Efforts to curb 'doctor shopping' can be impeded by some states' lack of monitoring programs.
They're often called doctor shoppers, border hoppers, pharm-aholics and even hit-and-runners. They count on states' lack of communication and exploit professionals whose job is to heal, hurting themselves and feeding others' addictions through such feats.
They're prescription painkiller addicts and, like other drug addicts, often go to extreme measures to get their fix. It's not a new problem, just one that's recently become more visible with high-profile celebrity deaths being caused by prescription pill overdoses.
"The least fun part of my job is managing medications," said Connecticut-based pain physician Dr. David Kloth, who referred to Michael Jackson -- formerly the King of Pop -- as the King of Drug Popping. "You are suspicious of everybody -- it's sad, but everyone is painted with the same broad brush."
It may be sad, but it's what doctors face every day. Pain pill-related deaths have risen significantly over the years, with overdose deaths becoming the second leading cause of unintentional injury death in 2002, just behind motor-vehicle injuries, according to a Centers for Disease Control and Prevention (CDC) study. This increased death rate stems from prescription drugs known as opioid analgesics -- powerful, addictive drugs like OxyContin and Vicodin that produce heroin-like effects -- that were increasingly prescribed in the 1990s to treat pain.
"Their potential for misuse was underestimated, and opioid analgesics quickly became the most popular category of abused drugs," the CDC report stated.
In an attempt to track patients' prescriptions and prevent double dipping between doctors -- and states - many states have created prescription drug monitoring programs through federal funding sources. As it stands, 41 states have passed laws to create some type of program, but some states with multiple nearby neighbors -- like Maryland, Arkansas and Nebraska -- don't have any such law or bills pending.
"You need to know this information when you have a patient you're concerned about," Kloth said, adding that prescription drug abuse can often contribute to social ills such as divorce, child abuse and neglect. "The stories are endless."
Under the National All Schedules Prescription Electronic Reporting Act (NASPER) -- signed by President George W. Bush in 2005 -- more than $50 million has been given to states to enact programs that allow doctors and other authorized users, like police, to access patient records. Though the NASPER legislation called for $50 million in funding, to date it has received $2 million as a result of denials by the Appropriations Committee.
The law's aim is to have a coordinated national system that monitors an array of controlled substances -- all those in Schedules II, III and IV (e.g., cocaine and anabolic steroids), as defined by the U.S. Drug Enforcement Administration and the U.S. Food and Drug Administration. It permits states to exchange sensitive data with each other to deal with border hoppers, doctor shoppers and the like.
"Patients moving from one jurisdiction to another (as in cases involving Virginia, the District of Columbia and Maryland) will typically be able to obtain multiple prescriptions by merely crossing state lines," a NASPER fact sheet stated. "The conscious and more prevalent unconscious misuse of Schedule II, II and IV controlled substances, are a national problem that cannot be effectively addressed on a state-by-state basis."
But states are making progress toward implementing such monitoring programs, said Joanee Quirk, who runs the Nevada Prescription Drug Monitoring Program. "[States] have a common bond, but we all run our systems a bit differently," she said.
Those differences can sometimes create strife between states, she said. For example, unlike many other states, Vermont doesn't allow outside law enforcement agencies to access its system,
NASPER proponents are preparing to file for reauthorization of the bill with Congress, the effects
of which should allow states to create (if they haven't already) and standardize their programs, said American Society of Interventional Pain Physicians CEO Dr. Laxmaiah Manchikanti. "We are progressing toward better monitoring and it's becoming more doctor-friendly," he said.
Right now, Manchikanti, whose practice is in a small Kentucky town, has to tap into other states' databases to get information on a patient, he said. While a national database is becoming a reality for Manchikanti, its full implementation could take up to 10 more years, he said.
The U.S. Government Accountability Office in 2002 reported that state monitoring programs do indeed provide an effective tool to stem the growing problem of illegal diversion of prescription drugs, and noted that they offer quick access to comprehensive information, which often deters abusers from doctor shopping within the state.
"Further, only a few programs operate proactively, while most operate reactively," a NASPER fact sheet stated. "Incidents of drug diversion, however, are on the rise in neighboring states, indicating the problem is proliferating or shifting to states without monitoring programs."
Such a program recently came in handy for Kloth, who, after hearing a litany of excuses from one patient -- from running out of medication early, losing the bottle and saying his wife accidentally washed it -- checked the state database and found the patient had seen 35 doctors and was prescribed medications at 25 pharmacies. "It's very easy to get addicted to these medications," Kloth said. "The drugs ... will take hold of you."
In Nevada -- a typically transient state -- the state prescription drug monitoring program is run by the state board of pharmacy and anyone who prescribes a controlled substance is required by law to report that information to them, said Quirk, who runs the program.
"The real key here is it is just a tool," Quirk said. "We don't want a doctor to base prescribing or not prescribing on these reports, but to look at the big picture.
"We don't know the big picture, but the doctor may," she said. "That's why we have this incredible tool they can use."