July 2016

Using Technology to Fight Drug Abuse
By Ken Whittemore
For The Record
Vol. 28 No. 7 P. 8

It's hard to scroll through headlines or turn on the evening news without hearing about the nation's opioid epidemic. The numbers are staggering. According to the Centers for Disease Control and Prevention (CDC), from 1999 to 2014, more than 165,000 people in the United States died from prescription opioid overdoses. Given that 14,000 of those deaths occurred in 2014 alone, the problem is clearly escalating. Additionally, according to the Drug Abuse Warning Network, nearly 2 million Americans either abused or were dependent on prescription opioids in 2014, leading to more than 1,000 emergency department visits every day. Again, that's 1,000 visits every day.

In some cases, providers are overprescribing. In other instances, patients are "doctor shopping"—visiting multiple physicians to obtain multiple prescriptions. In nearly 9% of these cases, desperate patients are forging paper prescriptions to satisfy their painkiller fix.

The problem is undeniable and seemingly insurmountable. How can society hope to combat it?

Federal Steps
The FDA suggests that physicians receive training and certification before they can prescribe opioids. The CDC has developed guidelines for physicians prescribing opioids to patients with chronic pain. Recently, many states have taken action to make the opioid antidote naloxone widely available to rescue individuals who have overdosed. And states such as New York and Maine are using legislation rooted in the use of health care technology to directly address the abuse vectors. Specifically, they are championing the electronic prescribing of controlled substances (EPCS).

By electronically prescribing and dispensing controlled substances, both providers and pharmacists can play an even more proactive role in improving patient safety, stamping out drug diversion, and decreasing the abuse of these highly addictive and highly sought-after drugs. EPCS enables physicians to electronically and securely send, track, and monitor controlled substance prescriptions—from the time the prescription leaves their offices to when the patient picks it up at the pharmacy.

The configuration of EPCS provides an unmatched level of security. Unlike paper prescriptions, patients are unable to access or alter an electronic prescription. In addition, the practice of drug seekers stealing paper pads for bogus prescription writing is eliminated.

With EPCS, as well as secure health information exchange and connectivity to prescription drug monitoring programs (PDMPs), clinicians have a fighting chance to make a difference. Technology takes power away from drug seekers and doctor shoppers, and gives control back to prescribers. With such power available to them, some states are officially getting behind the effort.

At the federal level, it's been almost six years since the Drug Enforcement Administration (DEA) first adopted rules to permit EPCS. In September 2015, EPCS finally became legal in all 50 states and Washington, D.C. However, some states, including New York, have been making strides for years.

Through the passage of the Internet System for Tracking Over-Prescribing Act (I-STOP), New York has taken a hard stance on prescription opioid abuse. Effective March 27, I-STOP mandated that all prescriptions in the state, including controlled substances, be electronically prescribed.

Thus far, the results have been impressive. With I-STOP as a catalyst, New York prescribers and pharmacies have made huge progress toward becoming enabled for EPCS technology use. At the end of April, 66% of the state's prescribers featured EPCS capabilities, which far outpaces the national average of 10%. In addition, pharmacy enablement to receive controlled substance prescriptions electronically was nearly universal (95%). Impressively, 48% of all EPCS transactions nationwide in April were being transmitted in New York.

A Northeast Movement
Another state that is fully embracing the technology is Maine. Just weeks after the implementation of I-STOP's ePrescribing requirements, "An Act to Prevent Opiate Abuse by Strengthening the Controlled Substances Prescription Monitoring Program" was signed into law in Maine. The statute, which requires the electronic prescribing of opioid medications, is scheduled to take effect in July 2017.

The law also mandates that prescribers and—under certain circumstances—pharmacists check the state's prescription drug monitoring database before prescribing or dispensing an opioid or benzodiazepine prescription. It also imposes limitations on prescription strength, dosage, and frequency.

Mandates such as I-STOP have no doubt played a key role in moving EPCS technology adoption forward in New York, an outcome that will likely be mirrored in Maine and other states that pass similar statutes. (And perhaps will revive the discussion in Minnesota, a state that has technically had an ePrescribing mandate in effect for years, but has struggled to enforce it with no penalties imposed for those who do not comply).

The combination of the widespread availability of EPCS and the passing of related mandates shows just how impactful technology can be as a weapon against opioid abuse and drug diversion.

In addition to requiring ePrescribing across the board, New York also made changes to its PDMP program, requiring prescribers to access the prescription drug monitoring database before prescribing controlled substances. In Maine, this requirement is only for opioids and benzodiazepines. Such requirements not only help to reduce doctor shopping but also make it difficult for drug seekers to find a back door into the system for obtaining opioid drugs. In fact, six months after the implementation of New York's enhanced I-STOP PDMP requirement, the state determined that doctor shopping had been reduced by 75%.

An Uncertain Future
Why haven't more states taken a page out of New York and Maine's playbook and enacted legislation? Mainly, there is a lot of confusion about the processes required for becoming enabled. Prescribers must take certain steps before they can use EPCS technology, including using an EHR solution that is certified according to the DEA's rigorous EPCS requirements. Additionally, there are technology updates and other conditions that must be met before a physician can ePrescribe controlled substances.

Each of these reasons contributes to the relatively low levels of physician enablement and EPCS use across the country. While 95% of pharmacies are on board, only 10% of providers nationwide are ready to use the technology. However, as demonstrated in New York, the technology has the ability to make a huge impact in the fight against prescription fraud and abuse. With I-STOP serving as an accelerator, EPCS has made an impressive impact throughout the Empire State's health care community.

As the health care industry continues to embrace technology, patient safety and public health must be among the primary drivers of its adoption. For New York, I-STOP has been proof positive of the benefits of a state recognizing technology as a critical tool in the fight against opioid abuse. Only time will tell if and how the rest of the country will follow suit. Regardless of the timetable, prescribers, pharmacies, and policy makers must be aware of the technology at their disposal and continue to highlight just how valuable it can be in fighting the nation's opioid epidemic.

— Ken Whittemore is senior vice president of professional and regulatory affairs at Surescripts.