In the past 20 years, physicians have been urged by many groups to treat pain more aggressively — which often means prescribing more opioids and other prescription pain medications. This push has led to the number of prescriptions for opioids increasing dramatically, says Scott Glaser, MD, DABIPP, president of Pain Specialists of Greater Chicago and a board member of American Society of Interventional Pain Physicians.
But this increase in prescription drugs in the market has led to serious negative consequences — in some places in the country, a person is now more likely to die as a result of accidental poisoning secondary to prescription medication, either legally or illegally, than die in a car accident, Dr. Glaser says.
"Increased prescribing is correlating with an increase in death and emergency room visits," he says. "We prescribe these medications to patients with pain, but some of these patients are going to develop an abusive relationship with the medication or they may give it away, sell it, or have it taken from them by people who are abusing it. It's had this unintended consequence of a rapidly increasing number of accidental poisonings and emergency room visits."
Dr. Glaser says everyday in the United States, 75 people die from such accidental poisoning — essentially when a person dies from misusing, abusing or overdosing on a drug or drugs. Abuse of prescription drugs, including opioids, has risen to a level never before seen. In 2009, the number of first-time drug users reporting their first drug as nonmedical use of pain relievers (2.2 million) was almost the same as those reporting marijuana (2.4 million), and today, opioid overdoses cause more deaths than overdoses of cocaine and heroin combined.
"That's the kind of growth in the prescription drug abuse that we're seeing," Dr. Glaser says. "You don't have to buy it from a dealer, you don't have to smoke it. It is seen as safer since it is prescribed and this in combination with increased availability secondary to increased prescribing has caused these drugs to surge into the lead of illicit drug use. One of the ways prescription drug abuse can be battled is through prescription monitoring programs, Dr. Glaser says. He calls them "one of the most important aspects of the field of interventional pain management."
But, he warns, while monitoring programs are a tool to help physicians and others monitor drug use, but they aren't a solution for substance abuse.
"The prescription monitoring programs, in and of themselves, they don't cure or stop prescription drug abuse. They allow us to monitor people," he says. "They try to stop people from profiting from prescription drugs, from feeding off these problems of others. It also allows us to intercede when patients may be developing an abusive problem sooner rather than later when lives and families can be wrecked."
Dr. Glaser wants the monitoring program databases to be seen as a source of information for physicians to use when treating a patient for pain.
"The databases are information for doctors," Dr. Glaser says. "They don't say if the person is addicted. It's just information for a doctor to take into account so that they can assess the patient fully and help them whether it is uncontrolled pain or a substance abuse disorder."
About 90 percent of patients seeking treatment in a pain management practice are already on narcotics prescribed by their primary physician, emergency room physicians or orthopedic physicians, says Dr. Glaser, though his practice skews a little higher at 98 percent. Even though primary care physicians have been urged to treat pain more aggressively, pain management and prescribing controlled substances appropriately and safely is not part of their training.
"They know a little about a lot," Dr. Glaser says. "There's a big push at a national level to possibly require doctors who prescribe narcotics to have extra training. As specialists, we're already getting that training."
Dr. Glaser is in favor of providing extra training for primary care physicians. "I think it is important, I think there should be some extra training. The treatment of pain and the prescribing of controlled substances is woefully understood and not taught in a medical-school level," he says.
Training, such as continuing education and lectures, will impress upon physicians the seriousness of prescribing pain medications. Dr. Glaser also thinks there should be a certification program to confirm the physicians understand the risk involved. He is not among the physicians that think requiring extra training will have a negative effect on the treatment on pain, but he does not think primary care physicians should be legally obligated to check the databases.
"One interesting thing that I'm seeing is that a lot of states, like Nevada, require doctors to access the database before they prescribe a controlled substance," Dr. Glaser says. "I think that puts too much liability on the doctor's part. We do it naturally and routinely as specialists, but primary care doctors shouldn't have to do that. To require them to access the information exposes them to too much liability, it's too egregious."
Although not requiring certain physicians who prescribe pain medication might seem to weaken the databases and the monitoring programs, Dr. Glaser says it comes down to an issue of liability.
"Doctors are incredibly regulated and so liable — so out there as far as liability — [requiring them to check the database] just increases the liability of a doctor, but it's not going to make the database any better. The primary concern should not be penalties for not using the database. It should be on education on how to best use that database. I don't think any money or time or effort should go into creating a law to penalize doctors for not using it. All that time and effort should be used by medical societies and associations to require that doctors are getting education so they know they want to check the database and what to do with the information."
