Tracking the tracker: Long road for Pennsylvania's prescription drug monitoring program

In Pennsylvania, few took notice to the silent epidemic before deaths from prescription drug abuse started making the front pages of newspapers across the state. And, in fact, there was no reason to believe opioids would create such a problem particularly when Purdue Pharma launched a campaign in 1996 informing patients and doctors that a new, safe drug was available to combat pain.

But, there were some early warning signs and some did begin to take notice. Unfortunately, despite their best efforts at raising red flags, moving legislation was difficult if not impossible at the time.

During the 2011-'12 legislative session, with 45 co-sponsors including prime sponsor Eugene DiGirolamo, Pennsylvania House Bill 1651 aimed to establish the "Pharmaceutical Accountability Monitoring System." This would give physicians a tool to better understand if the person sitting in their exam room had legitimate pain or was doctor shopping. Sadly, the bill never received a vote on the floor of the state house of representatives.

"It was disappointing back then that no one would listen," says Scott Shapiro MD, president of the Pennsylvania Medical Society. "Members were coming to us and indicating that doctor shopping seemed to be increasing. They suspected an increasing number of addictions. We knew something had to be done."

With a new legislative session on the horizon, according to Dr. Shapiro, this time the medical society was determined to see legislation move and became considerably more vocal.

"We knew that this silent epidemic was going to get worse before it got better, and we knew we had to be louder if we were going to be successful," Dr. Shapiro says, explaining leadership at the Pennsylvania Medical Society directed staff to launch a campaign just prior to the 2012-'13 legislative session to push for a controlled substance database.

"That's how our 'Pills for Ills, Not Thrills' campaign got started," he says. "It was a complete push using all of our communications and government affairs tools available -- news releases, editorials, educational materials, and meetings with legislators."

How Did This Epidemic Grow?

York County in beautiful southcentral Pennsylvania is dealing with one of the larger number overdose deaths in the state. According to a DEA Intelligence Report, York County had 118 drug-related overdose deaths in 2014, nearly double any neighboring county.

With stereotypes in mind, it's a county that many would not think of being among the worst in the state. Its unemployment rate is near the average for Pennsylvania and the graduation rate of nearly all high schools is above the state average. This rural county with 85 percent of its population being white wouldn't seem to be a hotbed of drug problems.

Drug statistics say otherwise. In 2014, of the 118 deaths, 111 were white. And, combining all races, 48 of those who died were between the ages of 31 and 45.

"Not too many people would think this is a rural health issue, but it happens here too," says Bradley Levin, M.D., FACC, FACS, FASAM, DABAM, CMRO of York County Medical Society. He is a member of the York County Heroin Task Force.

Illicit drugs like heroin and marijuana are most often present in drug-related overdose deaths, but opioids are part of the picture 33 percent of the time.

According to York County Coroner Pam Gay, 2015 is likely to be similar to 2014 with its end of year statistics of 65 heroin-related deaths out of 95 drug deaths overall (with a few still pending). But Gay points out repeatedly that without Law Enforcement administering Naloxone in York County in 2015 (from April to December 2015), and the subsequent 99 saves that resulted, there would likely have been dozens more heroin-related deaths in York County in 2015.

So how did York County get to where it is at today?

Dr. Levin says that this problem grew out of another issue -- managing pain.

In mid-February 2016, Modern Healthcare took a closer look at the root of the problem and traces it back to 1996 when Purdue Pharma began promoting a new drug to fight pain -- OxyContin. Early on, the medication was billed as being safe because it would slowly release narcotic ingredients, making it unlikely to become addictive.

"We were told that this new drug would be the answer to many issues related to pain, particularly since a year earlier pain became the fifth vital sign and the American Pain Society recommended it be added to the indicators that assess overall health," says Dr.Levin mentioning there was even a time when physicians would be penalized for not prescribing opioids.

But Dr. Levin adds that problems were brewing.

Nearly 10 years later in 2007 Purdue would plead guilty in federal court to criminal charges that they misled regulators, doctors, and patients about the drug's risk of addiction as well as its potential to be abused.

