A closer look at health care solutions for the drug epidemic

Following months of hearings and testimony, the Massachusetts OxyContin and Heroin Commission issued its report and recommendations in November.

The commission, created by the state legislature to assess the drug problem, was blunt in its description.

“The Commonwealth is in the midst of a serious and dangerous epidemic. … Prescription drug use is skyrocketing, opioid overdose deaths are steadily increasing. … Addiction is a medical disorder, and we have a public health epidemic on our hands that is larger than the flu pandemic.”

The problem is severe. Between 2002 and 2007, 3,265 Massachusetts citizens died of opiate-related overdoses. Further, the Partnership for a Drug-Free America estimates that every day 2,500 teenagers use prescription drugs to get high for the first time.

While the causes of the problem are complex, the solutions must be implemented with a commitment to government fiscal allocations for prevention and drug treatment programs. As substance abuse and addiction treatment research grows, the Commonwealth can be more effective in reducing these problems.

The commission offered recommendations in 20 areas of public policy, including education, criminal justice, law enforcement, job training, family issues and health care.

As the top three recommendations relate to health care, I would like to comment on those from a physician’s perspective.

Prescription Monitoring Program

The commission recommended an “overhaul” of this program, saying its failure was a “consistent theme” at public hearings and that the “opiate crisis in Massachusetts is largely fueled by the misuse of prescription medication.”

The commission added: “In almost every case … in which these medications reach the street, the PMP could have acted as a preventive measure. … [T]he state’s inability to use this system to intervene in clear cases of prescription drug abuse, to reduce the frequency of ‘doctor shopping’ or use data from this program to target resources is, perhaps, one of the greater tragedies in this decade-long struggle with opiate abuse.”

If this program has failed, I submit it’s not due to system design. It contains adequate mechanisms and funding from prescriber fees to look for prescribing patterns and issue warnings. It’s capable of identifying patients who “doctor shop” and doctors who may be outliers in prescribing habits.

The system is sound and can be retooled with an appropriate focus on staffing and reallocation of resources. Further, opiate abuse is a significant public health problem, so monitoring should remain, as regulations stipulate, with public health professionals at the Department of Public Health. Moving monitoring to another state or non-governmental agency may have unintended consequences.

Pain Management Training and Education

The commission stated that educating providers is “a major tool in fighting the legal prescription drug abuse trade” and that “the DPH and Board of Registration in Medicine should work closely together to further develop effective strategies to ensure physicians are properly and effectively trained.”

No profession believes more strongly in the value of training and education than physicians. But the unspecified nature of the recommendation precludes any legislative or regulatory mandate and provides more questions than answers.

Who would design and deliver the training? Who must be trained?  Would lack of training prevent medical or nursing licensure? Where would training resources come from? Would the focus be pharmacology, addiction psychology, pain management, or would it tilt elsewhere, towards a law enforcement perspective?

More training and education – of physicians, other providers, patients and the public – are desirable, as are better focus and more details for this recommendation.

Tamper-Resistant Prescription Pads

Saying that “fraudulent prescriptions have become a growing problem,” the commission believes a fraud-resistant prescription pad program would allow “additional safeguards” for prescription delivery. It urges that all prescriptions for controlled substances be written on official state pads and that “no exemptions to this rule may exist.”

I make two points in response to this recommendation.

First, the federal government already requires tamper-proof prescriptions for Medicaid. What purpose would another state program serve and would it be compatible with the federal one?

Second, a paper system would create more bureaucracy (as well as more transportation storage and review costs) at a time when the health industry is moving – and being urged by the state to move – toward information technology and electronic prescribing methods.

I commend the commission for its comprehensive look at an intolerable situation and its dedicated approach to finding solutions. Its report heralds the magnitude of the problem, which is unacceptable.

While a multi-pronged approach is necessary, the results must be continuously studied to direct efforts for the greatest impact. But with state resources incredibly scarce and essential programs being cut, the attack on this epidemic from a health care perspective is best accomplished with full utilization of the well-designed resources we have in place and a rededicated commitment to protecting our patients.

Alice Coombs, M.D., a critical care specialist and anesthesiologist, is president-elect of the Massachusetts Medical Society.