Dr. Benjamin Rathert explains why doctors need proper training on prescribing opioids
Editor’s note: This is the third installment in an occasional series about the opioid crisis in Illinois.
Like many states, Illinois passed legislation trying to control the opioid and heroin epidemic.
The Heroin Crisis Act, which took effect Sept. 9, 2015, included a series of changes to the Illinois Prescription Monitoring Program, a statewide database maintained by the Illinois Department of Human Services.
The PMP records prescriptions for opioids and other potentially addictive drugs when they are filled at pharmacies. Through the program, medical providers can see what their patients are taking and help catch people seeking fraudulent prescriptions, a practice known as “doctor-shopping.”
The PMP is “a centralized online repository dedicated to preventing the misuse, abuse, and diversion of controlled prescription medications,” the DHS says on its website.
The Heroin Crisis Act made the PMP more effective through several changes: It required pharmacists to report prescriptions faster, allowed doctors to delegate checking the database to nurses and physician’s assistants, and lowered the number of medical professionals whom patients can see before the PMP alerts them about suspected behavior.
What the bill didn’t do was require doctors and pharmacists to actually use the program.
“It was a toothless tiger,” said John Roberts, a Chicago activist whose son died of a heroin overdose, a year after the Heroin Crisis Act. Roberts praised the bill when it was being considered, but now, he said, “it could be more powerful and robust.”
Thirty-five states require doctors to check a PMP in some form. Mandatory compliance has become more popular in recent years. California recently required it, decades after becoming the first state to establish its own PMP.
“The voluntary approach was never particularly effective at attracting participation,” California State Sen. Ricardo Lara, who sponsored the legislation, said in an email. “Given the scope and scale of the opioid abuse problem and that California has invested millions of dollars into a prescription drug monitoring program that very few prescribers were using, it is critical to put into policy the mandatory check.”
Illinois’ PMP records prescriptions for opioids, anti-anxiety medication, sleeping aids and other medications. The drugs, classified in four groups called “schedules,” range from Schedule II, III, IV and V, based on their medical uses and abuse potential, according to the U.S. Drug Enforcement Agency. Schedule I includes drugs like heroin, which isn’t tracked because it isn’t legally distributed.
In 2014, the Illinois PMP recorded 18.3 million prescriptions — 5.8 million of which were Schedule II opioids, the most dangerous type legally available.
In Illinois, users checked the PMP 1.9 million times that year, according to reports sent to the Department of Justice. About 1.15 million of those checks were by “prescribers,” so if Illinois physicians checked the PMP only for Schedule II opioids, it would have been about 20 percent of the time.
Low enrollment hinders use
Although participating in the PMP is not mandatory in Illinois, one of the program’s main goals has been to get more doctors to use it. Still, enrollment goals were almost never met, even as the system got easier to use, documents from various grant proposals show.
Before the PMP became electronic on Jan. 1, 2000, it had been a paper system for 15 years. The old way was expensive, costing the state more than $800,000 a year, and it was inefficient. Three clerks manually processed 300,000 handwritten records a year, but there was a six- to nine-month backlog and a 30 percent information error rate.
After 2000, the PMP’s performance improved dramatically. It processed 1.7 million Schedule II prescriptions; time spent processing information shrank from six months to 15 days, and information errors were reduced from 30 percent to less than 1 percent. The cost to run the program also fell by 75 percent.
In 2008, the PMP expanded with the help of federal funding and began recording Schedules III through V drugs. Accompanying the expansion, the General Assembly shortened the time pharmacists had to report sales from 15 to seven days, giving medical providers a quicker and more complete look at patients’ drug histories.
In 2015, a total of 46,104 Illinois prescribers prescribed a controlled substance while only 16,049 of those were registered users of the (PMP). The percentage of prescribers utilizing the (PMP) on a yearly basis is only 35 (percent).
2016 PMP report
PMP enrollment increased steadily from 2008, but by 2012, the program was 7,000 users short of its target of 22,000. In 2015, registered users grew to 30,000.
“In 2015, a total of 46,104 Illinois prescribers prescribed a controlled substance while only 16,049 of those were registered users of the (PMP),” the program noted in a 2016 report. “The percentage of prescribers utilizing the (PMP) on a yearly basis is only 35 (percent).”
But, that percentage doesn’t reflect how many times individual prescribers actually checked the PMP; instead, it only shows whether they accessed the database at least once.
In all, those who prescribed controlled substances far outnumbered those who registered for the PMP, and those who registered for the PMP far outnumbered those who actually used it.
Despite training sessions, PMP expansion relied mainly on word-of-mouth, said Stan Tylman, who worked at the PMP for 20 years until recently.
To help boost enrollment, the 2015 Heroin Crisis Act required everyone with a controlled substance license to sign up for the PMP when they renew their licenses. The act also required DHS to create a pilot program to integrate electronic health records with the PMP, automatically logging a “check” when doctors open patient files.
The PMP won a grants to implement this strategy at two-thirds of the state’s nearly 300 hospital systems. Several have already connected with the PMP, but it will take a few years to connect the rest.
‘Voluntary works best when its mandatory’
Drug-control experts generally support making it mandatory to check the PMP for every prescription.
“Voluntary works best when it’s mandatory,” said Carmen Catizone, executive director of the Chicago-based National Boards of Pharmacy, an organization that offers pharmacist accreditation and license transfer services.
The National Alliance for Model State Drug Laws also supports the requirement. It recommends checking the PMP before each initial prescription as well as when pain treatment lasts longer than 90 days.
