Am Fam Physician. 2007 Mar 15;75(6):810-811.
Controlled substances are potentially beneficial medications, but they also have the capacity to produce euphoria. Some regular users lose control over their use, escalate the dosage, and become addicted.1 Misuse of prescription narcotics commonly occurs in the United States; in 2003, 10 percent of the population reported using prescription opioids for nontherapeutic purposes.2 Narcotic misuse also has received considerable attention in the news media.
Some drug users and sellers obtain their supplies by seeking out physicians to write prescriptions for seemingly legitimate medical complaints, and then sell the drugs or use them to produce euphoria or to relieve symptoms of withdrawal. Even experienced prescribers can be misled into writing prescriptions that are used or resold illegally.3 In response, most countries have laws that restrict patient access to these substances. In the United States, the federal Controlled Substances Act places strict requirements on pharmacists to track dispensing and report the data to central authorities (or at least be able to present detailed records on demand). There also are similar laws in each state that help to regulate prescribing; identify medications that are associated with addiction; and make some medications illegal to possess, use, dispense, manufacture, sell, and distribute, if unauthorized.4
Drug monitoring programs recently were developed in response to the misuse of prescription drugs.5 These programs are intended to reduce or eliminate the flow of controlled substances from legitimate medical sources to nonmedical users or dealers. Drug monitoring programs go beyond the Controlled Substances Act by requiring pharmacists to more actively track prescriptions and compile data into searchable computer databases. They also sometimes introduce aspects of control at the point of the prescriber. For example, states such as New York and California have required prescribers to handwrite prescriptions on triplicate prescription pads, with one copy sent to the retail pharmacy so the patient's prescription can be filled, one copy kept with the prescriber, and one copy sent to a central government-authorized location. Although triplicate prescriptions may reduce inappropriate use, they also can impede access to clinically appropriate pharmacotherapy. Many states that had such prescription requirements have replaced them with more workable processes.6
Newer laws establishing the provisions of drug monitoring programs have taken advantage of electronic informatics.7 Pharmacists may enter into a database such information as the medication and quantity dispensed, the prescriber, and the person for whom the medication was prescribed. Authorities then may identify physicians who authorize prescriptions in potentially harmful patterns and persons who receive potentially dangerous medications from multiple sites or prescribers simultaneously. Drug monitoring programs also can identify potential drug-drug interactions.
One problem inherent in such data collection is the potential to mistakenly identify high-frequency, high-volume use or prescribing of a controlled substance as inappropriate. Physicians who care for patients with terminal illnesses or chronic noncancer pain may prescribe clinically appropriate, high-dosage, high-volume analgesia.8 Precautions should be incorporated into drug monitoring programs to allow for objective peer review in determining the appropriateness of prescribing patterns such as these.
Drug monitoring programs may form the evidence base for health policy and other public policy (e.g., to determine if there is an epidemic of overdose-related deaths from oxycodone [Roxicodone, Oxycontin]). Ideally, prescribers would be able to access drug monitoring programs at the point of care to review real-time medication information and avoid inappropriate prescribing. However, safeguards must be required to ensure the protection of personally identifiable health care information.
With currently available informatics, systems might require patients taking high dosages of controlled substances to fill their prescriptions at one designated retail pharmacy. Such controls would not prevent patients from obtaining medication, but they would reduce the opportunity for unintended use. We believe that data entry into drug monitoring programs should be mandated for the dispenser but not the prescriber. Requirements to document dispensing may dissuade physicians from dispensing pharmaceuticals from their own offices, thereby centralizing dispensing with retail pharmacies where, arguably, this function should reside.
Physician organizations often protest when drug monitoring programs are proposed in areas where they have not been used previously; however, the time probably is right for such a system. It also may be the right time for electronic prescribing to replace handwritten and telephone prescribing to help decrease medical errors. Population health is an important aspect of medical care, and collecting information on population trends provides useful information that can assist individual providers as well as policy makers.
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2. Overview of findings from the 2003 National Survey of Drug Use and Health. Rockville, Md: Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2003.
3. Drug abuse related to prescribing practices. JAMA. 1982;247:864–6.
4. Drug Abuse Prevention and Control, Controlled Substances Act, 21 USC §801 (1996).
5. Brushwood DB. Maximizing the value of electronic prescription monioring programs. J Law Med Ethics. 2003;31:41–54.
6. Ross-Degnan D, Simoni-Wastila L, Brown JS, Gao X, Mah C, Cosler LE, et al. A controlled study of the effects of state surveillance on indicators of problematic and non-problematic benzodiazepine use in a Medicaid population. Int J Psychiatry Med. 2004;34:103–23.
7. Manchikanti L, Brown KR, Singh V. National All Schedules Prescription Electronic Reporting Act (NASPER): balancing substance abuse and medical necessity. Pain Physician. 2002;5:294–319.
8. Horgan C, Prottas J, Tompkins C, Wastila L, Bowden M. Summary and conclusions of a review of prescription drug diversion control methods. NIDA Res Monogr. 1993;131:206–23.
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