As part of the 2005 National All Schedules Prescription Electronic Reporting bill, all states are required to have prescription monitoring programs. Although 48 states have laws on the books, only 36 currently have active programs. Dr. Glaser says the most effective state regulation is the Kentucky All Schedule Prescription Electronic Reporting act, which the NASPER bill was based on.
"KASPER is truly fulfilling the goal of having an active program," he says. "It is about to be interconnected with their bordering states."
Interconnectivity, which is mandated in the NASPER bill, is something that states are starting to implement, Dr. Glaser says. It's an important aspect to prescription monitoring programs.
"In Chicago, we've had patients who we found out were getting prescriptions from us, and when we checked the database, the database was fine. Turns out that they were going to Indiana and Wisconsin to get drugs. We need that interconnectivity," he says.
Kentucky is planning a pilot program to share its prescription monitoring program data with Ohio and vice versa. This way, a physician can look up prescription data for a patient in both states to prevent prescription drug shopping. Kentucky also recently created a task force with Ohio, Tennessee and West Virginia. The task force, which includes representatives from state agencies such as the Justice and Public Safety Cabinet, state police, the Office of Drug Control Policy and the attorney general's office, will make recommendations on policy to the state governors.
Even though the NASPER bill passed in 2005, it has yet to be fully funded, Dr. Glaser says. That's why only 36 states have functional prescription monitoring programs on the books. There's a competing bill known as the Ryan Creedon Act of 2011, introduced by Rep. Hal Rogers of Kentucky. According to Dr. Glaser, the bill is the reason NASPER has not been fully funded; conflicting support within the legislative bodies has slowed forward movement. The bills differ slightly. The Creedon Act of 2011 focuses more on law and order, Dr. Glaser says, while the NASPER bill is from a medical viewpoint.
"Substance abuse is really a medical problem," he says. "These programs need to be oriented toward doctors. The police don't have the knowledge base to understand all of the medical issues associated with the treatment of pain and substance abuse. Doctors need to be the ones evaluating the statistics in the prescription monitoring program. We can't allow law enforcement to have unhindered access."
The important thing to remember, Dr. Glaser says, is that the reason physicians are prescribing pain medication is that there are a lot of people with chronic pain — more than 100 million according to recent government estimates. The key is being able to monitor prescription drug use and minimize negative side effects.
Learn more about Pain Specialists of Greater Chicago.
More Expertise From Dr. Scott Glaser:
IPAB and PCORI Must Go: 6 Points From Dr. Scott Glaser on Why Repeal is Necessary
How Interventional Pain Management Will Contribute to ACOs: Q&A With Dr. Scott Glaser
Interventional Pain Management: New Concepts to Reduce ER Visits, Hospitalizations and Re-Admissions
"Increased prescribing is correlating with an increase in death and emergency room visits," he says. "We prescribe these medications to patients with pain, but some of these patients are going to develop an abusive relationship with the medication or they may give it away, sell it, or have it taken from them by people who are abusing it. It's had this unintended consequence of a rapidly increasing number of accidental poisonings and emergency room visits."
Dr. Glaser says everyday in the United States, 75 people die from such accidental poisoning — essentially when a person dies from misusing, abusing or overdosing on a drug or drugs. Abuse of prescription drugs, including opioids, has risen to a level never before seen. In 2009, the number of first-time drug users reporting their first drug as nonmedical use of pain relievers (2.2 million) was almost the same as those reporting marijuana (2.4 million), and today, opioid overdoses cause more deaths than overdoses of cocaine and heroin combined.
"That's the kind of growth in the prescription drug abuse that we're seeing," Dr. Glaser says. "You don't have to buy it from a dealer, you don't have to smoke it. It is seen as safer since it is prescribed and this in combination with increased availability secondary to increased prescribing has caused these drugs to surge into the lead of illicit drug use. One of the ways prescription drug abuse can be battled is through prescription monitoring programs, Dr. Glaser says. He calls them "one of the most important aspects of the field of interventional pain management."
But, he warns, while monitoring programs are a tool to help physicians and others monitor drug use, but they aren't a solution for substance abuse.
"The prescription monitoring programs, in and of themselves, they don't cure or stop prescription drug abuse. They allow us to monitor people," he says. "They try to stop people from profiting from prescription drugs, from feeding off these problems of others. It also allows us to intercede when patients may be developing an abusive problem sooner rather than later when lives and families can be wrecked."
Dr. Glaser wants the monitoring program databases to be seen as a source of information for physicians to use when treating a patient for pain.
"The databases are information for doctors," Dr. Glaser says. "They don't say if the person is addicted. It's just information for a doctor to take into account so that they can assess the patient fully and help them whether it is uncontrolled pain or a substance abuse disorder."
