One patient received opioids from 64 prescribers across three states. Another received thousands of painkillers from 11 different prescribers. In a third case, a patient being treated for opioid dependence filled two dozen prescriptions for oxycodone from clinicians at 18 separate practices.
More than 27,000 Medicaid patients were prescribed opioids from 2010 to 2013, according to data acquired from the state by NHPR. More than half received the drugs from a single health care provider, and 80 percent filled just one prescription.
But hundreds of Medicaid patients obtained opioids, which are used to treat moderate and severe pain, from six or more prescribers in a single year. It's a pattern that suggests potentially dangerous misuse of the medication.
The overuse of prescription painkillers is one of the root drivers of New Hampshire’s growing opioid addiction crisis, which has claimed more than 550 lives since January 2014.
Gilbert Fanciullo, a professor of anesthesiology at Dartmouth’s Geisel School of Medicine and director of pain management at Dartmouth-Hitchcock Medical Center, says providers are increasingly aware of the risks of opioids. But many patients demand them.
“Patients are coming into our offices and saying, 'I’ve tried everything, I still have this pain and I want it treated,’ ” Fanciullo said. “And it’s very hard for some doctors to tell the patient, 'No.' ”
Prologue to an addiction crisis
Before there was a heroin crisis in New Hampshire, there was an epidemic of prescription drug abuse.
Between 2000 and 2011, eight of every 10 overdose deaths were caused by prescription narcotics, and state-funded treatment programs saw a sharp rise in admissions for oxycodone addiction.
Medicaid beneficiaries, who are twice as likely to receive prescription narcotics then non-Medicaid patients, account for a significant amount of opioid use in New Hampshire.
According to data on eight common painkillers prescribed from 2010 to 2103:
· A total of 220,643 opioid prescriptions were written by more than 7,200 doctors, nurses and other providers;
· 14.6 million individual doses were prescribed, 70 percent of which contained oxycodone;
· Medicaid spent $15.7 million on prescription painkillers;
· Spending on the anti-addiction drug buprenorphine increased 23 percent, to $2.3 million in 2013.
The fight against “doctor shopping”
The state’s data predates New Hampshire’s prescription-drug monitoring program, or PDMP, which went live a year ago. Passed by the legislature in 2012, the program allows a patient’s history of opioid prescriptions to be shared electronically by doctors, nurses and pharmacists.
While still in its infancy, the PDMP is considered a key front in the battle against doctor shopping – the practice of filling prescriptions from multiple prescribers who are unaware the patient is obtaining the same or similar drugs from other providers.
Many people who acquire drugs from several providers do so for good reason.
Someone who breaks an ankle, for example, is often prescribed painkillers in the emergency room, then by a primary care physician. That doctor may then send the patient to a surgeon, who writes an opioid prescription that is later refilled by a nurse or a physician assistant. Patients at specialized clinics that treat chronic pain or sports injuries may be under the care of a physician who delegates medication management to nurses and physician assistants.
But the data show that a subset of Medicaid patients is willing to travel far and wide to acquire opioids.
One example: On December 9, 2010, one patient received a prescription for hydromorphone tablets from a physician’s assistant in Concord.
Four days later, an M.D. in Wolfeboro prescribed 20 5-mg oxycodone.
One week later, that same patient was in Manchester for more oxycodone. And before the end of the month, they got another 20 oxycodone in Burlington, Vt., followed in short order by visits to a Concord urologist and a P.A in Rochester for more.
In August 2012, a patient filled prescriptions for Percocet, a mix of oxycodone and acetaminophen, from providers in Portland, Me., Rochester, Somersworth, Nashua, Concord, New Boston, Laconia and Manchester.
“Just having six doctors prescribing an opiate does not necessarily mean doctor shopping,” said David Strang, an emergency room physician who chairs a committee that oversees the state's prescription-drug monitoring program. “Multiple prescriptions, filled in multiple towns at multiple pharmacies - that is concerning.”
Doctor shopping is often associated with diversion, or the re-sale of prescription narcotics obtained from health care providers. But research on non-medical use of opioids shows that users typically steal or otherwise obtain the opioids for free from friends or family; less than two percent reported getting the drugs from more than one doctor.
Anupam Jena, an associate professor of health care policy and medicine at Harvard Medical School, has studied the use of multiple prescribers in the Medicare program. He says diversion of opioids for non-medical use is less of an issue than people who shop for prescribers to feed an addiction or dependency.
“These are people going to multiple doctors, saying they are in pain,” he says. “And the doctors are writing short-term prescriptions, just a few days, to - for lack of better words – to get rid of them.”
New Hampshire Medicaid patients with six or more prescribers accounted for a disproportionate share of prescriptions overall, about 15 percent of the total. But they received fewer opioids at each pharmacy visit than other patients.
Patients who saw at least 20 prescribers in a year received an average of 40 doses per prescription, compared to about 70 for patients with five or fewer prescribers. The patient who obtained prescriptions from 64 different doctors received an average of 21 5-mg oxycodone tablets, or about three days’ worth.