"We know better today, but the beast was unleashed and as addictions grew so did doctor shopping and other illegal activities," says Dr. Levin. "Those seeking pills got really good at finding what they wanted and in some cases pushed the drug out onto the street."

According to the National Institute on Drug Abuse, the most popular source for non-medically used prescription drugs are friends and relatives with 54.2 percent receiving them for free and another 16.6 percent either stealing or purchasing the drug. NIDA estimates that 6.1 million Americans are using prescription drugs for non-medical reasons every month.

Gaining Momentum

Dr. Todd Fijewski, President of the Pennsylvania College of Emergency Physicians, has had a front-row seat in this growing epidemic. He's seen his share of drug overdoses, infections secondary to drug use, and deaths. Addiction can affect anyone. It does not discriminate.

"It's pretty safe to say that if you work in emergency medicine, you've seen more than enough overdose victims," says Dr. Fijewski. "It's a problem that impacts so many different types of people, whether you live in rural or urban settings."

His organization too saw an urgent need for more tools to help physicians fight prescription drug abuse and like the Pennsylvania Medical Society was an active member of the choir calling for the state to pass legislation to give physicians access to a controlled substance database.

He says, after the failure of HB 1651, clearly what was once a silent epidemic was becoming quite visible.

"It was getting hard to ignore," Dr. Fijewski says. "There was suddenly a greater awareness of the issue and the media made it clear that Pennsylvania lagged behind other states in passing prescription drug monitoring legislation."

Fortunately, the issue had more heroes stepping up in Harrisburg. Rep. Matt Baker teamed up with Rep. DiGirolamo and others to push House Bill 1694 to a successful 191-7 vote in October 2013.

At about the same time, Sen. Pat Vance had Senate Bill 1180 introduced and moving as well. Her bill ultimately would be the bill to cross the finish line on October 27, 2014, when then-Governor Tom Corbett signed it into law. Prior to Gov. Corbett signature, SB 1180 passed the Senate 47-2 and the House 194-2.

SB 1180 established the Achieving Better Care by Monitoring All Prescriptions Program (ABC-MAP) and was scheduled to be in place by mid-2015.

More help, but still waiting

Since October 2014, other in-state initiatives to address opioid abuse were developed. Medication drop boxes are available throughout the state. Pennsylvania Physician General Rachel Levine signed a statewide prescription for Naloxone, a life-saving drug that has the power to reverse an overdose.

Physician education to correct pharmaceutical misinformation from years earlier also became important. Opioid prescribing guidelines were developed by groups like the Pennsylvania Medical Society, Pennsylvania College of Emergency Physicians, Pennsylvania Department of Health, and Pennsylvania Department of Drug and Alcohol Programs. And continuing medical education specific to opioid prescribing has been developed by multiple medical organizations.

But, despite the success of SB 1180 in 2014 and the high awareness level of the state's opioid abuse crisis, Pennsylvania physicians continue to practice without that extra arrow in their quiver. To date, Pennsylvania's prescription drug monitoring tool has yet to go live.

But progress is being made.

During a mid-February meeting of the ABC-MAP Board, the Pennsylvania Department of Health introduced the project vendor -- Appriss, which manufactures the PMP AWARxE system. Currently 23 states utilize Appriss' PMP solution. Additionally, Appriss is the company that the National Association of Boards of Pharmacy used to create and manage their PMP InterConnect system, which facilitates interoperability and interstate data sharing between prescription monitoring programs.

Sources inside the Pennsylvania Medical Society are hopeful for the system to be delivered to the state during the summer months and available for physician use shortly later.

"When you factor in all that health care professionals and state officials are doing, there likely is no other public health issue in Pennsylvania getting as much attention," says Lawrence John, MD, president of the Allegheny County Medical Society and a family physician in Pittsburgh. "This crisis hit us like a tidal wave. It was the perfect storm of misunderstanding at a time when pain was being undermanaged. Time has shown us more now than we were able to see back then about the potential for misuse and abuse."

Pennsylvania Medical Society's Dr. Shapiro agrees, and adds, "it's going to take some time to see the benefits of all these initiatives, but we are on the right path and we will see results."