POCP Blog

By Maria Friedman, Senior Consultant

The war on drug abuse is taking a turn with the growing spotlight on physician overprescribing. More fuel has been thrown on the fire with new studies showing that it’s overprescribing physicians who are putting patients at risk, not just the friendly neighborhood drug dealers.

According one study, nearly one in three Medicare beneficiaries who get prescriptions for painkillers can get them from multiple doctors and, not surprisingly, they have higher hospitalization rates. What’s worse, the physician prescribing them is unaware that they are already receiving prescriptions from another doctor. Possible results are easy to predict: further drug abuse, inadvertent drug-drug interactions, avoidable hospitalizations and premature deaths. Although nobody has quantified these impacts on the Medicare budget, a back-of-the-envelope computation leads to big costs very quickly.

Another study focused on the drug abuse problem in Tennessee.  One of every three Tennesseans fills a prescription for narcotic painkillers at least once a year. Nearly 5.2 million Tennessee residents received painkillers — 37 million total prescriptions — between 2007 and 2011.  This adds up to about 1.4 prescriptions per resident. Among patients who received narcotic pain killers in 2011, 7.6 percent got prescriptions from more than four doctors and 2.5 percent went to more than four pharmacies to get their medication. Topping the list in 2011, 32,000 Tennesseans received 25 or more prescriptions for opiates, and 5,500 got prescriptions from 10 or more doctors. The researchers and law enforcement think this kind of scenario is not necessarily limited to Tennessee, and is found nationwide to one degree or another.

Opioid Abuse Linked to Heroin Use

Prescription drug abuse—especially for opioids–is at epidemic proportions.The Centers for Disease Control and Prevention (CDC) has characterized prescription drug abuse and overdose as 2014’s second highest health threat. Deaths from overdoses of opioids have risen to more than 16,600 in 2010. Moreover, experts believe opioid abuse has led to the recent spike in heroin use, as well as heroin overdose deaths. The reason is that many patients often abuse painkillers before switching to heroin. Attorney General Holder has announced law enforcement’s commitment to address the problem.

Stopping doctor overprescribing is complicated. There is no question that opioids are a front line of defense against pain and suffering. But then there is the overprescribing aspect. First, there are the doctors who unknowingly overprescribe—either because they lack the knowledge about what medications their patients are taking across the board or because they are not well educated about addiction. Then there are the rogue physicians who are in it mostly for the money. And it’s good money. Take, for example, Anand Persaud. This Long Island, N.Y., internist, wrote more than $1 million in prescriptions for painkillers for 5,800 patients. He accepted only cash from his patients, many of whom subsequently were reimbursed by Medicaid. (Such fraudulent activity is rampant elsewhere. Pro Publica published an interesting article on the extent of fraud in Medicare Part D, if you’re interested.)

Health IT Solutions and Policy Levers Key

However, law enforcement, state governments, pharmacies and others are developing solutions.  Electronic prescribing (ePrescribing) is among the first lines of defense. New York will require that all prescriptions—including those for controlled substances—be ePrescribed by March 27, 2015. Efforts to make medication histories more complete will help, especially if we can figure out how to fold in drugs that are paid for by cash. Nearly all states have Prescription Drug Monitoring Programs (PDMPs), which are in the process of being beefed up both in terms of content and technology. Some states are moving to require real-time access to data; others are requiring at the PDMP data base be checked and annotated when a prescription is written or dispensed.  Pharmacies, including CVS-Caremark and Walgreens, are on the case as well.  CVS-Caremark is using data analytics to identify potential problem prescribers. Walgreens has a “Good Faith Dispensing” policy, which requires pharmacists to use a checklist before dispensing controlled substances. Medicare is beginning to get on board by starting to use data analytics to identify problem prescribers. Medicare also is exploring policy levers for better oversight, such as requiring all Part D prescribers to becoming Medicare participating physicians. The American College of Physicians is concerned about the problem enough to issue a white paper about it.

It’s disheartening to learn that physicians are a bigger part of the Nation’s drug abuse problem than we might have suspected. On the other hand, it’s heartening to see that stakeholders are recognizing the problem and are stepping up.  But it’s only a beginning. We all can, and should, do more.  

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