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February 10, 2014

Pill problems

Prescription drug overdoses continue to climb in state

OKLA. CITY — Oklahoma pharmacies filled nearly 10 million prescriptions for narcotic painkillers and other controlled dangerous substances last year, according to newly obtained state data.

Those prescriptions — an average of 68 per patient, including refills — contained 597 million doses of painkillers, tranquilizers, sleeping pills, steroids and other controlled pharmaceuticals tracked by the state’s Prescription Monitoring Program.

Nearly 16,000 medical professionals are registered to write narcotics prescriptions in Oklahoma. About 1,500 of them accounted for nearly three-fourths of all controlled substance prescriptions filled in 2013, officials said.

The statistics, provided to Oklahoma Watch in response to an open records request, also show that many medical professionals do not routinely check the PMP’s online database before writing or refilling scripts. Under current law, they are not required to do so.

“The more we drill down, the more we realize that we obviously have a prescription drug problem in Oklahoma,” said Darrell Weaver, director of the Oklahoma Bureau of Narcotics and Dangerous Drugs.

“We’ve got to be aggressive in doing something to drive these numbers down.”

Meanwhile, the toll from prescription drug abuse continues to rise. In 2012, the most recent year for which data is available, 844 Oklahomans were killed by overdoses, most of them accidental. That’s more than the 708 people killed in vehicle crashes that year.

Three out of four overdose deaths involved prescription drugs, often in combination.

The prescribing data, compiled by Weaver’s bureau, provides new insight into one of the causes of Oklahoma’s escalating prescription drug crisis.

It also provides ammunition to Gov. Mary Fallin and others who want the Legislature to take new steps this year to require more physician participation in the PMP.

“I think it’s more likely than not that we will endorse an approach that will have an element of mandatory checks of the Prescription Monitoring Program,” said Steve Mullins, Fallin’s general counsel.

“It’s a pretty high priority for the governor,” Mullins said. “She’s seen the data. It’s affecting way too many Oklahomans. It really is tearing up families.”

Leading the list of PMP prescriptions and overdose contributors are three popular pharmaceuticals: hydrocodone, an opiod painkiller sold under the brand names Lortab, Vicodin, Vicoprofen, Norco and Tussionex; oxycodone, another opiod painkiller sold as OxyContin and Percoset, and alprazolam, an anti-anxiety drug marketed as Xanax.

Although the overdose rate from alprazolam is generally not high when used by itself, physicians say it can become lethal when combined with narcotic painkillers. Many overdose deaths involve a “cocktail” of more than one controlled substance, and sometimes alcohol.

The prescriptions filled in 2013 were issued to 142,369 patients. That’s an average of 68 prescriptions per patient. Since many controlled substances require a new prescription with every refill, a patient with chronic problems would typically log 12 prescriptions per year for each controlled substance he or she receives.

Last year’s PMP prescriptions were written by 12,096 doctors, osteopaths, dentists, physician assistants, nurse practitioners and other medical professionals. Of those, 3,529 registered prescribers ran PMP checks during the year.

Some of the prescribers were located out of state and can’t access Oklahoma’s PMP system before writing prescriptions, bureau officials said. Some were Oklahoma practitioners who write only a handful of controlled substance prescriptions per year and aren’t necessarily expected to check the PMP regularly.

Officials say the usage statistics understate prescriber participation in the PMP system, which is designed to deter “doctor shopping” by allowing doctors to see every narcotic prescription filled by a patient during the previous 12 months.

In some clinics, for example, one staff person might be running PMP checks for several doctors but entering only one registration number for each check. Also, one PMP check might apply to several prescriptions being written at the same time by a single doctor.

Bureau officials said about 74 percent of Oklahoma prescribers who wrote more than 10 controlled substance prescriptions logged into the PMP system at some point last year.

Fallin’s office is working with lawmakers, law enforcement authorities, health officials and medical practitioners to devise a collaborative strategy acceptable to all sides. It is likely to include new restrictions on prescribing practices, tougher penalties for offenders and more public and professional outreach campaigns.

“We’re all in this together,” Weaver said. “We’re not going to arrest our way out of this problem. We’ve got to have our physicians involved. They’ve got to police themselves.”

The latest overdose data show that Oklahomans are being killed by prescription drugs at a rate of nearly two people per day.

The drug overdose fatality count climbed 80 percent over the past decade. Deaths caused by hydrocodone and oxycodone more than quadrupled over the 10-year period.

