News 13 Investigates: Many NC doctors in violation of opioid prescription law
Thousands of doctors appear to be breaking the new state law aimed at limiting opioid prescriptions.
Starting January 1, 2018, the NC Stop Act limited the amount of opioids that can be prescribed for acute pain. While rates are down, a News 13 investigation found plenty of physicians still prescribing more than they should.
Patients being cut back
“Come on you guys, run, run, run, run, run,” said Paula Arriaga, laughing as she walked her dog on her Buncombe County property.
It is the simple things that lift Arriaga's spirit.
“You make me smile, yes you do,” Arriaga coed at her dogs, “I love gardening, this is my time to be outside and gardening,” said Arriaga.
But more often, she ends up indoors on the couch.
“You have to quit. I have to lie down for a couple of hours,” Arriaga said. She says she doesn’t sleep, just rests.
A year ago, Paula was sweating both her workouts and her VA doctor's decision to scale back the narcotics she took for chronic pain.
“She said, 'You know, you're an addict. We have to get you off of this.' I felt hurt by that, and I've asked myself this whole time, what do I need to do?”
Arriaga said she never felt addicted.
“By February 1, 2018, I was off the medication completely,” Arriaga said.
But now she finds herself sidelined with chronic pain. Paula turned to the classroom, looking for alternatives for her aches.
“I took (classes) because I wanted to know, especially food things, that might help with pain. Right now I added turmeric to my multiple vitamin regimen,” Arriaga said.
Treatment alternatives to opioids
It is not unlike the alternative Mission Health's exploring.
“We've gone to preoperative acetaminophen and Gabapentin, two medicines that aren't narcotics but are designed to spare the use of narcotics in the post-operative phase,” said Dr. William Hathaway, chief medical officer at Mission Hospital.
Mission is using regional anesthesia before surgery to keep Paula and others from ever relying on pills post-op.
“They inject Lidocaine and other medications locally to numb a joint before they do the surgery,” Dr. Hathaway said.
This is as the NC Stop Act works to put a serious dent in the amount of prescribed opioids.
“We've got to shut down the supply of the drugs that come into the community or patients getting started on prescription drugs that lead to addiction problems,” Dr. Hathaway said.
NC STOP Act new measures
The state is off to a slow start. Through March, some 16,000 doctors were still prescribing more than a weeks’ worth of opioids to at least one patient in a six month period.
The State Department of Health and Human Services says that doesn't necessarily mean those physicians are in violation of the NC STOP Act. Whether or not a given prescription complies with the terms of the STOP Act depends on a variety of factors related to an individual patient, their medical history, and their relationship with the provider. Most of those data elements are not part of the record, and so it is tough to determine how many are complying with the law.
Blue Cross Blue Shield of North Carolina counted 4,500 medical professionals exceeding state law through mid-April. North Carolina Attorney General Josh Stein, who pioneered the STOP Act did not expect instantaneous compliance.
“It was going to take time to reeducate them about what the law actually requires,” Stein said.
In April, Blue Cross Blue Shield N.C. electronically started blocking prescriptions that exceeded seven days, stopping some 50,000 pills from making it into homes.
But what about physicians who do not comply?
“For those doctors who are still over prescribing, they're going to get notices from the North Carolina Medical Board alerting them that what they're prescribing is not in compliance, and if they continue to violate the law, then the medical board as the licensing agency will have some authority over those doctors,” Stein said.
The NC STOP Act provision as of January 1, 2018
According to the NC Medical Board as of January 1, 2018:
"Practitioners cannot prescribe more than a five-day supply of any Schedule II or Schedule III Opioid or narcotic up on the initial consultation and treatment of a patient for acute pain unless the prescription is for post-operative acute pain relief for immediate use following a surgical procedure, in which case the prescription cannot exceed a seven-day supply. Upon subsequent consultation for the same pain, practitioners may issue any appropriate renewal, refill, or new prescription for a targeted controlled substance. This provision does not apply to prescriptions issued by practitioners ordering targeted controlled substances to be wholly administered in a hospital, nursing home, hospice facility, or residential care facility."
Safe Opioid Prescribing Initiative sends concern letters to mountain doctors
The Medical Board's Safe Opioid Prescribing Initiative has watched prescribing practices since 2016. It opened 106 cases.
