Josh Green says there’s one drawback of being both a doctor and a Hawaii state senator.
“I have people who tell me they won’t vote for me if I don’t give them a prescription” for opioid painkillers, he said.
But his dual roles also give Green an unusual view of the opioid epidemic that’s been sweeping the country.
On the one hand, he sees the carnage of addiction, including overdoses that end up in his emergency room. On the other, his seat in the Legislature shows him what the state is doing to address the crisis – and more importantly, failing to do.
With that in mind, two years ago Green formed a group of more than 20 experts who deal with pain pills at one stage or another to come up with ways to strengthen the state’s strategy.
One of their primary targets: the prescription drug monitoring program, which can alert prescribers, pharmacists and others to patients who may be on opioid binges, going from doctor to doctor to avoid detection.
Hawaii was the second state (or in this case, future state) to create such a so-called PDMP in 1943, behind only California in 1939.
But in recent years, as opioids have deluged parts of the U.S., Hawaii did not adopt measures taken by many other states.
“We did have some catching up to do,” Green said.
In part, that could be because the epidemic has not been as severe here. By various measures, the state is toward the bottom for opioid prescribing, overdoses and deaths, although data also shows some hot spots.
But Green and others in his Hawaii Opioid and Overdose Leadership Action Workgroup see their work as a bulwark against the epidemic ever reaching the point that it has in Appalachia and other hard-hit parts of the nation.
“We have an opportunity to not let our population go there,” said Dr. Scott Miscovich, a Kaneohe family physician who chairs the group.
In the last legislative session, Green pushed through a bill to require prescribers to sign up to use the prescription drug database, and to allow others besides doctors to check in – nurses, physician’s assistants, administrators. That was an important step, Green said, because doctors worried that they would have to take time away from patients to check the database.
But experts in the field say the single most important step in making the database effective is requiring doctors to check it, at least for certain patients or circumstances.
A recent survey by the Hawaii Department of Health found that many prescribers know little to nothing about the drug database. Slightly more than half said they were unfamiliar with it. For some groups it was even higher – 70 percent of dentists said they didn’t know about it.
More than eight of 10 prescribers who were actively using the database said it allowed them to identify “doctor-shoppers,” gave them a better grasp of their patients’ medicine regimens and gave them confidence in telling patients “no.”
Still, four in 10 said they had had trouble using the database. The top problem was not being able to find updated information on a patient, or not being able to locate a patient known to have received controlled substances at all.
Less than half – 42 percent – said they would support legislation to require them to check patient histories before prescribing controlled substances.
But Miscovich says that support is growing for requiring prescribers to check, especially with improvements to the database making it easier to use. Prescribers would also be more likely to support a system that “pushed” data, he said – issuing alerts, for instance, that someone is trying to get extra prescriptions.
Advocates for stronger laws to deal with opioids say making it mandatory is the most important step a state can take.
“This has turned out to be the most significant and beneficial way to use the drug monitoring program,” said John Eadie, PDMP coordinator for the National Emerging Threats Initiative of the High Intensity Drug Trafficking Areas program.
Eadie said doctors in states that have approved such mandates usually oppose them at first. But all of those states have also passed laws allowing others in doctor’s offices to query the database, as Hawaii already has. And prescribers have come around, he said – surprised to find how many of their patients turned out to be doctor-shopping.
“It’s a very workable system, and it’s proven to be very effective,” he said.
A total of 18 states have passed laws requiring prescribers to check the database. They’ve taken many different approaches. Some require the checks for all new prescriptions for opioids and other controlled substances, and afterwards every three months.
Others don’t include all opioids, or require follow-up checks at intervals greater than three months. Some are more lenient in various ways, such as only requiring a database check when a doctor sees signs a patient might be addicted or works in an opioid treatment clinic.
After New York state’s law went into effect in 2013, database queries shot up from an average of 11,000 a month to 1.2 million. The number of patients getting opioid prescriptions dropped by 10.4 percent. Two-and-a-half years later, incidents of doctor-shopping had fallen by more than 90 percent, according to statistics compiled by the High Intensity Drug Trafficking Areas program, created by Congress in 1988.
Even if there’s support for making the database checks mandatory, the Legislature will have to decide how far to go – where it will end up on the spectrum of approaches taken by other states.
Hawaii could also choose to follow other states in making changes to its current database.
“If someone goes on a binge, they can hit six places on Oahu in two days.” — State Sen. Josh Green
The state, for instance, is one of only three that does not authorize its medical board to use the database to identify doctors who are overprescribing controlled substances.
“That’s a definite deficit,” said Tom Clark, senior research associate at the Heller School for Social Policy and Management at Brandeis University . “The use by medical boards of the PDMP data is crucial.”
It’s tricky in Hawaii, however, because the medical board does not conduct its own investigations of its licensees. That responsibility belongs to the state Regulated Industries Complaints Office, which also handles investigations for many other licensing boards and commissions.
Hawaii also is one of about a dozen states that gives dispensers a week or more to enter prescriptions into the database. Time can be crucial in such cases, because addicts can move quickly.
Green said it would make sense to shorten that time. “If someone goes on a binge, they can hit six places on Oahu in two days,” he said. It’s just a question of balancing the mandates with the added burden for pharmacists and doctors.