Focus on Opioids May be Curbing Prescriptions

Pennsylvania’s avalanche of opioids that rolled from factories through pharmacies to medicine cabinets, and then tumbled into the streets with tragic results, may finally be slowing thanks to pressure on the prescribing practices of its doctors.

This year, the long-lagging state caught up with the regulatory steps of many of its neighbors, as Gov. Tom Wolf and legislators from overdose-plagued districts wrote new laws. Initial data suggests that attention to the overprescribing of opioids – widely blamed for starting addictions that progress to heroin use – has started to affect doctors’ decisions.

“I think that our message is getting out, and I think there is the beginning of a change in prescribing culture,” said state Physician General Rachel Levine. “There is evidence that there has been, both in Pennsylvania and nationally, less prescribing for opioids by physicians and other health care providers.”

Highmark shared data showing that the number of prescriptions for opioids it reimbursed in each of the past three months was lower than in any of the prior nine months. UPMC Health Plan would not provide detailed data or an interview, but wrote that 16 percent of its insured population received at least one opioid prescription this year, down from 20 percent in 2015.

Highmark is working to identify and treat patients with conditions like depression, which can lead to prescription abuse and illicit drug use, said Dr. Charles DeShazer, the insurer’s vice president and executive medical director for clinical services. And in West Virginia, the insurer has hired Axial Healthcare to comb its data for indications of overprescribing, so that it can “discuss with (doctors) appropriate behaviors and prescribing guidelines,” he said. If it works, Highmark may expand that effort to Pennsylvania.

UPMC Health Plan indicated it is using “an algorithm to identify patients who may be at risk for opioid addiction,” and training doctors to use other pain management tools.

If the experiences of Highmark and UPMC are any indication, this year might mark a turning point following more than a decade of stubbornly rising opioid prescribing that continued through 2015. The Drug Enforcement Administration reported last week that more than 3.7 million prescriptions were filled by Pennsylvania pharmacies for 283 million oxycodone pills, up 3.8 percent from the prior year.

In the eastern half of the state, federal prosecutors working with the DEA and FBI have continued to criminally charge high-prescribing physicians. Former Philadelphia physician Jeffrey Bado, who had vigorously defended his opioid prescribing, was found guilty this month of 308 federal felony counts, including one count of drug distribution resulting in death. He faces sentencing in March.

Spurred largely by such prosecutions, the state Board of Medicine and Board of Osteopathic Medicine this year acted against the licenses of at least 18 Pennsylvania doctors accused of overprescribing narcotics. From 2011 through 2015, those boards totaled just 53 such actions, fewer than 11 a year, a rate far lower than that of numerous other states.

The Pittsburgh Post-Gazette in May found that over the past five years, 608 physicians were disciplined for their narcotics prescribing practices in seven Appalachian states, of which Pennsylvania had taken the fewest measures to rein in rogue doctors.

In October, the General Assembly passed, and Wolf signed, laws that could lead to more disciplinary actions should doctors wantonly prescribe opioids.

Doctors can no longer prescribe more than a week’s worth of opioids to minors, unless they thoroughly document the need.

Effective next week, emergency medicine practitioners will also be largely restricted to prescribing a week’s supply of opioids.

Also in 2017, medical schools will have to include proper narcotics prescribing in the curriculum.

Doctors will be required to take biennial refresher courses in painkiller practices.

Practitioners planning to prescribe opioids or benzodiazepine tranquilizers will have to first check the patient’s drug history using an online database.

If that database shows that the patient is getting prescriptions from multiple sources – called “doctor shopping” – the physician can refer them to rehab. That database, though, doesn’t yet connect to similar programs in neighboring states, so abusers or pill pushers might be able to get drugs via multiple physicians by crossing borders. Dr. Levine said the state intends to link its database to those of its neighbors, but has no timeline for doing so.

Experts are not predicting any quick reversal of the surge of heroin and fentanyl that, along with prescription narcotics, was implicated in 81 percent of the state’s 3,383 fatal overdoses last year.

“The pills still supply a feeder system to the heroin epidemic,” said Gary Tuggle, special agent in charge of the DEA for Pennsylvania. “It’s still an issue, and it’s always going to be an issue, until we can get a handle on overprescribing, diversion and doctor shopping.

“Hopefully,” said Tuggle, “gone are the days of just mass prescribing.”