Among them, letters of concern were sent to mountain doctors. An Arden doctor was warned for prescribed fentanyl to a family member, and an Asheville doctor received a letter after prescribing controlled substances for herself.
A Hendersonville doctor was also sent a letter for over-prescribing in South Carolina, and the board prohibited a Marion doctor from prescribing controlled substances altogether.
“It's a complicated problem. We're not going to be able to make it go away in 2018, but we know this is primarily a problem of over prescription,” Attorney General Josh Stein said.
All the more reason for medical directors at mountain hospitals to ensure doctors know their numbers.
“I think most doctors do know, at least intuitively, what their numbers are, perhaps not total number of prescriptions, but certainly how many of these pills they're given per episode,” said Dr. David Ellis, chief medical officer at Pardee Hospital in Hendersonville.
He hopes education of both patients and physicians can turn the tide.
“It's all about education and realization that we're talking about a group of medications that are not without risk," Dr. Ellis said.
North Carolina files suit against big pharma
The efforts continue as the North Carolina Attorney General goes after big pharma, filing suit against Purdue, a Connecticut-based private company, alleging the company engages in deceptive trade practices in marketing OxyContin.
On Monday, Stein moved to hold drug manufacturer Insys Therapeutics, Inc., responsible for its deceptive marketing and sales practices by intervening in two lawsuits, accusing Insys of violating the Fair Claims Act.
The schemes were used to increase prescriptions of Subsys, a highly potent fentanyl painkiller used to treat cancer. Fentanyl is 50 times stronger than heroin and 100 times more potent that morphine and is highly addictive.
The complaint alleges that Insys paid kickbacks to entice doctors and nurse practitioners to prescribe Subsys to patients.
“They helped to create this mess. They have to help us clean this up,” Stein said.
How much have local health systems slashed their prescribing rates in the last year?
Mission Health cut post-op opioid prescriptions 60 percent after hip surgery and 30 percent for knee surgeries.
Pardee Hospital, overall, is down 15 to 20 percent in prescribing opioids.
Haywood Regional's Emergency Department cut its opioid prescribing rate 17 percent.
The Charles George VA Medical Center reports its absolute change is down 11 percent.
Haywood Regional Hospital gave News 13 the following comment:
Opioid addiction is a real and widespread problem across our nation. Recent reports by the CDC on opiate use are very concerning to us and underscore the need for our entire community to work together to address these issues. In fact, in 2017, our hospital saw an increase in the number of people searching for opiates, which led us to implement new guidelines around our hospital’s emergency department providers’ prescribing practices that aim to reduce the number of Opioids prescribed to patients. Specifically, the guidelines recommend physicians to prescribe the lowest effective dose and that Opioid medications should not be used for the treatment of minor pain-related complaints or chronic conditions. If patients require treatment for pain beyond an acute episode, they are referred to their primary care provider (PCP) or pain specialist. In just one year, as a result of these new guidelines, we have seen a 17% decline in the number of controlled substances prescribed by our emergency department.
As part of this, our hospital offers numerous non-opioid alternative methods for managing pain, including, but not limited to NSAIDs, acetaminophen, steroids and lidocaine patches. In addition, Haywood supports the statewide STOP legislation, which is intended to reduce the supply of unused, misused and diverted opioids in North Carolina.
This is a very serious issue for our community and nation, and one that must be addressed. We are proud to partner with our physicians and other members of our local community as we explore ways to work together to educate our community, curb prescription drug abuse and help make our communities healthier."
Letters of concern
Here are the copies of the letters of concern sent to area doctors from the NC Medical Board. This is a public letter of concern sent to the following doctor from the NC Medical Board. It is not a disciplinary action.
The letter was issued as a result of prescribed medications prohibited by Rule 21 NCAC 32 B .1001, which is the Medical Board's Safe Opioid Prescribing Initiative.
Want to know your doctor's numbers?
Here’s a link to the Center for Medicare & Medicaid prescribing numbers for area physicians where you can see what your doctor is prescribing.
This look-up tool is a searchable database that allows you to look up a Medicare Part D prescriber by name and location. According to CMS, "The look-up tool will return information on prescriptions provided to and filled by Medicare beneficiaries, including drug name, total number of prescriptions dispensed (including original prescriptions and refills) and total drug cost. The data covers calendar year 2016 and is based on final-action Part D claims for the entire Medicare Part D population."