New Jersey’s Recent Efforts to Combat Prescription Drug Abuse
New Jersey is adding to its arsenal of resources to investigate and combat prescription drug abuse and diversion.
On January 18, 2012, New Jersey’s new Attorney General, Jeffrey S. Chiesa, announced the launch of the State’s long-awaited Prescription Monitoring Program (”PMP”), which permits the State to monitor prescriptions for controlled substances. (I blogged last June about the passage of the statute authorizing the PMP, N.J.S.A. 45:1-45-1-52.) According to AG Chiesa, the PMP is “a powerful new tool in the State’s fight against the abuse and diversion of prescription drugs, and the often-heavy reimbursement costs of fraudulently-obtained prescription medication borne by health insurance companies, the State, and ultimately taxpayers.”
Before the PMP, investigators of inappropriate prescribing or usage patterns, absent timely and reliable complaints, had to pick which pharmacies, providers, or patients to investigate and then cobble together data from these various sources, looking for the proverbial needle in a haystack. It often took quite a bit of time and resources, not to mention a bit of luck, to find the evidence required to demonstrate diversion or abuse.
The PMP now centralizes these data in a searchable database maintained by the State’s Division of Consumer Affairs. Since September 1, 2011, the PMP has been collecting information from 2,000 pharmacies throughout the State every 15 days regarding the prescription sale of all drugs classified as controlled dangerous substances (CDS) and human growth hormone (HGH). As AG Chiesa explains, the PMP “database will help the Division of Consumer Affairs and other law enforcement agencies identify and investigate individuals and businesses suspected of fraudulently diverting controlled drugs for abuse. By highlighting the location, nature, and extent of abuse throughout the state, the information collected will also better inform our healthcare initiatives and addiction-treatment efforts.”
Investigators are not the only folks with access to this data. Beginning January 4, 2012, State-licensed prescribers and pharmacists may register to be able to access the PMP database to help inform their professional decision making with regard to current patients. Consumer affairs also will provide information garnered from the database to other law enforcement agencies and the professional licensing boards, as permitted by law.
By May 2012, the State intends to enhance and expand the PMP database to permit more sophisticated statistical analysis. According to the State:
When fully expanded, the NJPMP will generate reports on geographical areas with unusual CDS or HGH prescription activity during a specific time frame; identify practitioners in each county who prescribed the largest quantities of a specific drug during a given time period; and provide other information that can help identify and compare troubling patterns of CDS and HGH activity.
By using the PMP, investigators may more swiftly identify patients who are filling multiple prescriptions for CDS or providers who are authorizing large quantities of CDS. With this information, investigators may examine whether there are medically appropriate justifications for these prescriptions, or if this is evidence of diversion, abuse, or fraud. For example, the State’s press release recounts that investigators used the PMP to identify a patient who obtained a four-month supply of methadone and oxycodone in just over one month by presenting what are now believed to be fourteen forged prescriptions to three different pharmacies, and they made this discovery within a month of the abusive behavior.
To help the State maximize the potential of the PMP, AG Chiesa announced the “next step” in the State’s “comprehensive, statewide plan to fight the diversion and abuse of prescription drugs” — a reorganization and expansion of the Enforcement Bureau (”EB”) of the Division of Consumer Affairs. The EB is the investigative arm of the various state professional boards, including the State Board of Medical Examiners and Board of Pharmacy, which investigates potential professional misconduct by the licensees of these Boards. The AG plans to add investigators to the three investigative sections that play “a key role in the Division’s effort to curb prescription drug diversion and abuse” to permit the EB to develop expertise in identifying “the unlawful distribution and diversion of prescription medications.”
First, the AG plans to grow from 7 to 9 the number of undercover investigators in its drug diversion section, which investigates “cases related to the distribution and diversion of prescription drugs; indiscriminate prescribing and dispensing; prescription fraud; and enforcing the bans enacted by the Division of Consumer Affairs on so-called “bath salts” and other designer drugs.” Indeed, the State’s press release reports that one investigator has already been hired.
The AG also plans to add 4 pharmacist/investigators to the current 9 in the pharmacy inspection section, to inspect pharmacies and review security protocols to try to prevent theft of CDS.
It then will add three nurse/investigators to its quality of healthcare section, which currently has 7 registered nurses or other experienced investigators. By monitoring the quality of care provided by licensees primarily of the medical and nursing boards, this section often oversees investigations concerning “drug impairment and self-use by practitioners, and health insurance fraud.”
The AG also said that the 20 investigators in EB’s other 2 investigative sections will be available as needed to support the State’s efforts to fight prescription drug diversion.