Strang says two scenarios could explain these types of patterns: a primary care physician isn’t willing to prescribe opioids, forcing the patient to seek the drugs from other providers; or the patient has no primary care physician to oversee treatment of the underlying condition.
“If they do have a primary-care physician, then the question is, ‘Why aren’t you going to your primary-care doc for this?’ ” Strang said. “If they don’t and they have this pattern going on for weeks or months, the question is, 'Why aren’t you setting yourself up with a [primary-care physician]?' Because this is not a one-time thing.”
Numerous studies have found a link between multiple prescribers and increased risk of injury or death.
A study of high-risk opioid use in Tennessee, published in the Journal of the American Medical Association, found four or more prescribers was associated with a greater chance of a fatal overdose.
Jena led a study at Harvard that found Medicare patients with four or more prescribers were twice as likely to be hospitalized then patients with a single provider managing their medication, which he described as "the classic teaching" on opioid prescribing.
“We know these drugs are dangerous and that if you take too much, you could end up in the hospital,” he said. “So it makes sense that if no one is really coordinating the care and keeping track of how much opioids you are taking, you could fall into that category.”
Indeed, the strength and number of opioids prescribed to some Medicaid patients who use multiple providers varied greatly from one pharmacy visit to the next. According to the state data, it wasn’t unusual for a New Hampshire Medicaid patient to receive 50 milligrams of opioid from one provider and, a few days later, receive a prescription for three times that amount.
Dartmouth pain specialist Gil Fanciullo said that increases the chances of accidental overdose significantly.
“There is no question that it is poor care, and there is no question that it is dangerous,” he said.
Better data, better care
The good news is that Medicaid prescriptions for opioids declined 27 percent between 2010 and 2013, and the number of patients using multiple prescribers went down as well. New Hampshire Medicaid’s shift to a managed-care model in 2014 is also expected to cut down on patients who use more than one physician.
Meanwhile, after a slow start, nearly 8,500 doctors, nurses and physician assistants have registered with the New Hampshire prescription-drug monitoring program. The program allows prescribers to log into the database and find out if a patient has been receiving opioids from another physician.
Fanciullo says he’s been using a PDMP every day since Vermont’s program went online in 2009. In a recent interview, he recalled learning one of his pain patients had received “two or three dozen prescriptions” from 11 doctors that were filled at three different pharmacies.
“She was clearly a person who was doctor shopping or using opioids for some other reason,” he said. “And she would have gone undetected if not for the PDMP in the state of Vermont.”
Vermont is one of 22 states with a PDMP that requires prescribers, under certain conditions, to check the database before writing a prescription for opioids and other controlled substances with known potential for abuse.
According to the Prescription Drug Monitoring Program Center for Excellence at Brandeis University, mandates increase prescriber participation in PDMPs while reducing doctor shopping by patients.
Kentucky, Tennessee and New York require prescribers to query the system before prescribing opioids to most patients. All three states saw a marked decline in “multiple prescriber episodes,” including a 36 percent decrease in Tennessee. In Kentucky, total doses of controlled substances prescribed dropped almost 9 percent, including an 11.5 percent decrease in oxycodone.
Peter Kreiner, the principal investigator of the PDMP Center for Excellence and senior scientist at Brandeis’ Heller School for Social Science and management, said making the programs mandatory also improves prescribers attitudes toward them.
“When prescribers can get the data easily and quickly, they find it of great value and it seems to reduce over-prescribing and improve appropriate prescribing,” Kreiner said. “But it takes a while, especially in a state where it’s pretty new, for people to learn about it and see the value."
In March, New Hampshire lawmakers approved several technical changes to the PDMP, including requiring prescribers to register with the program as a condition for license renewal. The bill also established a five-member legislative committee to study whether the state’s PDMP should be made mandatory.
The study committee has met twice, where members have encountered almost universal resistance to the idea from the New Hampshire Medical Society, the New Hampshire Hospital Association and the Board of Pharmacy.
Sen. Jeb Bradley, who chairs the committee, said the mandate is off the table for now.
“At this point, I think the recommendation of the committee will be to just let it lie for another year,” he said.
Instead, the committee’s focus has shifted to requiring prescribers to demonstrate an understanding of best prescribing practices, either through continuing medical education or an online test. This week, Bradley gave lobbyists representing physicians, hospitals and pharmacists until later in the month to develop proposals for how prescribers would receive the training.
David Strang, who chairs the New Hampshire PDMP Advisory Council, said mandates could sour health care providers on the program before it gets very far. He said it may make sense to impose requirements on prescribers in the case of the kind of opioids, such as oxycodone and fentanyl, that helped trigger the state's heroin problem.
For now, though, Strang said prescribers need more training and education, which may make a mandate easier to sell in the future.
“People want to do things because it’s the right thing to do,” he said.