Dr. Benjamin Rathert explains why doctors need proper training on prescribing opioids
Editor’s note: This story is part of a series about the opioid epidemic in Illinois.
A bill that would require Illinois doctors to check the state’s Prescription Monitoring Program before writing a prescription for potentially addictive medications was weakened by a House amendment on June 26.
The original bill would have required most prescribers or a designee to check the program every time before they prescribe a variety of drugs, including opioids, anti-anxiety medication and others. The House amendment reduced the types of drugs that need to be checked as well as the number of times prescribers need to access the program.
Sen. Melinda Bush, D-Grayslake, first drafted the bill as one solution to the problem of opioid abuse, which can often begin with legal prescriptions. Opioid and heroin overdoses claimed the lives of more than 2,000 Illinoisans in 2016, according to provisional data from the Illinois Department of Public Health.
Illinois’ Prescription Monitoring Program, or PMP, records controlled substances when they are filled at pharmacies. The drugs fall into four categories, called Schedules, ranging from 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 aren’t tracked because they aren’t legally distributed.
Prescribers do not often check the PMP, according to previous reporting by the BND. In 2014, for example, the Illinois PMP recorded 18.3 million prescriptions for controlled substances, 5.8 million of which were for Schedule II opioids like hydrocodone, oxycodone, codeine and others.
In the same year, Illinois prescribers checked the program only 1.15 million times. That means that if Illinois physicians had checked the PMP only for Schedule II opioids, it would have been used about 20 percent of the time.
Several states that have adopted must-access laws regarding their own PMPs have seen reductions in the number of opioid prescriptions, but others say that checking the program for every prescription is overkill.
1.15 million times the Prescription Monitoring Program was checked in 2014, out of 18.3 million recorded prescriptions
They say that the requirement takes up valuable time during doctors’ appointments and reduces medical professionals to box-checkers. Some prescribers also believe that checking the PMP is redundant because they develop a close relationship with their patients.
The House amendment agrees.
The new version of Bush’s bill would require doctors to check the program only for Schedule II drugs, and only the first time they are prescribed. Both her bill and the new one exempted oncologists and hospice care workers, who often prescribe large amounts of opioids for great amounts of pain.
Rep. Mike Zalewski, D-Riverside, submitted the amendment after he said the Illinois State Medical Society had some concerns about the original language.
“Our underlying concern remains preventing any unintended consequences that negatively impact patient care and treatment,” said Dr. Nestor Ramirez, the president of the Illinois State Medical Society, in a statement. He was concerned that chronic pain patients would not get the drugs they need if doctors prescribe fewer opioids.
Zalewski believes the new bill still gets at one of the worst problems in the opioid epidemic — doctor-shopping.
“I believe this initial check deters that dynamic,” Zalewski wrote to the BND, “and if we feel like every single script needs a check we can revisit it upon empirical data.”
The number of doctor-shoppers has gone down in recent years, but there is more than one way to view the problem. Doctor-shoppers declined from 1,700 in 2008 to 270 in 2016, according to a previous way used by the Illinois Department of Human Services. In 2015, however, the method changed, and the numbers recalibrated to about 50,000 a year, a figure that included many more false-positives.
The original bill passed the Senate 58-0, with only Sen. Bill Haine, D-Alton, abstaining. Just before the vote, Bush said that the Illinois State Medical Society had stopped opposing the bill, but the organization again expressed interest in changing it when it came to the House.
“Though we were able to pass it out of committee, some stakeholders wanted consideration of an amendment before the bill reached the full House for a vote,” Zalewski wrote in an email. “It makes sense to give (doctors) the flexibility to manage (the PMP).”
The bill passed the House’s Human Services Committee unanimously, but Zalewski said it was because legislators understood it would be amended. Otherwise, the bill would face opposition on the floor. The new version passed out of committee again without a single “no” vote.
The House, consumed with budget negotiations, had yet to to pass the bill as of last week, but it appeared as though the language had been finalized and that the stakeholders had reached a compromise.
“I’m happy to see that there is an agreement so that the bill can pass,” Bush said. “This is a step in the right direction.”
Sometimes you have to take the victories in the size that they are
Bill Gentes, Lake County Opioid Initiative
The Medical Society also now supports the bill, but others think more could have been done.
“It’s a little watered down, but it hits the Schedule II drugs, which is what we were really interested in,” said Bill Gentes, who serves on the board of directors of the Lake County Opioid Initiative, which first approached Bush about the legislation.
One issue concerning Gentes was that some opioids in lower Schedules would not be checked, including Tramadol, a popular drug he believes should be in a higher classification. The Schedule IV drug made up a little more than 10 percent of all opioid prescriptions filled in Illinois from 2012 through 2016, according to data from the Prescription Monitoring Program.
Categorizing drugs based on their addictive potential and medical uses is an inexact science, and drugs are sometimes reclassified. For example, without any change in how it’s made, hydrocodone was moved to Schedule II from Schedule III in 2014.
The most popular opioid in Illinois by far, hydrocodone is considered to give the same amount of pain relief as morphine, a Schedule II drug. It would not have been included in the PMP bill just a few years ago, but Gentes is still pleased the measure is going forward.
“Sometimes you have to take the victories in the size that they are,” he said.