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Prescription drug war

By: Leigh Ann Laube

New Tennessee law designed to stop 'doctor shopping' for access to narcotics

Tennessee leads the nation in prescription drug use, and is second only to West Virginia in prescription drug abuse.

But those statistics may change thanks to a new Tennessee law that threatens criminal prosecution to anyone who fraudulently seek prescriptions for controlled substances through so-called doctor shopping.

Under the new law, effective July 1, anyone who attempts to get a prescription for a controlled substance without revealing to the doctor any other prescriptions for that substance or one similar to it issued in the last 30 days can be charged.

Doctor shopping refers to the practice of a patient requesting care from multiple physicians, often simultaneously, without making efforts to coordinate care or informing physicians of the multiple caregivers. This usually stems from a patient’s addiction to, or reliance on, certain prescription drugs or other medical treatment.

“Doctor shopping is a huge issue. If you look at it across the state of Tennessee, the state of Virginia, Kentucky, West Virginia ... it’s declared an epidemic in eastern Kentucky,” said Randall Jessee, senior vice president of Addiction & Drug Specialty Services for Frontier Health and head of the Coalition on Appalachian Substance Abuse Policy.

“It's a huge problem in Northeast Tennessee and Southwest Virginia, and it's been that way for a number of years, ever since OxyContin came on the scene.”

According to the U.S. Drug Enforcement Administration, OxyContin, methadone, morphine and Xanax are the most commonly abused and diverted pharmaceuticals in Tennessee.

“In this part of the country, you hardly ever see street drug abuse ... but the prescription drug abuse is unbelievable,” said Dr. Bill Devens, emergency room medical director at Holston Valley Medical Center.

Wellmont Health System’s five Tennessee hospitals have alerted patients to the new law by posting signs in each emergency department that say:

“Under Tennessee state law, you must disclose to your medical provider any controlled substances you have been prescribed in the past 30 days. Failure to do so will be considered an attempt to deceive your provider, who will have a legal obligation to report this activity to local law enforcement. You then become subject to criminal prosecution. Providers at all Wellmont hospitals access a comprehensive database to verify a patient’s prior prescriptions for controlled substances.”

So far, the threat seems to be working.

“They seem to be aware of the law,” Devens said. “I think they’ve figured it out, so they’re being real cautious.”

Brenda Neas, vice president of Blue Ridge Medical Management — a wholly owned subsidiary of Mountain States Health Alliance that owns or manages approximately 75 physician practices in Northeast Tennessee and Southwest Virginia — says while it’s too early to tell what impact this law has had, they have had very few instances of patients intentionally trying to deceive physicians since it was enacted.

“It’s so new and we’ve had so few occasions to utilize it, thank goodness,” she said. “I receive a copy of each report we’ve had to file with law enforcement and I’m estimating that there have been no more than a dozen since July 1.”

Devens said it’s not uncommon to encounter a patient who requests a narcotic for pain relief even after being recently prescribed the same medication by another provider at another facility. But he emphasized the law doesn’t apply to the majority of patients who are prescribed narcotics and use them ethically and legally for pain associated with injuries or chronic medical issues.

The law is geared instead toward those who visit multiple health facilities and multiple providers in a short time span, often exaggerating an illness or injury to obtain multiple prescriptions for the same drug.

It’s a small percentage of overall patient volume, said Dr. Mark Woodard, emergency department medical director at Bristol Regional Medical Center, but a significant percentage nonetheless.

“It’s a serious problem, and I think this law highlights that it’s a problem in our community and our state, and really, a problem throughout the nation,” Woodard said. “This is an attempt to combat the issue, and I think it will make a difference.”

Prescription Drug Abuse Facts

Nearly 7 million Americans abuse prescription drugs — more than the number who abuse cocaine, heroin, hallucinogens, Ecstasy and inhalants, combined.
Prescription pain relievers are new drug users’ drug of choice vs. marijuana or cocaine.
In Tennessee, OxyContin, methadone, morphine and Xanax are the most commonly abused and diverted pharmaceuticals.
Tennessee ranks fourth in the nation in the sale of all hydrocodone medications, which translates into substantial abuse problems.
Tennessee is uniquely bordered by eight states, making it a transshipment corridor and destination location for all manner of illicit drugs. The interstate and state highway systems crisscross Tennessee’s four major cities, carrying a large volume of traffic and making them the primary means of moving drugs to and through Tennessee.
Tennessee is predominantly a “user” and transshipment state, not a major source area for any drug except domestically grown marijuana.
A special report prepared for the Tennessee Medical Board showed that consumption of hydromorphine, hydrocodone, meperidine and amphetamine was above average in the state. Dilaudid and morphine are also mentioned as heavily abused drugs.