Weaver said he’s perplexed that the toll has continued to rise despite concerted efforts to call more attention to the problem., which claimed the life of University of Oklahoma linebacker Austin Box and sidelined the career of Oklahoma State University basketball coach Sean Sutton.

“This is something that’s affecting normal Oklahomans,” Weaver said. “School teachers. Police officers. People who are out there functioning in their day-to-day business.”

At least Oklahoma no longer ranks No. 1 in prescription painkiller abuse, as it did several years ago. The latest survey by the federal Substance Abuse and Mental Health Services Administration shows that the Sooner state has fallen to No. 8 on the Rx drug-abuse list.

According to the 2012 survey, 5.2 percent of Oklahomans above the age of 11 took prescription pain medicines for nonmedical reasons during the previous 12 months. The biggest pill poppers were 18- to-25 year-olds, who had an abuse rate of 10.9 percent.

State officials and addiction specialists say they have been particularly alarmed by recent data suggesting that some people who become addicted to prescription painkillers eventually switch to street heroin.

“We’re learning that it’s become a gateway drug to heroin,” Mullins said.

The danger of rising heroin use made headlines last week when actor Philip Seymour Hoffman died of an apparent overdose. Authorities said they found heroin and prescription drugs at his residence. Hoffman told an interviewer he had resumed a history of drug abuse last year by taking prescription painkillers, then progressing to heroin.

Hal Vorse, a physician who treats habitual drug users and teaches new doctors about addiction at the University of Oklahoma Health Sciences Center, said he’s seen the phenomenon in his own practice.

“We’re seeing a big surge in heroin, and 85 percent of those people started on prescription opiates,” Vorse said. “The cost of their addiction got so high that they switched to heroin because it’s cheaper.”

Vorse said the price on the street for OxyContin has risen to $1 to $1.50 per milligram. Addicts typically use 200 to 300 milligrams per day, he said. “They find out they can get an equivalent dose of heroin for a third of what it costs for Oxys,” Vorse said.

“It’s just like Prohibition in the ’20s. People who couldn’t get good whiskey bought moonshine. The problem with heroin is there’s no quality control. You don’t know what you’re getting.”

Getting more doctors to participate in the Prescription Monitoring Program is a central element of the state’s prescription drug-abuse offensive.

The PMP is an online database designed to flag patients who seek multiple prescriptions for painkillers and other narcotic drugs from more than one physician.

Oklahoma’s system is considered one of the most advanced in the nation, officials say. All pharmacists are required to enter data for every controlled drug prescription within 5 minutes of filling it. No other state has a “real-time” reporting requirement like that.

But doctors and other health practitioners are not required to check the database before prescribing controlled dangerous substances, and some don’t bother to do so. The only exception is methadone.

Although pharmacists are required to log controlled substance prescriptions into the system, current law does not require them to review a patient’s prescribing history before filling the order. Bureau officials said checking a patient’s history requires a different computer log-in process than entering prescription data.

If they do review a patient’s history and see evidence of multiple concurrent prescriptions, pharmacists have the authority to refuse to fill a prescription, alert the prescribing physician or contact state authorities, bureau officials said.

Oklahoma’s doctors have resisted proposals to require them to use the system each time they write a prescription for a controlled substance.

Two years ago, the Oklahoma State Medical Association sent a letter to lawmakers saying that mandatory PMP checks for every narcotics prescription “will require additional staff time and resources in physicians’ offices and result in higher costs and longer waits for patients.” It urged them to reject the proposal.

But the medical group says it is willing to consider a less comprehensive mandate, one that requires occasional checks and lets office staffers handle the job instead of the requiring doctors to do it.  

“We are meeting with the governor’s staff and all of the stakeholders involved with that,” said Ken King, executive director of the medical association. “We want to make sure that any solution is a true solution, and not something that tries to make the physician the policeman in this process.”

State Medical Association President Robert McCaffree, a pulmonary disease physician, said Oklahoma doctors continue to hear a mixed message about the use of prescription painkillers.

“We’re often told as physicians that pain is undertreated,” McCaffree said.

“But we also have this issue that there are prescription drug abuses. The physicians are caught in the middle. How do we best be the advocates for our patients but also be responsible to society?”

State officials said they will look at several options for new legislation to increase physician use of the PMP.

OKLAHOMA WATCH is a nonprofit, nonpartisan journalism service that produces in-depth and investigative content on important public-policy issues facing the state. For other content, go to www.oklahomawatch.org.

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