The Oregon Health Authority adopted a prescription monitoring program in 2011 to help prevent the abuse of controlled substances like opioids and help ensure that prescription medicines are used safely.
But the program has loopholes that prevent it from being a useful tool, according to an audit released Tuesday by the Secretary of State’s office.
“Oregon’s laws have put constraints on the program that limit its effectiveness and impact,” the audit said. “Correcting weaknesses in Oregon’s program will maximize its potential and help address opioid and other substance abuse issues the state faces.”
The audit is the latest step by the state to address the opioid epidemic, which Gov. Kate Brown declared an emergency in March 2018. Over the last nine years, the state has created opioid prescribing guidelines for patients with chronic pain, created a task force to address the epidemic and expanded the authority for trained people to administer naloxone, a drug meant to reverse an opioid overdose.
The drug monitoring program requires prescribers and pharmacies to record prescriptions that have a high potential for abuse into a database. Oregon is among many states that do this in an effort to identify frequent opioid prescribers and “doctor shopping” by patients who seek prescriptions from multiple providers.
However, Oregon’s program falls short on data collection, analysis and sharing.
Across the country, 26 states produce prescriber report cards using prescription drug monitoring data but Oregon bans patient and prescriber analysis. It does not require prescribers to review the database before prescribing a controlled substance, either.
The state does not collect information on dangerous prescription combinations, diagnoses or whether a patient is “locked in” to using one doctor and pharmacy. And it fails to log prescriptions for a class of lower-risk controlled substances like cough medicine with codeine, the audit said.
Furthermore, the state prohibits the sharing of data it collects with health licensing boards and law enforcement, both of which are tasked with keeping patients safe.
“We’ve got this data out there that we don’t do anything with,” state Rep. Cedric Hayden, R-Roseburg, told The Lund Report.
Oregon does not know whether it has a pill mill problem like Florida or doctors who overprescribe because nobody is analyzing the data, Hayden said.
When auditors sifted through the information, they found evidence of doctor shopping. Nearly 150 patients had received controlled substances from 30 or more providers and filled their prescriptions at 15 or more pharmacies. Auditors also found evidence of prescriptions for dangerous combinations. Medicaid paid for a dangerous prescription combination for at least one patient, including a patient on Medicaid.
Hayden said licensing boards should be able to identify prescribers and health facilities with an unusually high number of opioid prescriptions. That way they can identify whether or not the high number of prescriptions is appropriate -- as it might be in a pain clinic -- or suspect, he said.
“If we don’t look at the data and it sits on a dusty shelf for years, what’s the point of having it,” Hayden said.
Much of Oregon’s opioid abuse stemmed from a liberal prescribing policy meant to promote patient comfort. The state has since suffered the consequences.
Oregon has the highest rate of seniors hospitalized for opioids and the sixth highest rate of teenage drug users. Deaths and hospitalizations from opioids peaked in 2011, with 12 hospitalizations per 100,000 people and more than 330 deaths. Still, the number of prescriptions rose to as much as 260 per 100,000 patients in 2015.
In 2016, almost 500 pregnancies were complicated by maternal opioid use. More than 314 children entered foster care from 2015 to 2017 due to parental drug abuse. And in 2017, more than a quarter of Oregon eighth-graders and a third of 11-graders said it was easy to get a prescription drug not prescribed to them.
“It’s an urgent matter,” Debra Royal, the secretary of state’s chief of staff, said in an email.
The report recommended several areas for analysis.
It called for analyzing prescriptions based on providers and patients. The monitoring program currently tracks frequently prescribed drugs and prescriptions used for substance abuse disorder. However, it does not identify patterns among prescribers, pharmacies, patients or regions.
This year, the state required prescribers to register with the program. But the audit said the state should also require pharmacists and prescribers to review the database for a patient before writing an opioid prescription. Oregon is among just nine states that do not require that review.
The audit called on the Oregon Health Authority to work with health licensing boards to get all prescribers registered. It also recommended the agency provide guidance for prescribers to integrate the system into their workflow and improve data sharing between the monitoring program and Medicaid to better monitor Medicaid patients.
It also suggested the health agency work with the Legislature to change state policy to allow for an analysis of prescribers and patient prescribing practices. It said the health agency should be able to send reports to licensing boards and law enforcement and that access to the database should be widened
“The state needs to be responsible for (collaborating) with pharmacies and docs and office managers,” said Charles Gallia, a former Oregon Health Authority senior policy advisor.
Oregon Health Authority spokeswoman Saerom England told The Lund Report that as of September 2018, the drug monitoring program is integrated into the electronic records system used by 600 prescribing clinicians at 25 Oregon hospital emergency departments.
The current program is a burden for doctors, Gallia said. Already, doctors have to go into electronic databases to track the medical record. Introducing another data process is burdensome, he said, particularly when that system is not integrated with their current workflow and technology.
The state should take responsibility for helping pharmacies, prescribers and offices managers introduce the system to their workflow and put it to the best use, Gallia said.
“You want your doctor to be focused,” Gallia said.
Oregon Health Authority Director Patrick Allen agreed with the recommendations in a statement released after the report. He noted that Oregon has seen a decline in opioid-related deaths and opioid prescribing in recent years and attributed that in part to the prescription drug monitoring program.
“Many (recommendations) align with work already going on at OHA,” Allen said in a statement. “Other recommendations require legislative action, and we look forward to advising the Legislature on these policy ideas.”
Officials at the Secretary of State’s Office will follow-up in the future with a new report that looks at what the health authority does to implement the recommendations, Royal said.
You can reach Jessica Floum at [email protected].
Correction: A previous version of this story mischaracterized access to the drug monitoring program, which is accessible by prescribers and their delegates.
I would be happy to contribute more but at the moment I would like to address inaccuracies in the story. First OHA didn't create the PDMP. The state legislature did in 2009. The "loopholes" aren't really loopholes. They are privacy protections for Oregon residents. As an example, law enforcement isn't barred from accessing PDMP data. They just need to have probable cause and a subpoena.
Oregon's PDMP was not law enforcement based which is significantly different than other state PDMPs. Oregon was a pioneer in seeking to improve patient care rather than being a gotcha and a tool for law enforcement to use as it pleases. The audit report included recommendations that may improve the program's usefulness, but they need to be carefully considered, balancing improving patient care and safety with the need to analyze the data by others and adversely impacting Oregonians' privacy.
There is one statement included in this article that is false or misleading that I'd like to point out. The statement is, "Much of Oregon’s opioid abuse stemmed from a liberal prescribing policy meant to promote patient comfort. The state has since suffered the consequences." It needs to be pointed out that over the years that the PDMP has been in existence opioid prescribing has been declining steadily. While I agree there is a n opioid crisis in this state, you need to clearly define whether or not the opioids are prescribed or purchased illegally. It's unlikely that the PDMP will become law enforcement and root out all opioids that were not prescribed leading to high rates of abuse and the deaths of some Oregonians.
Chris Apgar, Chair
Oregon Prescription Drug Monitoring Program Advisory Commission
I will ensure that Jess Floum, the writer, sees your thoughtful comments. We really appreciate you reading and weighing in. On the prescribing practices, according to Oregon's Opioid Dashboard, prescriptions hit a high in the fourth quarter of 2014 - 262 per 1,000 - and then again in the third quarter 2015 - 263 per 1,000 - but it's true they have been declining ever since. Please keep your comments coming and consider writing an opinion piece. We welcome your thoughts!