Doctor with folderSay you go to the dentist and need to have a root canal.

As you leave, the dentist writes a prescription for an opioid pain reliever such as Vicodin or Percocet.

When you arrive at the pharmacist to fill your prescription, what you probably don't know is that your name and prescription information will be entered into a database of people in North Carolina who receive controlled substances. Doctors are encouraged to check the database before writing a prescription and pharmacists are supposed to check it to see that the medications they're distributing haven't been given too often to a specific person.

That database is to help identify people who might be "doctor shopping" for pain medication, arriving at one doctor's office and emergency department after another in an effort to collect enough pills for their abuse or perhaps for sale.

This year, Senate lawmakers are pushing a bill to strengthen the controlled substances reporting system by putting some money toward connecting North Carolina's system with that of other states; by requiring doctors, nurses, dentists and podiatrists who can prescribe narcotics to take continuing-education courses on prescription-drug abuse; and by mandating the creation of provider guidelines for prescribing opioids.

According to Sen. Ben Clark (D-Hoke, Cumberland), co-sponsor of the bill, a big impetus for looking at the issue was a series of articles in the Fayetteville Observer that looked at the high rate of opioid use in North Carolina.

"It was hitting hard in some communities where you have military populations, as a result of them being assigned over in Iraq and Afghanistan, and them being prescribed these medications and ... coming back having developed tendencies for these particular substances," Clark said.

At least 792 people in North Carolina unintentionally overdosed from opioids in 2012, according to the state Department of Health and Human Services' Injury and Violence Prevention Branch.

Guidance strong enough?

A law passed by the General Assembly last year requires pharmacists to enter into the CSRS information on who picks up narcotic prescriptions within three business days of dispensing the medications, and they're "encouraged" to do it within 24 hours.

But there's no requirement for doctors, dentists or pharmacists to check the system before writing a prescription, something that caused concern among the sponsors.
Lawmakers are concerned that physicians don't check the system for patients who ask for opioid pain relievers, and that some of those patients could be trying to collect as many prescriptions from as many providers as possible.

According to a study conducted by the Program Evaluation Division, North Carolina's CSRS is underused. In 2012, doctors and pharmacists in the state used the system less than 6 percent of the time they wrote or filled a prescription.

Last year's law allowed anyone working in a doctor's office to have access to the system. But physicians have resisted any requirement that they check the database.

And they're not alone. People who advocate for better oversight of prescription drugs agree that requiring doctors to check for every prescription will cause more problems than it solves.

Requiring education

Bill co-sponsors Clark and Sen. Fletcher Hartsell (R-Concord) said they would also like to see a requirement that physicians and other opioid prescribers complete continuing education on best practices for prescribing.

Physicians have resisted that too.

According to Sandra Brown, a physician from Concord who sat in on the meeting, physicians already have to take hundreds of hours of continuing medical education to maintain licensure.

She said doctors already know when they're writing a prescription for "legitimate pain medication and when we're writing for legal dope."

Brown argued that some doctors, in particular emergency-department physicians, will dispense a prescription for opioids because they are under pressure to avoid poor patient-satisfaction scores, something used increasingly by hospitals to determine doctor compensation and even continued employment.

She argued that there are doctors who run "pill mills" and others who write prescriptions for narcotics because they're afraid.

Under protocols developed by Project Lazarus and being rolled out across the state, emergency-room doctors only write for two or three days' worth of medications, instead of, say, for 30 days.

Those same protocols advise dentists to only write for a few days' worth of narcotics, instead of reflexively writing for 30 or 60 pills, most of which end up sitting in a medicine cabinet and tempting a family member with a drug problem.

Best practice
The bill also includes language ordering that the CSRS share information with the Prescription Drug Monitoring Program Center of Excellence at Brandeis University in Massachusetts. The program collects data from individual states, spreads information on best practices and can help states predict areas where prescription-drug abuse might be a growing problem.