[Noozhawk’s note: This article is part of Day 5 in Noozhawk’s 12-day, six-week special investigative series, Prescription for Abuse. Related links are below.]
Prescribing controlled substances is a highly regulated process, especially as abuse and addiction become more prevalent, but oversight is fractured between agencies with the burden falling on local health-care providers.
Local facilities are more proactive in efforts to prevent or intervene in drug-seeking behavior, while state and federal oversight is mostly driven by those local providers reporting violations.
The federal Drug Enforcement Administration usually will only get involved if there’s a strong possibility of interstate actions, but can send in tactical division squads for an investigation or enforcement, said Ashley Schapitl, press secretary for Rep. Lois Capps, D-Santa Barbara.
Congressional legislation established two grant programs for creating or enhancing drug-monitoring systems, one of which is still funded with a $5.6 million budget in 2011, but running these databases and any subsequent investigations fall to state agencies. California is one of 35 states with such a program in place.
California’s database — called CURES, which stands for Controlled Substance Utilization Review and Evaluation System — was established in 2009 by then-Attorney General Jerry Brown. It is intended to lower health-care provider and insurance costs while reducing drug trafficking and the high number of drug-related medical emergencies from overdoses.
As of Jan. 1, any health-care provider who dispenses controlled substances is required to report that information weekly to the state Department of Justice. (The DEA classifies controlled substances in five categories, or schedules, depending on their accepted medical use in treatment and their relative abuse potential and likelihood of causing dependence.)
Medical professionals, law enforcement and regulatory boards have instant access to patient records, instead of submitting a request via mail or fax. Before CURES, the Attorney General’s Office received more than 60,000 requests every year and had a slower turnaround time, officials say.
Records include the drug name, quantity and strength of pills, pharmacy information and physician information, so access is limited as a result of patient privacy concerns.
Bureau of Narcotic Enforcement specialists monitor and analyze the data and can refer potential abuses — by overprescribing doctors or drug-seeking patients — to regional offices.
The Bureau of Narcotic Enforcement is involved in the Santa Barbara Regional Narcotic Enforcement Team, but neither the Santa Barbara County Sheriff’s Department nor the District Attorney’s Office monitor the CURES program for investigations, officials say.
Instead, local health-care providers are the most vigilant in looking for potential abuses.
As medical administrative systems make the switch to electronic health records and monitoring patient records becomes easier, South Coast providers have responded to the problem of abuse with programs and protocols of their own.
With electronic records, a patient’s full prescription history can be gleaned with a glance and steps can be taken if overuse, abuse or addiction is suspected, he said.
Sansum Clinic is in the process of implementing a comprehensive record-keeping system, known as the Wave, which will maintain health data on file for each Sansum patient so the clinic can minimize duplications or bad drug interactions, Dr. Marjorie Newman, Sansum’s assistant medical director, told Noozhawk in an email.
The installation will be complete in early 2012, according to Sansum marketing director Jill Fonte, who said the system is much more than a prescription database. Sansum caregivers will be able to quickly see a patient’s records to review medications, allergies, test results, alerts and treatments received.
“Having that information readily available can enhance the care patients receive, and could make a big difference in an emergency, when time matters most,” she said.
A secure web portal will enable patients to access information such as educational materials, visit details, lab results and immunization records, Fonte added.
Sansum’s clinics also have “opiate contracts” that outline “rules” for long-term pain medication management and are signed by patients and the physician, Newman said.
The clinics can use prescription history to look for misuse, abuse or dependence and prompt a frank discussion with the patient, she said. Patients can be referred to a specialist or reported to CURES.
Cottage Health System has the only three emergency rooms on the South Coast — at its hospitals in Santa Barbara, the Goleta Valley and the Santa Ynez Valley — and has implemented a Frequent Opiate User Program, which is run by Lambert.
An increase in prescription drug abuse has been documented mostly through emergency department admission records, and hospitals can be a target for abusers and “doctor shoppers” who visit multiple physicians to get medication, officials say.
Any physician can alert Lambert if they suspect a pattern of abuse through frequent visits, and he can then access patient records and contact the primary-care physician. Once a month, the hospitals’ department heads, physicians and pharmacists review the records to determine if patient interventions are required, with three options: do nothing, put a patient on a watch list, or place him or her on a restriction list.
When patients are placed on a restriction list, they cannot be prescribed a specific drug in the emergency department unless they bring a formal letter from their primary-care physician, Lambert said. About 10 people are restricted per month, half of whom are “cruising through town,” he said, referring to out-of-town patients whose behavior implies they are here seeking drugs.
It’s not about punishment or judgment, Lambert said. Doctors are trying to refer someone with a pain management or substance abuse problem to get help, he explained.
“These drugs are very good and very effective,” he said. “People can get hooked before they know it.”
Painkillers are the biggest concern since they’re the No. 1 drugs of abuse, and practitioners have to balance patient care with the reality of addiction potential.
The Medical Board of California has clinical guidelines for prescribing controlled substances for pain but all health-care providers struggle with how to provide medication to the right patients for the intended purpose when abuse is so prevalent, said Dr. Alfredo Bimbela of the Santa Barbara Neighborhood Clinics.
“We certainly do not want fear to guide our prescription practices, but we do make every effort to use sound judgment in prescribing medications to patients,” he said.
“What we do know is these medications change peoples’ lives, allow them to function and allow them to not be suffering.”
While it’s inevitable that some people will come into the clinics with all the right answers to acquire drugs on false pretenses, Bimbela said, close relationships with patients and pharmacies can help prevent or identify a problem.
Lambert agreed, saying that pain management is delivered early and appropriately in the emergency department.
“Until it’s a clearly flagrant example that I’m getting worked, so to speak, I treat them,” he said.
Cottage Health System’s emergency department doesn’t prescribe more than 30 pills at a time, since any ongoing pain issues should be dealt with by a primary-care doctor, he said.
Patient education for drugs — and spotting abuse — also falls to physicians and pharmacists.
Both Sansum Clinic and the Santa Barbara Neighborhood Clinics have their own contracts outlining the understanding between patient and physician about the possible consequences of taking opiates or other drugs with abuse potential.
Pharmacists have their parts to play in oversight, too, and Bimbela said they are an invaluable resource in monitoring patients to make sure medication is taken appropriately.
Chain pharmacy stores like CVS and Vons have information-sharing databases so pharmacists can tell if one person attempts to get the same prescription filled at two locations or tries to get an early refill, Bimbela said.
Allan Cohen, pharmacy director of Cottage Health System, has a largely automated system as most hospitals do, but personal checks are in place to “look for weirdness,” he said.
“It’s too easy to divert drugs if you don’t have some kind of automation,” Cohen said.
Cohen’s staff is very aware of the abuse potential for certain drugs, especially strong painkillers, and acts accordingly, he said.
“If you know they refilled eight days ago, you may want to talk to them,” he said.
“It’s easy enough for people who may not even think of themselves slipping into addiction to slip into addiction,” he said. “They make rationalizations all the time about what’s happening but are not aware of it.”