By JOHN WOODROW COX,
c.2012 Tampa Bay Times@
One year ago, Florida created a weapon meant to help stop the prescription drug epidemic that kills an average of more than six people a day in this state.
Since then, anyone filling prescriptions for controlled substances such as OxyContin or Xanax has been required to record the details into a database known as the Prescription Drug Monitoring Program. In less than a minute, doctors and pharmacists who use the program can see where and when their patients filled previous prescriptions, the type and quantity of drugs they got and who prescribed them.
The system can help medical practitioners determine whether a patient has a legitimate medical need for these highly addictive medications or is a drug abuser seeking the next high.
But the program came with a major loophole: Nobody is required to check it.
Now, a Tampa Bay Times investigation has discovered what experts feared the vast majority of medical practitioners have never touched the much-touted database:
Since the system's inception on Sept. 1, 2011, more than 48 million prescriptions have been written in Florida for controlled substances that's about 2.5 for every man, woman and child in the state. Prescribers, however, checked the database before writing just 2 percent of them.
Among physicians in the Tampa Bay area permitted by the federal government to prescribe these potent drugs, fewer than one in 12 has ever used the database.
A Times reporter surveyed all 91 local pain-management clinics registered with the state and that appeared to be in business. Fewer than half reported using the program. Employees at 46 of the clinics declined to answer questions or did not respond to calls. One acknowledged never using the program.
Many who backed the system including drug abuse experts, lawmakers, law enforcement officials, pharmacists, doctors and parents who lost children to overdoses were stunned to hear that it's barely ever used.
Others saw it coming.
"People think it's this silver bullet, this magic thing," said Pinellas County Sheriff Bob Gualtieri. "But it's so underutilized."
That's hard for Cindy Harney to hear. Her son, Garrett, died of a prescription drug overdose in 2006. He was 20.
The Sarasota woman pleaded with legislators to create the monitoring program. Harney fought for it in Tallahassee and formed an organization that has advocated on its behalf. She can't comprehend why a physician wouldn't check the database before prescribing a potentially deadly medication.
"It's not going to save my boy," she said. "But think of all the others it could save."
So, why aren't more doctors using it?
Kurt Schultz, owner of Fix All Medical Clinic in Tampa, says he knows the answer.
"It's not required. That's the problem," he said. "I think it should be mandated any time pain medication is prescribed. Why would you not use it?"
Schultz said his medical staff checks it regularly, but he knows of many practices that never do.
At a registered pain management operation called Glory Medical Center & Weight Loss Clinic in Tampa, no one answered several calls or returned a voicemail asking if they use it.
A recording says first visits cost $350; insurance is not accepted.
"When speaking to one of the staff members," it says, "please remember to ask if we are currently running any specials for pain management."
Physicians or owners at only nine of the 91 clinics surveyed by the Times agreed to interviews.
Most said use of the database should be mandated.
"This monitoring program is a godsend," said Dr. Joseph Rashkin of Bay Area Pain Management in Tampa. "The health care providers who are prescribing this medication ought to be checking very frequently."
Rashkin said he personally consults it 10 times per day. He runs reports on new patients and, every few weeks, on established patients. He used to get at least 20 visitors a week he considered "doctor shoppers," people who seek multiple prescriptions. Now, like other clinics that spoke to the Times, he hears from just one or two a week.
Checking patient histories inevitably means turning some away. That potential loss of business could be a reason for certain doctors to ignore the database, speculated Christopher Wittmann, a physician's assistant at Trinity Pain Clinic who uses the program.
"If they're making a lot of money they may just not want to know," he said.
Though experts say all doctors who prescribe these medications should check the database, they are adamant that pain management physicians who typically prescribe thousands of the addictive drugs every year should use it as a standard of practice.
But Dr. Manjul Derasari of Professional Pain Management in Tampa said he has never consulted the program.
"Should I be using it?" he said. "I think I should be using it. At present, I am not using it."
Derasari explained that he reviews his patients' medical records and his staff periodically checks the Hillsborough arrest records. The doctor also said he screens potential clients before accepting them.
If the doctor suspects someone is doing something wrong or has a problem, he said he asks pharmacists to check for him.
"Am I missing somebody?" he mused. "I probably am missing somebody."
Between 2002 and 2008, the Legislature rejected proposals to create a drug monitoring database each year but one, when it wasn't proposed at all.
In that same period, more than 10,000 Floridians died from prescription drug overdoses.
People from across the country flocked here, lured by the state's easy access to drugs. Embarrassed by the mounting death toll and a growing reputation as the "pill mill capital of the nation," in 2009 legislators followed the example of many other states and approved a database.
But lawmakers refused to budget money for the program. Then, in February 2011, Gov. Rick Scott announced that he would repeal the law, citing concerns about patients' privacy.
He eventually relented, but even now the program's future is tenuous. According to the Department of Health, funding has only been secured through the end of June 2013.
To its backers, the program is a watered-down casualty of compromise. The law includes just one requirement: dispensers of the drugs, primarily pharmacies, must enter the prescription's details into the state database within seven days.