“(The PMP is) the one place where you can actually get the most complete history of the prescriptions that have been filled for a patient,” said alliance President Sherry Green.
The main concerns of those who oppose mandatory checks are:
▪ Every minute counts in a typical 15-minute doctor’s appointment, and adding another task would eat up time and turn doctors into box-checkers. That’s why states like Illinois allow physicians to delegate checking reports to staffers.
▪ Checking the PMP could also delay the time it would take in emergency situations to give someone pain relief. States such as California give medical professionals reprieve if it is not possible to check the program in a reasonable time.
▪ A PMP check could foster an atmosphere of distrust with patients, create tension during appointments, and lead to inevitable false-positives.
But for supporters of mandatory checks, such as Green and Catizone, that’s where professional discretion comes into play.
“The PMP at its most basic is an information tool,” Green said.
A 2014 study by Brandeis University found that the number of PMP checks rose and the amount of opioids decreased when Kentucky, Tennessee and New York passed mandatory check laws. Despite initial complaints, everyone got used to the program.
But not everyone is convinced.
One of the largest and most influential professional societies that opposes mandatory checks of the PMP is the Illinois State Medical Society.
Other Illinois groups think mandatory checks don’t have an effect on prescriptions; that the PMP should be checked only in certain circumstances, or oppose mandatory checks outright. They include the Illinois Academy of Family Physicians; the Illinois Pharmacists Association, and the Illinois Retail Merchants Association, a lobbying group on behalf of retailers.
Other groups have taken no position on the issue, including the American Medical Society, the American Society of Addiction Medicine and the Pain Care Coalition.
Former president of the Illinois State Medical Society, Dr. Thomas Anderson, told the BND in a statement the society thought mandatory checks were “cumbersome for some physicians” and could lead to “delays in accessing medication for patients experiencing pain.”
ISMS submitted a report on its positions to the Illinois House Task Force on the Heroin Crisis in February 2015. In it, the medical society said that Illinois already had a low rate of prescribing, picking out oxycodone as an example.
However, prescribing trends vary from state to state, and oxycodone is just one of many opioids. In 2014, for example, there were 400,000 prescriptions for oxycodone tablets, the most popular form of the drug, but there were 4 million prescriptions for hydrocodone tablets, according to data from the PMP.
The ISMS also pointed to the fast pace of medical advances as another reason why mandating PMP checks would be shortsighted, citing an article published in the Journal of the American Medical Association.
“Legislative mandates ... are inflexible, static, and not as easily changed as science advances,” the article stated.
But Peter Jacobson, who wrote the study, told the BND that although he opposes laws on decision-making, mandatory checks don’t change that. They just require doctors to be more informed.
“Yes, I’m in favor of that,” he said.
Continuing medical education
In 2017, State Sen. Melinda Bush, D-Grayslake, sponsored legislation that would make PMP checks mandatory for prescribers or people they designate to.
“It’s indefensible and reprehensible (not to check),” Bush said on the Senate floor before her bill passed without a single “no” vote.
The bill then sailed through the House Human Services Committee unanimously, but it was held for an amendment by state Rep. Michael Zalewski, D-Riverside, after the ISMS voiced concerns. Zalewski said he asked the organization twice before the legislative deadline for the amendment it wanted to submit, but ISMS didn’t send it.
Even if mandatory checks were required, though, the point isn’t necessarily about increasing use of the PMP — it’s about helping doctors make more educated decisions.
Dr. Benjamin Rathert, a family-practice doctor who also treats opioid addiction in Du Quoin, worked in 2014 with another doctor who was more liberal with prescribing opioids. After the other doctor retired, Rathert began losing patients because he was uncomfortable writing such large prescriptions.
“It turns out I was losing them for the right reason,” Rathert said.
Rathert thinks checking the PMP should be mandatory, but he also wants medical professionals to take classes on opioids and addiction. If doctors were better trained, then prescribing trends shouldn’t swing between too many prescriptions to too few.
The Illinois State Medical Society encourages its members to check the PMP, and it supports pill take-back programs, insurance coverage for treatment programs and training first-responders on the opioid-reversal medication naloxone. The medical society also supplies educational and training materials on its website, and says it “has already embarked upon an aggressive campaign to educate its member physicians on the most up-to-date treatment guidelines.”
Mandating courses, though, is a “dangerous precedent for the future of medicine in Illinois,” ISMS wrote in its policy paper.
“It makes no sense,” Rathert said about medical society’s position. He has to be certified for a variety of services, so training on controlled substances makes sense, too, he said.
Other states are beating Illinois to the punch.
Kentucky, for example, requires anyone prescribing or dispensing controlled substances to take 4.5 hours in classes specifically about the state’s PMP, pain management or addiction disorders, out of a required 60 hours in continuing education every three years.
In Illinois, doctors must take 150 hours of training every three years to obtain a controlled substance license, but the state has no instructions on what doctors should take. Sixty hours must be “formal,” or classes approved by accredited organizations, but 90 hours may be “informal,” which includes things like “journal reading,” “preparation of educational exhibits,” and “small group discussions.”
The ISMS was also dismayed that Rhode Island required two hours of training related to the AIDS crisis that the Rhode Island Medical Society considered “repetitive and irrelevant to some specialties.”
Joseph Wendelken, a public information officer with the Rhode Island Department of Public Health, defended the course. Classes are evaluated every two years, so they likely changed to reflect medical updates, he said. In fact, the Rhode Island Medical Society helps the agency change them, and today the AIDS-related class is no longer required.
What courses are required? opioids and chronic pain management.