ePrescribing and scheduled narcotics for pain control in cancer patients

ePrescribing and scheduled narcotics for pain control in cancer patients

Douglas W. Blayney, MD, FASCO

Jan 23, 2009

Incentives for ePrescribing

The Wall Street Journal has a story last week on ePrescribing, written by Laura Landro, a WSJ managing editor and CML survivor:

"Medicare this month began paying doctors a bonus if they switch their patients over to e-prescribing. Some private health plans also have begun offering extra payments along with free equipment, such as digital handheld devices. And a coalition of technology companies is giving doctors free software to encourage them to ditch their paper prescription pads. As a result, the number of physicians prescribing medicines electronically has more than doubled in the past year to about 70,000, or about 12% of all office-based doctors....

"But there are still barriers to full-fledged adoption of e-prescribing. Federal drug laws, which are under review, prohibit electronic prescribing of controlled medications such as narcotics, insomnia drugs and anti-depressants...

"In a study published last month in the Archives of Internal Medicine, researchers at Brigham and Women's Hospital found that e-prescribing systems that allow doctors to select generic or lower-cost medications can reduce annual costs of delivering drugs to consumers by $845,000 for every 100,000 patients..."

Comments on the story

The comments from user physicians and pharmacists have been generally negative, revolving around privacy concerns, cost of use, the cumbersome nature of the interface, and how it's not integrated into the billing and existing practice management systems. One commentor draws an analagy to the travel industry, when early adopters got free miles for booking flignts online instead of using the telephone, and now one is charged for using the telephone and not booking online—he predicts the same will happen with ePrescribing (surprise!).

Make ePrescribing convenient—reduce the friction and maintain safety

My concern has to do with prescribing of schedule II and above narcotics, which are mandatory for treating pain in cancer patients. I was in practice in California when we had "triplicate" perscriptions. These were purchased from the state, and had to be filled in precisely. The back copy of the perscription was kept in my "triplicate book," the two copies handed to the patient; when the patient filled the perscription with the pharmacist, the pharmacist kept the original on file (for the inevitable audit), and forwarded the remaining copy to the state. We were forever running out of them, and forever getting calls from the pharmacists because of writing errors. They could not be faxed, so that people who lived far away or legitimately ran out of their narcotics over the weekend were out of luck. This procedure certainly increased the hassle factor for prescribing narcotics over say, Tamoxifen, but I don't know whether it reduced the narcotic diversion problem. Triplicate prescribing had been abandoned by 2003, when I moved away.

ASCO's comments on the Drug Enforcement Administration's proposed rule on ePrescribing

ASCO joined the AMA, ASH, and thirty-one other professional societies (letter here) in encouraging the Drug Enforcement Administration (DEA), which has jurisdiction over narcotic prescribing on a federal level, to accomodate ePrescribing. The letter was written in response to a proposed rule on ePerscribing, in which "DEA proposes a process for electronic prescribing (eprescribing) of controlled substances that supplements, but does not replace, existing prescribing and dispensing requirements established by the Controlled SubstancesAct (CSA) and DEA regulations."

From a user perspective, we should have minimal hassles to prescribing necessary narcotics to cancer patients, consistent with the applicable law on narcotic prescribing. ePrescribing should be designed to meet both needs—that of the cancer doctor and the regulatory and law-enforcement authorities.


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Douglas W. Blayney, MD, FASCO

Feb, 11 2009 6:07 PM

The FDA is gearing up to put in place a risk management program on long acting narcotic analgesic program, according to a story in the Wall Street Journal (here).

"The Food and Drug Administration said Monday it will subject the makers of certain extended-release pain drugs to a new risk-management program designed to cut down on misuse and abuse of the products. New government figures show a rise in non-medical use of prescription pain drugs among adults...extended-release versions of OxyContin, morphine and fentanyl patches are meant for round-the-clock pain management for patients with cancer ...FDA officials have said they've seen reports of inappropriate prescribing by doctors ...

"We continue to see reports of an ankle sprain and (patients) are given a fentanyl patch," said John Jenkins, the director of the FDA's office of new drugs. He said a major part of the new program will be efforts to educate doctors about appropriate prescribing of the products. "This obviously is going to be the largest risk-management program we've undertaken," he said."

Those of you who prescribe thalidomide, lenolidamide, and other anti-cancer agents are familiar with the FDA's risk management programs; the registration necessary for each one, the limited time and the multiple renewals required, and the paperwork necessary for each prescription and each patient.

In a sense, my DEA certificate is like enrolling in a risk management program for narcotics, so I am already registered, at some personal expense, in a system.

In addition, Michigan has a program (MAPS) which tracks narcotic prescriptions in the state, and has sent me report in the past regarding one of my breast cancer patients who was receiving narcotic analgesics from multiple physicians. Surely my prescriptions of narcotics are being tracked somewhere.

While diversion of narcotics is a legitimate problem, creating yet another enrollment program for me and for other cancer doctors to treat cancer-related pain seems redundant, not likely to capture meaningful data, and is one more hassle which is not likely to be reimbursed.

There are multiple systems out there -- they should be coordinated. The more hassles we have to deal with, the less likely are cancer patients to receive adequate analgesia.

Robert S. Miller, FASCO

Jan, 29 2009 3:48 PM

Doug, a few comments re e-prescribing in California today from my practice in Sacramento. We have been using a commercial Web-based e-prescribing product for the last few years and generally have been very satisfied. The cost has been reasonable and the staff and physician acceptance have been satisfactory albeit a little slow on the part of some of the physicians. (I try not to advertise commercial products in a public space so if anyone wants to discuss specifics please contact me directly.) We do not yet have an EHR (on the waiting list for iKnowMed 2010) so this is integrated into paper charts. I have pushed my docs to do the e-prescribing from the point of care at their PC's on their workstations, right after or during a visit. I have also told our nurses and MA's that I did not want them to call pharmacies any more but to do it electronically.

As you note, California did away with its triplicate law a few years ago, only to replace it with an annoying and cumbersome "duplicate" requirement, meaning that I need to use a special prescription pad (costing $$$) for all drugs Schedule II-V. Yes, even for Vicodin and Ativan. Here is the irony of the whole thing - if I want to prescribe a Schedule III-V drug I must do one of the following, either write it on the special pad and hand it to the patient, or call it in to the pharmacy, or create it on the e-prescribing program, print it, sign it, and then fax it. We generally try to do the last since then the record of the prescription is captured in the program. We keep paper med lists in the chart which we update each visit. These are printed directly from the e-prescribing program. But this extra step does not help the daily workflow or advance patient care. For Schedule II drugs you are still stuck with paper.

The logic of this DEA prescription requirement for scheduled drugs totally escapes me. To prescribe anything on my e-prescribing program I need to log into a secure web site then use a separate password for signing a prescription. Seems pretty secure to me. However, under current DEA regs, it is ok for me to call a local pharmacy and verbally prescribe 200 Vicodin for anyone I want. I can't tell you how few times the retail pharmacists ask me for any identifying information or even my first name, and its not like I have a distinctive surname. Oh they need my DEA and license number. Doh, that's not exactly secret information! Tell me how this helps prevent narcotic diversion. The electronic route seems much more secure. Hopefully the DEA will consider ASCO's comments and those of others interested in the patient care experience.


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