New HHS Report on Prescription Drug Abuse Lacks Comprehensive Proposals
We have written previously, including here and here, about this nation’s epidemic problem with abuse of prescription drugs, particularly painkillers. So we approached a new Department of Health and Human Services (HHS) report, “Addressing Prescription Drug Abuse in the United States, Current Activities and Future Opportunities,” with some interest.
But we were disappointed by the report because it is mainly a catalog of the extensive, but not particularly effective, efforts by various federal (and state) agencies to address the prescription drug abuse problem. It is never a good sign when an agency report states “HHS has been at the forefront on this issue” because such horn-tooting suggests turf consciousness and efforts to justify additional appropriations to the agency rather than a candid assessment of efforts, successes, and failures.
While the report identifies fourteen “overarching opportunities to enhance current efforts,” a close examination reveals that these are not much more than optimistic bullet points. There is little or no specificity on steps that might be taken to realize these “opportunities.” For example, the first identified opportunity is to “Strengthen surveillance systems and capacity.” Surely someone within HHS might have recognized that, following recent revelations of NSA spying, this might not be the best way of describing what a government agency would like to do. In the context of the report, the term “surveillance” is actually a puffed-up word for gathering and interpreting various drug abuse statistics.
We focused on the HHS report’s discussion of state prescription drug monitoring programs (PDMPs). The report called PDMPs “one of the most promising clinical tools to address prescription drug abuse” but noted that these programs are “significantly underutilized by providers” for a number of reasons including “the cumbersome nature of accessing current systems and privacy concerns.” One of the report’s fourteen action items is to “support efforts to increase provider use of PDMPs.”
A June 2013 article by Emory University Associate Professor of Law Joanna Shepherd, “Combatting the Prescription Painkiller Epidemic: A National Prescription Drug Reporting Program,” provides a detailed explanation of how state PDMPs “suffer from a number of deficiencies that limit their efficacy” including “inadequate data collection, ineffective utilization of data, insufficient inter-state sharing of data, and underuse of certain data by law enforcement.” Instead of expending greater efforts on PDMPs, Professor Shepherd recommends “using an existing infrastructure – pharmacy benefit managers’ (PBMs) links with retail pharmacies – to create a national controlled substance reporting framework. As we noted:
This simple, yet effective, national reporting solution would flag indicators of likely prescription drug abuse in real time. These include cash-paying customers visiting multiple doctors or crossing state lines to visit multiple pharmacies, and physicians / other providers who are disproportionate prescribers of prescription drug painkillers. In addition, since all pharmacies and providers are required to have a National Provider Identifier (NPI), rogue pharmacies or physicians engaged in fraudulent activities related to prescription painkillers would also be captured by this system. In short, this model would likely capture a substantial share of illicit behavior by patients, physicians, and/or retail pharmacies thereby providing an important tool for law enforcement to crack down on prescription drug abuse.
In an August 2013 article in the New England Journal of Medicine, “Abusive Prescribing of Controlled Substances – A Pharmacy View,” CVS Caremark Corporation’s (CVS) Chief Medical Officer Troyen Brennan and his colleague Mitch Benses explained how CVS had been able to use the data on all prescriptions filled at the various pharmacies in its chain to identify high risk prescribers. CVS used several benchmarking parameters: the volume of prescriptions for high-risk drugs and the proportion of the prescriber’s prescriptions that were for such drugs, compared to other prescribers in the same specialty and region; the number of the prescribers’ patients who paid cash for high-risk drug prescriptions; the percentage of their patients in the 18 to 35 age group; and a comparison of the prescribers’ prescriptions for non-controlled substances vs. controlled substances. Based on this data, CVS identified 42 “outlier” prescribers and, after giving them the opportunity to provide legitimate reasons for their prescribing practices, it identified 36 prescribers from this group whose controlled substance prescriptions CVS would no longer fill through its pharmacies.
Brennan and Benses acknowledged that CVS’s program “is certainly not a comprehensive solution.” Consistent with Professor Shepherd’s recommendation, they said “A comprehensive solution would involve the use of a national prescription-drug-monitoring database that would be used by clinicians at the point of prescribing and by all pharmacies at the point of dispensing.”
The HHS report gets only part of the way towards this comprehensive solution. It includes as two of its action items:
- Collaborate with insurers and pharmacy benefit managers to implement robust claims review programs; and
- Collaborate with insurers and pharmacy benefit managers to identify and implement robust programs that improve oversight of high-risk prescribing.
These are things that insurers and pharmacy benefit managers are already doing with respect to the limited share of prescriptions and claims they are seeing. However, because of intentional drug-seeking behavior – e.g., doctor shopping, pharmacy shopping, and cash payments for controlled substance prescriptions – no insurer or PBM, and no pharmacy, will have a sufficiently comprehensive overview to be fully effective in combatting abusive controlled substance prescriptions. HHS needs to think more globally as to how to take advantage of current PBM tools to combat prescription painkiller abuse.