(Source: U.S. Drug Enforcement Administration)

Providers at Tennessee hospitals, and any other health facility where narcotic prescriptions can be written, have access to a comprehensive, detailed database that tracks prescriptions issued for controlled substances. Providers are able to cross-reference and verify prescription information provided by patients — regardless of where they received their prescription.

Information can only be obtained, however, for patients issued prescriptions in Tennessee and Virginia. Jessee would like to see the database expanded.

“There needs to be a national system, and if you have that national system and it gives you the detail you need ... and it covers all providers, then you've really got a good chance at that point to impact what's going on,” he said. “Without some governmental influence, you're going to continue to see ... people who are treating it as a business, to get [pills] to sell, and they will get as creative as possible. Sometimes you tighten it up to where their access is really limited.”

Jessee said there has been talk by the Substance Abuse and Mental Health Services Administration (SAMHSA) of creating a national database.

The Tennessee Board of Pharmacy began accepting prescription information into the Controlled Substance Monitoring Database on Dec. 1, 2006. The database includes data on controlled substance prescriptions of Schedule II through Schedule V drugs. The database includes who the prescribing practitioner is; who filled the prescription; basic patient information; and the name and form of medication that the patient received. The database information is maintained and secured by the Tennessee Department of Health.

Prior to having access to the database, Devens said, Wellmont physicians could track a patient’s prescription history only if they were seen previously in a Wellmont hospital, but otherwise had no way to do so.

When he sees a patient in the emergency room, Devens will question them about their prescription history.

“In the interview process, I will point blank ask them, ‘What are you taking for your pain? Have you had anything filled in the last 30 days?’”

Devens said if a patient has a condition that warrants or justifies a prescription for a controlled substance, he won’t hesitate to write it.

“The purpose of the law is not to deny pain medicine to those who really need it,” he said. “It’s more the patient in a lot of pain with no obvious injuries.”

If he finds out a patient has deceived him in trying to get narcotics, Devens tells the patient that he is obligated to report him to the Kingsport Police Department’s vice and narcotics division. Under the law, that person is subject to criminal prosecution for up to a class D felony.

Devens said having the law makes him feel better about writing pain prescriptions and not getting burned.

“It gives us more teeth. That way, if we feel someone’s abusing the system, we have some teeth to confront them. ... It does make us feel better. Having to deal with this does take our time away from the patients who really need us. It’s a pain in the butt to deal with ... but it’s worth it. It protects the patient from himself.

“I think Tennessee lawmakers have done the right thing by coming up with this law,” Devens said, “because patients need to know up front what can happen if they seek a controlled substance and they’re not honest and above-board about the prescriptions they’ve received in the last 30 days.

“We’re not going to go overboard with this. If someone comes in, and they can’t remember whether they’ve had a prescription for 10 Tylenol 3s 28 days ago, we’re not going to report them. If someone is overt, if they make a clear-cut effort to deceive us, that’s when it’s our duty to report them to the authorities.”

Woodard said it’s a troubling issue that will take a concerted, multi-fold effort to have an effect.

“We’re going to do our part as providers by reporting to the authorities those who are violating the law. It’ll take a concerted effort on the part of providers, law enforcement agencies and local prosecutors for this law to have an effect.”

Jessee said he believes the law is trying to get a handle on the supply side.

“You may have people see doctors two or three times a day, or in different states on the same day, or in a short period of time. Where it’s not watched over well, you can see what will happen — if nobody’s watching the hen house. People are getting multiple ‘scripts.’ Doctors, in their defense, they're trying to help people, and some people are really compelling and the first line of treatment in medical service today is medication.

“I think the law, in terms of the tracking process, tightens the system up of observation and monitoring. It holds different parts of the system accountable, and it gets to an illegal activity. I would like to see addicts get treatment. I’m for that, that’s what we do, but at the same time I understand how demand works, and we've got a drug-taking culture in this country.”

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Leigh Ann Laube is lead writer for the Kingsport Times-News’ Health & Wellness magazine. E-mail her at lalaube@timesnews.net