About 90 percent of patients seeking treatment in a pain management practice are already on narcotics prescribed by their primary physician, emergency room physicians or orthopedic physicians, says Dr. Glaser, though his practice skews a little higher at 98 percent. Even though primary care physicians have been urged to treat pain more aggressively, pain management and prescribing controlled substances appropriately and safely is not part of their training.
"They know a little about a lot," Dr. Glaser says. "There's a big push at a national level to possibly require doctors who prescribe narcotics to have extra training. As specialists, we're already getting that training."
Dr. Glaser is in favor of providing extra training for primary care physicians. "I think it is important, I think there should be some extra training. The treatment of pain and the prescribing of controlled substances is woefully understood and not taught in a medical-school level," he says.
Training, such as continuing education and lectures, will impress upon physicians the seriousness of prescribing pain medications. Dr. Glaser also thinks there should be a certification program to confirm the physicians understand the risk involved. He is not among the physicians that think requiring extra training will have a negative effect on the treatment on pain, but he does not think primary care physicians should be legally obligated to check the databases.
"One interesting thing that I'm seeing is that a lot of states, like Nevada, require doctors to access the database before they prescribe a controlled substance," Dr. Glaser says. "I think that puts too much liability on the doctor's part. We do it naturally and routinely as specialists, but primary care doctors shouldn't have to do that. To require them to access the information exposes them to too much liability, it's too egregious."
Although not requiring certain physicians who prescribe pain medication might seem to weaken the databases and the monitoring programs, Dr. Glaser says it comes down to an issue of liability.
"Doctors are incredibly regulated and so liable — so out there as far as liability — [requiring them to check the database] just increases the liability of a doctor, but it's not going to make the database any better. The primary concern should not be penalties for not using the database. It should be on education on how to best use that database. I don't think any money or time or effort should go into creating a law to penalize doctors for not using it. All that time and effort should be used by medical societies and associations to require that doctors are getting education so they know they want to check the database and what to do with the information."
As part of the 2005 National All Schedules Prescription Electronic Reporting bill, all states are required to have prescription monitoring programs. Although 48 states have laws on the books, only 36 currently have active programs. Dr. Glaser says the most effective state regulation is the Kentucky All Schedule Prescription Electronic Reporting act, which the NASPER bill was based on.
"KASPER is truly fulfilling the goal of having an active program," he says. "It is about to be interconnected with their bordering states."
Interconnectivity, which is mandated in the NASPER bill, is something that states are starting to implement, Dr. Glaser says. It's an important aspect to prescription monitoring programs.
"In Chicago, we've had patients who we found out were getting prescriptions from us, and when we checked the database, the database was fine. Turns out that they were going to Indiana and Wisconsin to get drugs. We need that interconnectivity," he says.
Kentucky is planning a pilot program to share its prescription monitoring program data with Ohio and vice versa. This way, a physician can look up prescription data for a patient in both states to prevent prescription drug shopping. Kentucky also recently created a task force with Ohio, Tennessee and West Virginia. The task force, which includes representatives from state agencies such as the Justice and Public Safety Cabinet, state police, the Office of Drug Control Policy and the attorney general's office, will make recommendations on policy to the state governors.
Even though the NASPER bill passed in 2005, it has yet to be fully funded, Dr. Glaser says. That's why only 36 states have functional prescription monitoring programs on the books. There's a competing bill known as the Ryan Creedon Act of 2011, introduced by Rep. Hal Rogers of Kentucky. According to Dr. Glaser, the bill is the reason NASPER has not been fully funded; conflicting support within the legislative bodies has slowed forward movement. The bills differ slightly. The Creedon Act of 2011 focuses more on law and order, Dr. Glaser says, while the NASPER bill is from a medical viewpoint.
"Substance abuse is really a medical problem," he says. "These programs need to be oriented toward doctors. The police don't have the knowledge base to understand all of the medical issues associated with the treatment of pain and substance abuse. Doctors need to be the ones evaluating the statistics in the prescription monitoring program. We can't allow law enforcement to have unhindered access."
The important thing to remember, Dr. Glaser says, is that the reason physicians are prescribing pain medication is that there are a lot of people with chronic pain — more than 100 million according to recent government estimates. The key is being able to monitor prescription drug use and minimize negative side effects.
Learn more about Pain Specialists of Greater Chicago.
More Expertise From Dr. Scott Glaser:
IPAB and PCORI Must Go: 6 Points From Dr. Scott Glaser on Why Repeal is Necessary
How Interventional Pain Management Will Contribute to ACOs: Q&A With Dr. Scott Glaser
Interventional Pain Management: New Concepts to Reduce ER Visits, Hospitalizations and Re-Admissions