prescription tracking. In the old system, data only had to be updated every 30 days -- meaning someone could hit several emergency rooms or doctors' offices over the course of a month before the data showed up.

Under the new system, the data from pharmacies has to be uploaded every seven days.

Doctors say they hope the law will not affect patients appropriately dealing with chronic pain. If they have patients who regularly receive painkillers, doctors are obligated to check them in the database during their first appointment after Monday. After that, they just have to be checked once a year.

The law also allows for a number of exceptions, like prescriptions for people who are undergoing surgery, in hospice patients or in a narcotic treatment program, among others.

Hendricks said the check usually takes a few minutes, and recent upgrades have made the database easier to use.

But he said doctors in private practice dealing with a large volume of pain patients will likely have a tougher time complying.

"You add this five-minute process to a bunch of encounters, and it starts to add up. Medicine has become so paperwork-heavy -- it just becomes overwhelming."

Hendricks said he worries the extra work will cause some doctors to stop prescribing controlled substances, as some have done in the face of growing abuse.

DOCTOR-PATIENT RELATIONS

Bond worries about how the new requirement may affect doctor-patient relationships.

"I think it's going to be challenging for doctors to communicate what the requirements are without potentially creating some strain," she said. "I hope that everyone will be patient and understand the reason behind this."

Hendricks said he has had to learn to use careful judgment when analyzing a patient's prescription record.

"You may look on their record and see they got 120 pills the week before -- and it's really obvious they are doctor shopping. But sometimes you've got people who had a toothache one month, and a sprained ankle the next."

If he believes someone is clearly abusing the system, he will report the patient to the state and refuse a prescription. In less-clear cases, he may prescribe only a small dose of medication to get someone through the weekend till they can see their doctor, or just prescribe noncontrolled pain medication.

When he confronts patients, they are often upset, he said. But on a few rare occasions, a patient will admit a problem and seek help, Hendricks said.

The local medical society has been working for six months to prepare the staffs of local medical facilities for the shift. At a recent training seminar, 160 clinicians packed the room.

Bond said the society also is planning more workshops to help doctors learn how to best confront patients they suspect of drug abuse.

"The goal in this process is to give physicians an effective tool to help get a grip on what a serious problem this has become," she said. "If this helps identify problem and helps people address their medication issues, it is a good thing."

While Hendricks is glad he has the system, he laments the dynamic it has brought to medicine.

"As doctors, it is important for us to help treat pain in our patients, but when you get taken advantage of a few times it affects a level of trust we have with all our patients. It's a sad dilemma."

Contact staff writer Kate Harrison at kharrison@timesfreepress.com or 423-757-6673.

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