Curbing Prescription Drug Abuse Poses Challenges in Montana

In Sunday church pews, in the grandstands of the baseball game, in the big box store checkout line, most of the people around you have gotten a prescription for painkillers in the past year.

In fact, there are 82 painkiller prescriptions for every 100 Montanans and more than 300 deaths from prescription drug overdoses in 2010 and in 2011.

We know this because governments and medical professionals have been keeping track of prescription drugs since it became clear that both the prescriptions and related deaths were skyrocketing. From 1999 to 2010, the number of painkiller overdose deaths nationally quadrupled, according to the Centers for Disease Control.

Those 300 prescription drug deaths in Montana in 2010 outnumbered car crash deaths, according to the state Justice Department. The state now requires that all prescriptions for painkillers be registered with the Board of Pharmacy. The list, less than two years old, is 5 million prescriptions long and growing as more scripts for opioids like OxyContin, Diluadid, Demoral and morphine are added.

“It’s not as bad as it used to be. They’re getting a hold on it,” said Elisha Finley, a Billings mother whose hydrocodone prescription for an injured shoulder in 2010 turned into an addiction that led to a bad car wreck and sobriety in 2012. “The problem is, people who legitimately get their pain meds oftentimes sell them.”

Statistics would suggest the state is gaining the upper hand on prescription drug abuse. The number of prescription drug-related deaths in Montana numbered 109 in 2013, according to the state Department of Public Health and Human Services. The number of people prosecuted for prescription drug crimes in Yellowstone County has fallen 70 percent from 2011 to 2013.

And yet there’s criticism that Montana’s prescription drug work is incomplete, specifically concerning the prescription drug registry. County attorneys say the drug registry is so wrapped up in judicial red tape that it’s difficult for law enforcement to use.

All Montana doctors and pharmacists are required to report prescriptions to the state registry, but they aren’t required to check a patient’s name against the registry before writing a prescription. Many don’t.

“I’ve accessed it a couple times and had varying degrees of success,” said Wyatt Glade, Custer County attorney. For law enforcement, accessing the list “not only takes law enforcement involvement, it takes prosecutor involvement because it takes an investigative subpoena.”

Investigative subpoenas require a judge’s signature, which doesn’t come unless there’s agreement that a criminal offense has probably been committed and that the information relative to the offense is in the registry.

Montana’s privacy laws make the process so difficult the drug registry hasn’t been a go-to source for law enforcement, which isn’t to say that the registry hasn’t curbed prescription drug abuse.

In Yellowstone County, the number of criminal cases of fraudulently obtained dangerous drugs dropped from 42 the year before the registry was created to 13 last year, said Scott Twito, Yellowstone County attorney. The attorney assumes the decline is because people shopping for prescriptions are being turned away by doctors and pharmacists.

“I think it’s done more to prevent fraudulently obtaining dangerous drugs,” Twito told The Billings Gazette. “Pharmacists are able to communicate better and get better information. Doctors are able to communicate better. As a tool for us, we still have to go through the subpoena process.”

The Board of Pharmacy does receive subpoena requests, said Marcie Bough, executive director. Since the registry went live in October 2012, prosecutors have received responses to 264 subpoenas. Health care licensing boards have also requested information for 18 investigations of care providers.

“We consider it to be very successful in terms of how far we have come at this stage,” Bough said.

There are 5 million prescriptions in the registry, but roughly 620,000 patients behind the pills, Bough said. There’s some duplication, some Robert Smiths and Bob Smiths in the registry, who are actually the same person and their prescriptions consequently counted more than once. All 700 Montana pharmacies report to the registry, including the Indian Health Service and Veterans Affairs.

Although pharmacists and doctors are required to submit prescriptions to the list – and pay an annual $15 fee to support it – using the registry to ferret out fraud is optional.

Medical professionals must register to use the database, and those registration numbers indicate that a significant number of professionals don’t sign up. Just more than 56 percent of the state’s pharmacists are registered to check patient names against the list. That means someone committing prescription fraud has a 43.5 percent chance of the pharmacist not being registered to see whether the customer is being overprescribed narcotics.

Only 24.4 percent of health care providers eligible to use the list actually do, according to a May report by the Montana Board of Pharmacy to state legislators.

State Sen. Roger Webb, R-Billings, said many doctors won’t use the list because it’s cumbersome.

“Right now, the doctors are saying their time is too valuable to sit there and fill out prescriptions,” Webb said. “A lot of them aren’t using it, and we want to make it a much more usable, too.”

Webb is a member of the Legislature’s Children, Families, Health and Human Services Interim Committee. By month’s end, the committee plans to roll out proposals for making the registry not only more doctor friendly, but also more useful for fighting drug crime.

The 2015 Legislature will have to revisit the registry to determine whether to change the fee that supports the $300,000 program. Making the registry more useful will be part of that discussion, Webb said.

Bough said the board is working to increase the number of professionals using the list, and also to improve the information on it. One goal is to link the database with registries from other states to track prescription fraud across state lines.

In Wyoming, it has taken some time to get doctors and pharmacists to use the list, said Mary Walker, the state’s Pharmacy Board executive. Wyoming started its registry in 2003. It took several years before the majority of the state’s medical professionals were using the list, but most now do, Walker said. Large pharmacy chains concerned about liability in prescription drug cases played a big role in boosting use, Walker said.

Wyoming’s prescription drug registry works differently than Montana’s. The Pharmacy Board is required to comb through the registry for fraud, and alert doctors and pharmacists when suspected criminal activity is found. Reports are also sent to police, who have much easier access to the registry. A police officer can fax a one-page information request to the board to get the details about a specific individual. No attorney or subpoena is required.

“One of the best uses, officers say, is getting reports when they’re starting to investigate a death,” Walker said. “Say a coroner has a case where there are prescriptions bottles. They can decide whether to rule that out.”

Wyoming law requires the Pharmacy Board to report suspected illegal activity to police. Montana law does not.