Pharmacists do not, however, have to check the patients' histories before handing over the medications.
Bruce Grant, former director of the now-defunct Governor's Office of Drug Control, foresaw the program's future.
"If it isn't utilized, then it doesn't accomplish anything," Grant told the state Board of Medicine in 2010. "It doesn't reduce prescription drug abuse. It doesn't reduce the crime. It doesn't reduce the addiction."
Florida physicians are not alone in their resistance to a drug monitoring database.
"There are a fair number of doctors who really feel they can tell what their patients are doing just by having a conversation with them," said David Hopkins, project manager for Kentucky's database. "They don't feel they need to check the monitoring program."
After years of voluntary use, just one in five Kentucky prescribers were using the system. Though impressive compared to Florida's one in 12, Kentucky last year mandated participation.
When it was still voluntary, the system processed about 2,900 requests for patient information a week. Now, it's 95,000.
Every state but Missouri has a database or has enacted legislation to create one, according to the National Alliance for Model State Drug Laws. Twelve states have approved mandates. The measures are too new to know how they will affect overdose deaths.
Since Ohio ordered participation, according to program administrator Danna Droz, doctors have been shocked to find out how many patients were abusing drugs.
"We had the program for five years, and people weren't using it enough," Droz said. "Now, they're seeing why they should be using it."
New York recently passed the most aggressive mandate in the country, largely to combat abuse of oxycodone, which like heroin is classified as an opioid drug.
"We've decided that heroin is so dangerously addictive that under no circumstances will we allow it to be sold," said New York state Sen. Andrew J. Lanza. "And yet we have the very same drug, only better because it's pure, that we dispense as medication."
As in Florida, Lanza said, most of the oxycodone that makes it to the street there is first prescribed by physicians, which is why a mandate is so important.
"The problem is so serious," he said, "you just can't leave it to chance."
Dr. John H. Armstrong, Florida's surgeon general, said he already considers the state's monitoring program a success.
Armstrong, appointed to the position by the governor earlier this year, said the Times should not have focused on the number of prescribers who have used the program about 8 percent.
"We would define 'use' as being registered in the system," he said. "We think that describes a readiness of use."
The group of prescribers registered, he noted, represents a larger figure: 14 percent.
That's more important, he said, than the fact that nearly half of those registrants have never actually used the program.
Others have also praised the system. Law enforcement officials have applauded their access to information from the database if it pertains to an active investigation. Also, the doctors and pharmacists who do use the program sometimes call to report suspicious patients.
But one key measure indicates that the street supply of oxycodone hasn't changed since the program's creation. Investigators say the price of a 30-milligram pill in Tampa Bay has remained at about $17.
"I think we're making progress," said Gualtieri, "but not to the level we need it to be."
Hillsborough sheriff's Detective Chris Tuminella said he has talked to physicians who haven't even heard of the program. Others know of it but don't use it.
"You see some that don't even pull it up," he said. "They're totally clueless."
The solution, officials say, is to require doctors to use it.
"It would cut down on the number of pills hitting the street, which contributes to people dying," said Hernando sheriff's Detective Chris Erickson. "You cut the numbers down, you cut down the number of people dying."
Like the physicians, investigators say the program's mere existence appears to have reduced doctor shopping.
Preliminary evidence shows that deaths have declined, though the most recent data is from the first half of 2011 before the program existed.
Those signs of progress are often attributed to other new laws requiring pain-management clinics to register with the state and undergo annual inspections. Plus, doctors in most cases can no longer dispense drugs directly to their patients.
Beyond a crime preventive, supporters say, the program has potential to improve the care of legitimate patients suffering from pain.
To be sure, the database can illustrate patterns of substance abuse. But it can also indicate potentially dangerous drug interactions and, when used properly, it may help show whether the medications are truly alleviating pain or if other therapies should be explored.
If this program has a face, it belongs to state Sen. Mike Fasano. The Pasco Republican fought for it over more than a decade.
When Fasano heard the Times' findings, he sighed.
"I'd like to see every medical physician in the state use it," he said. "If they don't, I think we're going to have to mandate it."
But how likely is that to happen?
"Neither the Legislature, nor this particular governor, would ever go along with that," said Claude Shipley, who worked in the state's Office of Drug Control before Scott shut it down. "For the foreseeable future, this is it."
Garrett Harney's mother, Cindy, can't accept that. She saw her son collapse into drug abuse after a friend offered him pills legally prescribed by a physician.
Why, she wonders, wouldn't every doctor use a tool that could help ensure these powerful drugs go to the people who need them and not land in the streets?
"Who would be opposed to this?" she said. "Who would ever be opposed to saving a life?"
Researcher Caryn Baird contributed to this report . John Woodrow Cox can be reached at firstname.lastname@example.org.
In the past decade, prescription drugs have killed more than 15,000 Floridians. In September 2011, the state set up a database for health practitioners to see if patients have a history of abuse. Prescribers checked the database for only 2 percent of the 48 million controlled substance prescriptions written in the past year. Meanwhile, people are still dying.