There is much to applaud here. Public health demands increased efforts to curb prescription drug abuse and diversion. If used appropriately, these initiatives offer considerable promise — individuals, including practicing health care professionals, in need of substance abuse treatment can be identified in a more timely fashion; practitioners lacking adequate training in the prescribing of controlled substances can be required to take additional courses; and dishonest or dangerous practitioners can lose the privilege of licensure.
These initiatives also raise a number of policy and legal questions that need to be fleshed out. These include, just to identify a few:
- How do we ensure patient privacy? Prescribing doctors and pharmacists must certify that they are accessing the database for a current patient, but how do we verify the truth of their certifications?
- When will information be shared with other law enforcement entities?
- New Jersey’s statute permits the State to enter interoperability agreements with other states so that each state may access the other’s data. When will other states be able to access New Jersey’s database?
- The statute does not require prescribing doctors and pharmacists to access the database — should it, to better inform care decisions? (The Massachusetts Senate unanimously passed S. 2122recently, generally requiring doctors to check the State’s PMP database before prescribing a Schedule II or III narcotic drug to a patient for the first time. Not everyone, however, thinks it’s a wise proposal.)
- Should New Jersey amend the PMP statute to permit non-prescribing substance abuse treatment providers, such as social workers or psychologists, to access the database?
- How do we discern from the data which high volume prescribers may be too readily prescribing — or even complicit in diversion — and which are needed palliative care doctors who treat a disproportionate number of patients in chronic pain? It is critical that well-trained, ethical pain management doctors are not deterred from practicing their specialty by fear of being caught up in a protracted, potentially career-ending investigation. (Somewhat relatedly, the Florida Legislature recently killed a bill that would have prohibited doctors from writing prescriptions for controlled substances while arrested and awaiting trial on — but not yet convicted of — a charge relating to controlled substances.)
- What public policy initiatives can be adopted to ensure that all patients with legitimate prescriptions for pain medication can get those prescriptions filled at local pharmacies?
I am encouraged by New Jersey’s continued efforts to combat the real and deadly challenges of prescription drug abuse and diversion, but I encourage balance in the implementation of these new tools so that patients suffering from pain are not denied appropriate palliative care. I am eager to work through these issues. Let’s start a dialogue. I welcome your ideas.
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We in Idaho have had a PMP database for several years. The use and success is dependent on several other factors:
adequate staff to manage the DB and research prescription and use patterns. This has been a problem with the last 3 years of economic distress in state government.
adequate treatment for chronic pain and addiction
training for primary care providers (and others) on pain management
public education on the dangers of diversion for unused medications not destroyed
a way to accept and destroy medications
integration of law enforcement and license disciplinary boards
health plan programs to “tie in” frequent users to single pharmacies
John Rusche, MD
Minority Leader, Idaho House
Representative Rusche, thank you so much for joining our conversation. We welcome further dialogue to try to identify what has, hasn’t, and might work to tackle these issues. Are there any efforts to study Idaho’s experiences and propose reforms? You are absolutely right to remind us that this is a multifaceted problem that requires various responses. New Jersey’s Operation Medicine Cabinet Campaign (http://www.nj.com/news/index.ssf/2010/09/prescription_drug_abuse_progra.html), for example, was the model for the American Medical Chest Challenge (http://www.americanmedicinechest.com/). It is imperative to improve training for prescribers and to make available effective treatment options that address chronic pain and abuse. We hope you’ll continue to share with us other thoughts you have about innovative strategies to address these vexing concerns, such as the health programs to “tie in” frequent users. We would like to help assess the strengths and weaknesses of these and other possibilities. Thank you.
I thoroughly enjoyed reading this article. As a former resident of New Jersey fully aware of the impact of prescription drugs and a Public Health graduate student in Administration and Policy, (currently doing a research paper on prescription drug control policy). I agree that the nature of the PDMP brings up many policy and ethics questions. With regard to opening up the database to mental health practitioners, I think it is a good idea. In cases of addiction clients, its incredibly difficult to judge how truthful a client is being, aside from commanding urinalysis testing–and access to the PDMP would allow more transparency in a convenient and less invasive manner.
Currently, I live in Tennessee, where a PDMP became operational in 2007. Since its inception, there has been marked improvement in the number of prescriptions being handed out, a reduction in the number of “doctor-shoppers”, and a better means of detecting “pill mills”.
Truth be told, a PDMP is a great step, yes, but certainly not an end-all-be-all in my view. A multi-pronged approach that combines education with mandates on PDMD usage and dispensation regulation would be a best-in-class, long-term solution.
J. Collins
ETSU–College of Public Health
Department of Health Management & Policy