Drug: a medicine or other substance which has a physiological effect when ingested or otherwise introduced into the body. Man has been using plants and food as drugs since the beginning of time to his benefit as well as detriment.
In past columns I have written about the unconscionable actions of “big pharma” and specifically Purdue Pharma. Starting in 1996, they lied to the public, including physicians about the addictive properties of their products.
In 2018 one would be hard-pressed to say they don’t know the danger of opioids and their addictive properties. Yet, as we completed open enrollment for Medicare Part D Rx plans, I was amazed at the number of clients with drug lists that included large doses of oxycodone, fentanyl and the like.
Health and drug plans are becoming more restrictive on the use of these drugs, requiring prior authorizations and more “hoop jumping” before they will pay for these medications. This has left some disgruntled patients as well as doctors. The patient response is typically that those addicts are “someone else”. Physicians complain that they don’t have the time to deal with this “second guessing” by insurance companies.
CMS (Center for Medicare & Medicaid Services) recently released a proposal to set new tighter limits through “hard formulary levels”. Overrides require plan consultation with the treating physician. Initial Rx for acute pain could be limited to 7 days. We often see health plans follow CMS guidelines, so expect to see more of this.
I was intrigued to read about a project called “Death Diaries” conducted by Dr. Roneet Lev, the head of Emergency Medicine at Scripps Mercy Hospital. According to an article in the San Diego Union-Tribute, she collected the following information from Coroners records for overdose deaths: name, age and a list of the prescription drugs they overdosed on, followed by a yearlong history of the deceased’s medications, the doctors who prescribed them and the pharmacies that filled them. Nothing more.
As she reviewed the data she found disturbing patterns that led her to believe many of these deaths were preventable. She suspected most of the physicians had no idea of their role in the death and decided to extend the project by sending letters to each of the doctors, notifying them that their patient had died.
She also suspected that a striking number of physicians were not using or not properly using the Controlled Substance Utilization Review and Evaluation System, or CURES database. Doctors are encouraged to check this data base before prescribing a new drug to a patient to be sure the patient hasn’t “forgotten” a medication they are using.
One could argue this is one more annoyance to an overly stretched physician’s day. But on the other hand, is it not a gift that we have this type of resource?
Dr. Lev shared a personal experience from the ER. A clean-cut, well-dressed man requested she fill a small prescription for Ambien- a sleep inducing drug. His said he was leaving on a trip and could not reach his own doctor.
Her check of CURES showed 17 doctors and 42 prescriptions in the past year. Seventy-five Ambien pills had already been filled that month — by five different doctors.
She declined to fill the prescription and counseled him about his apparent problem. He did not respond. Dr. Lev put a note in the CURES messaging system to the 17 doctors alerting them to her concerns. There is no way to alert doctors that a message is waiting for them. They have to sign into CURES to see it. Great tool, but clearly missing some functionality.
I wonder about the response of physicians to letters about their patients’ deaths. Would it be like that of a local orthopedic surgeon when he was advised by a local nurse that her son had become addicted to opioids following his surgery? Rather than examine his part in the process, the doctor said, “Had I known he was an addict, I would never had agreed to take him on as a patient”. The young man eventually died of a heroin overdose. Has that doctor since reviewed his post-surgical prescribing patterns?
Dr. Lev’s research into the records also showed that often the deceased patient had misused their prescriptions and/or had illicit substances in their bodies as well. Clearly this is a complicated issue and will require a multi-faceted solution.
There is a local group called NoRxAbuse that seeks to bring together players from law enforcement, social programs and medical providers to help address these issues from multiple fronts. One major task is to contact physicians to try to educate them about their prescribing patterns as well as alternate treatments. It’s a start.