State law forces doctors in Tennessee to log every painkiller prescription they write. They don't have to check a patient's log before writing another.
Critics have jumped on that gap after court records made public this month revealed the number of prescriptions filled by Richard Baumgartner, the ex-judge now on judicial diversion for buying pain pills from a probationer in his court.
Baumgartner filled 73 prescriptions from May 2006 to November 2010 for a total of nearly 2,200 hydrocodone pills and nearly 500 oxycodone pills — sometimes showing up at the pharmacy counter as often as five times in a single month.
Officials have called the judge's habits a clear case of doctor-shopping, going from doctor to doctor to obtain as many pills as possible. Some advocates point to the case and ask why prescribers and pharmacists shouldn't be required to check the database before writing or filling any painkiller prescription.
"I'm surprised, given the enormous cost of opioid abuse to the insurance industry, that it's not required already," said John Eadie, executive director of the Prescription Monitoring Program Center of Excellence at Brandeis University, a policy group that promotes guidelines for such databases. "Basically physicians are flying blind in a blizzard if they don't have it."
Doctors say that's an unworkable idea, given that state law allows them alone — not secretaries or others in the practice — to consult the database.
"I'm glad the database is there, and I think it's made a difference in my practice," said Dr. Leonard Brabson, a past president of the Knoxville Academy of Medicine. "But I don't think requiring somebody to look it up every time they write a prescription would solve the problem. For a family practice where the doctor's seeing 30 patients a day, that would take an unacceptable amount of time, and nobody's going to reimburse you for that."
Thirty-seven states, including Tennessee, operate prescription-drug monitoring databases. Only seven require prescribers and pharmacists to consult the state database, and even then only under special circumstances.
Doctors and pharmacists say the database was never meant to be mandatory or to turn physicians into police.
"It was not specifically intended to address doctor-shopping," said Andy Holt, executive director of the Tennessee Board of Pharmacy, which manages the database. "It's more of an educational tool. The original use did not include criminal investigation."
Holt said the database's designers intended it as more of a statistical yardstick and as an "interventional" means of spotting patients in need of treatment for addiction.
Doctors in only one type of practice in Tennessee will be required to check all new patients against the state database starting next year. Those operators of pain management clinics will have to run a new patient's profile on admission and conduct a follow-up check every six months.
Police can obtain the information only under special circumstances. "It would have to be relevant to an ongoing case," Knox County Sheriff's Office Detective Michelle Poteet said. The database as created offered no way to generate red flags that would alert pharmacists or prescribers to patients with an unusual amount of prescriptions. An update to state law added that requirement this summer. Officials said they didn't have numbers on how many alerts — if any — have been generated so far.
"The process has just started," said Holt, the pharmacy board director. Doctors say they'd like to see the database offer up-to-the-minute details on a patient's prescriptions. Tennessee's system relies on information that's typically at least two weeks old, with providers required to file updates only once a month.
"We would love to ask for real-time reporting," said Gary Zelizer, legislative affairs director for the Tennessee Medical Association. "There is absolutely a way to do that."
Only one state has attempted to operate a prescription-drug database that's updated in real time. Oklahoma launched a pilot program this year that now includes about 200-300 pharmacies. "They're going for being up to date within about five minutes," said Eadie, the Brandeis expert. "We think that should be the wave of the future, and we would encourage other states to do that."
State officials say that would require changing state law yet again.
"There's not anyone out there doing that right now," said Holt.