North Carolina provides a tool to curb prescription drug overdoses, but most doctors don't use it.
With a few rapid keystrokes, Dr. Don Teater demonstrates how quickly he can help prevent a drug overdose.
On his laptop, Teater types a password and then a patient’s name. Up pops North Carolina’s prescription database, which tracks patient information dating back to 2010.
Used correctly, the data can stop patients from inappropriately getting drugs from multiple doctors and help doctors avoid prescribing a fatal mix of medications.
But most doctors in North Carolina don’t take what appears to be a simple, potentially lifesaving measure.
A 2014 state report was a call to action. It found that doctors and pharmacists distributed more than 17 million prescriptions in North Carolina for controlled substances. Doctors used the database for only about 6 percent of prescriptions.
The most common complaint – that the computer program is cumbersome and time-consuming – doesn’t ring true to Teater.
“It takes about 60 seconds,” said Teater, an Asheville primary care physician and drug addiction specialist.
Prescription overdoses kill more than 1,000 people a year in North Carolina, more than heroin, cocaine and alcohol combined. Opioid narcotics such as OxyContin, Percocet and Vicodin are widely blamed for setting off the epidemic.
The federal Centers for Disease Control and Prevention recommends physicians use state drug databases. Some states such as Kentucky, Tennessee and New York require physicians check the data before prescribing medications.
North Carolina does not. For each patient, pharmacists have entered information about prescriptions such as type of medicine, dosages, quantities and dates filled. Less than half of the healthcare providers who prescribe opioids have signed up to use the state database, according to the 2014 report by the N.C. Program Evaluation Division, the research arm for the General Assembly.
State Rep. Craig Horn, a Union County Republican, said he is considering proposing a bill that would make it mandatory for doctors to check the database before prescribing narcotics. Horn noted that state and national experts have called the rising number of drug overdose deaths in North Carolina and nationwide a public health crisis.
“I’m not willing to accept from doctors that it’s too hard,” Horn said. “This is important. This needs to be done.”
State medical groups have encouraged doctors to use the database, but have staunchly opposed previous attempts to make it mandatory.
Critics say scant evidence is available to justify new rules. And they argue that most patients abusing prescription drugs get them from acquaintances and street dealers, not doctors.
Stephen Keene, general counsel for the the North Carolina Medical Society, said mandatory database checks would impose another administrative task on physicians already feeling overburdened.
“Every time you mandate, you create more regulations,” Keene said. “Doctors feel like they know their patients.”
Before writing prescriptions for new patients or those with chronic pain, Dr. Teater logs into the state’s prescription drug monitoring program.
On a recent day, he opens the database and it tells him the patient’s name, drugs prescribed, dosages and other information. Teater looks at records dating back years.
He demonstrates how to use the system and moments later finds information on his patient.
Teater serves as medical advisor for the National Safety Council and helped the CDC develop new guidelines on prescribing opioids.
Asked why more physician don’t take advantage of the state database, Teater said many work under severe time constraints and need more training on addiction.
“Our days are jammed and it interrupts the flow of things,” Teater said. “We receive no training on how to interpret the results. So if you find something, you’re like ‘What do I do now?’”
Teater recalled how the prescription monitoring program might have saved the life of one of his patients.
The woman is a recovering drug addict and he had prescribed buprenorphine, a drug used to treat addiction to opioid painkillers.
Teater went to the state drug database to review the patient’s history of prescribing narcotics. He saw that another doctor prescribed her benzodiazepines for anxiety.
He said taking benzodiazepines and buprenorphine, an opioid, can be fatal, so he requested she stop taking the anxiety medicine.
“Doctors don’t understand how dangerous these drugs are,” Teater said. “No one has shown them how valuable this tool can be.”
While the database can raise red flags, the decision whether to prescribe drugs still rests with physicians. That means that patients who suffer from severe chronic and acute pain could still be able to obtain needed medicine, Teater said.
The database can also help doctors spot possible substance abuse issues, and offer patients help, he said.
A typical doctor’s appointment is scheduled to last 15 minutes. That leaves physicians with little or no time to check the prescription database, some experts said.
Doctors, they said, rely on the familiarity with patients or look for signs of drug-seeking behavior.
But Donnie Varnell, a retired special agent in charge for the State Bureau of Investigation, said it is hard to understand why physicians don’t use the prescription database in most cases.
“It is as simple as getting money out of an ATM,” Varnell said.
Physicians often overestimate their ability to spot patients inappropriately seeking painkillers from multiple doctors and prescribe narcotics to people who abuse the drugs and divert for sale on the street, he said.
“A lot of doctors are just naive,” said Varnell, who helped oversee drug investigations. “There are just a lot of doctors who are being hoodwinked.”
Peter Kreiner, principal investigator for the Prescription Drug Database Program Center of Excellence at Brandeis University outside Boston, agrees more research is needed to determine the impact of required checks, but said attitudes are changing.
After Kentucky required doctors check the state’s database in 2012, prescribing for opioid painkillers dropped 8.5 percent, according to a report from the Center of Excellence.
Tennessee saw a 36 percent decrease in suspected doctor shopping after passing a measure mandating doctors use state prescription data, the report says.
“Doctors are starting to feel more ownership and feel like they need to change their behavior,” Kreiner said.
A 2013 survey by the UNC Injury Prevention Research Center found 23 percent of responding physicians anticipated they would never use the state prescription database. Some doctors told researchers they didn’t check the database because they forgot their passwords, didn’t know how to use it or simply didn’t have the time.
Dr. Joseph Hsu and Clinical Research Director Rachel Seymour, both of Carolinas Healthcare System, are leading a project that could help solve the problem.
Armed with $400,000 grant from the CDC, they have devised a system that provides doctors with instant information about a patient without the need to log into the state database.
When doctors in the emergency room, urgent care, clinic offices or patient discharge prepare to write a prescription for an opioid painkiller or a benzodiazepine, they get an automatic notification on their computer screen warning that the patient presents risk factors. Those may include a history of substance abuse, requests for early refills or recent prescriptions for the same drugs.
The idea is to bring information about patient’s risk factors to busy doctors and cut out legwork.
“It’s integrated into the workflow and doesn’t require any extra steps,” Seymour said. “It’s objective and more uniform.”
Seymour and Hsu said they are conducting research to see how the system impacts prescribing. For now, the pilot effort is limited mainly to the Charlotte metro area.
“We are trying to improve safety,” Seymour said. “We’re trying to address primary prevention and identify patients who are at risk.”