Audit Shows Limited Oversight of Prescribers of Controlled Substances Across Connecticut

23% say they've never accessed the database before writing a prescription

An audit report of the Department of Consumer Protection drug monitoring program released on Thursday found that state officials cannot ensure that prescribers of controlled substances have registered or are using the program as the law requires.

According to the report, the Department of Consumer Protection Division of Drug Enforcement, which oversees the prescription monitoring program, also can’t ensure that healthcare providers are looking up a patient’s history of being prescribed controlled substances, a step intended to help providers determine whether a patient is at a higher risk of abuse or misuse of medications.

The division has recently started the time consuming process of matching controlled substance registrations with registrations in the monitoring system, but it’s a moving target, Rod Marriott, director of the Drug Control Division, explained. The division receives 500 to 800 new controlled substance registrations each year.

The Connecticut Prescription Monitoring and Reporting System began in 2008, but practitioners who prescribe controlled substances were not required to register until 2013, and the division is still working to educate providers about the system.

Marriott said that because the goal of enforcing law is to have prescribers register for the program. The effort is mainly a matter of education.

The division works with professional organizations and directly with providers through emails and reminders in registration renewal documents, he said, in order to make sure providers are aware of the requirements of the program.

“Once we take the step of reaching out, our practitioners just get registered 95 percent or more of the time,” Marriott said. “For one reason or another, they hadn’t heard about it or didn’t understand what the PMP registration was all about.”

More practitioners have registered with the program in recent years. 

In 2018, there were 29,948 prescribers and their delegates registered in the program, up from 24,430 in 2016. There are spikes in registration when the division sends out reminder letters to providers and a ripple effect from practitioners talking to others about the letters, Marriott said.

“It’s encouraging that practitioners are gaining awareness of this program, because it’s incredibly valuable,” Marriott said. 

A survey conducted by the auditors found that practitioners who did use the program largely agreed that it was valuable. 

Of 3,497 respondents who had prescribed a controlled substance in the prior month, 17 percent accessed the database daily and 24 percent accessed it weekly.

  • 69 percent said they accessed the database when prescribing to a new patient

  • 58 percent accessed when prescribing a refill

  • 67 percent accessed to see if a patient could have a history of overuse

  • 53 percent accessed to ensure a patient wasn’t “doctor shopping”

According to the audit, use of the database has led healthcare providers to speak with patients about controlled substance use, warn of the danger of addiction before writing prescriptions, to confirm the need for the medication and to stop prescriptions for controlled substances when they are not needed. 

Mixed use of medical database

Despite this positive feedback, according to the audit, 23 percent of respondents said that they hadn’t ever accessed the database before writing a prescription for a controlled substance.

Of the 114 respondents who wrote 76 or more controlled substance prescriptions each month, 17 said they had not accessed the database at all, according to the audit.

Since 2015, registered providers have been required to check their patients’ prescription histories before prescribing more than a 72-hour supply of a controlled substance and to review records every 90 days if prescribing for long-term treatment requiring refills.

But the audit found that the division does not have a system to determine if providers are checking the database as required by law. And while the division trains prescribers on the system and about their requirement to use it, state officials can’t measure compliance with the law, the audit found.

Marriott said the plan for enforcing the requirement that prescribers use the database is to identify prescribers who are writing a large number of controlled substance prescriptions without reviewing patient records. He said that he doesn’t expect there will be many, but it’s still a time-consuming process for investigators. 

“If we’re going to do proactive enforcement, what you would do in theory is identify the prescribers who wrote those prescriptions and didn’t look anybody up and then try to get copies of all those prescriptions to ensure they were written by the correct physician and weren’t fraudulent,” Marriott said.

Currently, the division does enforce record requirements in response to complaints from patients and pharmacists, but Marriott said that the division lacks the resources to enforce the measure proactively.

According to Marriott, many of the program’s staff are grant-funded, meaning that their responsibilities are limited by the grant, and can’t simply be shifted to work on enforcement.

“From the inception of this program, our staff hasn’t really grown from the general fund portion in any significant way, so it does make it challenging to do widespread enforcement in a proactive way,” he said.

Appriss, the third-party vendor that Connecticut uses for the database program, has developed a pilot software to track compliance that has begun testing in other states. Marriott said that the division could more easily identify prescribers needing investigating, if the state can purchase the program when it becomes available.

Some evidence of progress

Dr. J. Craig Allen, medical director of Rushford and vice president of addiction services at Hartford HealthCare said that integrating the program into the system’s electronic health records makes checking a patient’s record a seamless process.

“It’s literally a button that you click as you’re writing your notes or before you write your notes, and it shows you the information from the Prescription Monitoring Program,” Allen said. “If you don’t have that button, then you have to log into the program, enter the patient’s name – it takes some time.”

The number of searches conducted by prescribers increased 9 percent from 2017 to 2018, the last two years for which data is available. Prescribers conducted 1,130,511 searches in 2017, and 1,237,933 in 2018.

Searches by pharmacists declined 6 percent from 675,926 to 634,497 searches in the same time period which, according to the audit, is likely because of the decline in opioids prescribed to patients.

Allen said that in his experience, the program has been beneficial for patients and prescribers, and can help identify potential dangers. 

“You have to use this as a piece of data that can be helpful in the conversation you’re having with your patient to try to help them achieve remission, or whatever their goals are,” Allen said. 

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