Do We Really Want e-Script Monitoring?

Do We Really Want e-Prescription Monitoring?; Alex DeLuca, M.D., MPH; War on Doctors/Pain Crisis; 2007-05-08.

From Tallahassee, Florida, comes this article: E-Prescribing Could Cut Down on Drug Abuse” by Geoff Oldfather;TCPalm News; 2007-04-08. Mr. Oldfather reports on a bill passed by the Florida legislature which aims to “cut down on prescription drug abuse and death.”

The article explains that the bill is the result of a four year effort by Rep. Gayle Harrell (R) who drew her inspiration from the criminal prosecution of Dr. Asuncion Luyao, convicted of manslaughter and drug trafficking in 2006, whose case involved six overdose deaths in which prescription drugs were judged to have played a part.

[Regarding Dr. Luyao's case, see: Siobhan Reynolds on the Conviction of Dr. Luyao, and, Jurors: Deciding Luyao's Fate was Difficult, Emotional]

What Rep. Harrell has succeeded in creating is a prescription monitoring program (PMP) - a networked computer database system linking prescription-originating physicians offices with dispensing pharmacies. Physicians are encouraged to opt-in by having license renewal fee’s waived for two years if they get the requisite e-prescribing software.

“It’s a portal to information for the doctors and the pharmacists through the private enterprise system and something that’s already being established,” Harrell said. “Doctors who ‘e-prescribe’ will be able to see what other medications other doctors might be prescribing and how much the patient is getting. It will be obvious immediately if someone is getting too much of a drug.”

So now when you go to your dermatologist for contact dermatitis she’ll be able to see, as she enters your 5% hydrocortisione cream prescription into the “portal”, that the doctor across town is treating you with interferon and ribavirin, and that you very probably have hepatitis C. And you didn’t even have to volunteer the information, and the doc didn’t even have to ask the question. See how carefree modern medicine can be? Nobody has to take any personal responsibility at all!

Also note that you, the patient, have no control over your prescription data; any medication order ‘e-prescribed’ is available to any participating doctor or pharmacist (or the nurse, the receptionist, the subsitute pharmacy clerk…).

And you will accept, gladly, this invasion into the privacy of your most intimate medical information, dear patient, toward the patriotic goal of preventing prescription drug abuse. And while you are thusly taking it on the chin for the greater good, you might meekly inquire exactly who is directly benefiting?

Well, federal law enforcement will thank you for making their difficult job of finding ever dwindling numbers of ‘opioid-overperscribing’ pain docs a little easier. Oh, and a couple of substance abusers who couldn’t get prescription medicine to OD on and weren’t resourceful enough to obtain illegal drugs, might someday want to shake your hand. (It could happen). Lucky you.

“We learned that we have more people who die from abuse of prescription drugs than die from heroin and cocaine abuse combined,” Harrell is quoted as saying. The Representative may be correct - heroin and cocaine use are stable to declining while prescription drug use is increasing. But it is very, certainly true that deaths from heroin, cocaine, and controlled substances combined are dwarfed by deaths from “adverse drug reactions”(ADRs), a term indicating medical error as opposed to patient abuse.

U.S. Recreational Drug Deaths vs. Adverse Drug Reaction Deaths, 2002

As this bar graph from Scherlen and Robinson shows, America does have a large substance-related public health problem, but it is very difficult to make a serious case that the substances we should be most concerned about are the illicit drugs and licit controlled substance prescriptions. Deaths related to the recreational use of tobacco, alcohol, illicit drugs, and cannabis are compared to deaths related to fatal adverse drug reactions (ADRs) which are captioned “PharmCo.”

Note that deaths related to illicit drugs are an order of magnitude lower than deaths related to the legal recreational substances tobacco and alcohol, and an order of magnitude lower than fatal ADRs. Also note, while we’re here, that deaths related to cannabis use are zero (giving cannabis a therapeutic index of infinity? :-) ).

For a sense of perspective, considering for a moment only ADR’s related to analgesic (pain-relieving) medications, in 2000 approximately 16,000 Americans suffered fatal ADRs from direct complications of NSAIDs (non-steroidal anti-inflammatory medications like Motrin and Naprosyn). In that year only some 200 died from OxyContin, usually in the context of abuse, not pain management, and almost always in combination with alcohol or other drug(s). [Chevlen; 2001]

From a public health perspective, if she were really interested in saving lives and health care dollars, Rep. Harrell would have spent the people’s time and money far more effectively had she mandated a prescription monitoring program where it would do significant good, inside hopsitals where 0.32% of all admissions suffer fatal ADRs. [Lazarou et al.; 1998] And hospitals would be far better able to protect against needless invasion of privacy than a loose network of doctors and pharmacies linked “through the private enterprise system”, as reassuring a ring as that might have to, ahh, a Republican congressperson.

Such hospital-based prescription management and error-detection systems were a major recommendation of The National Academies in their (government funded) 2000 report entitled, To Err is Human: Building a Safer Health System. But Rep. Harrell is more interested in exploiting six unfortunate deaths and capitalizing off of this year’s drug war moral panic, ‘prescription drug abuse’, than she is in pursuing rational, evidenced-based, cost-effective, expert-recommended public health measures; measures that would be more likely to improve peoples lives than infringe upon them.

But don’t worry, Friends. This is still the U.S. of A. And of course, you are free. Free to choose. You can choose to opt-out of Harrell’s cynical and very badly designed scheme, and refuse your permission. Just be aware that “[without] patient permission [allowing e-prescribing], doctors may refuse to prescribe medication, Harrell said.”

Ahh yes; the choice that is no choice. Pain patients already know this one all too well. Looks like the rest of you best prepare to get used to it.

See also:
Civil Liberties Implications of Our Nation’s Approach to ‘Drug Control’; by Siobhan Reynolds, Pain Relief Network; Comment #11 to John Tierney’s Dr. Hurwitz’ Mysterious Motive; TierneyLab; 2007-04-25.

H.R. 3015 (National All Schedules Prescription Electronic Reporting Act - NASPER) Continues War Against Pain Patients and Doctors - Michael Glueck, and Robert Cihak; NewsMax.com; 2004-11-23.

References:
Chevlen, E.; A Bad Prescription from DEA; The Weekly Standard; 2001.

Lazarou, J.; Pomeranz, B.H.; Corey, P.N.; Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-Analysis of Prospective Studies. JAMA; 279(15); 1200-1205; 1998-04-15.

Institute of Medicine; To Err is Human: Building a Safer Health System; The National Academies; 2000.

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