shows pills through the bottom of a pill vial
Credit: frankieleon, flickr creative commons

Provider use of North Carolina’s Controlled Substances Reporting System could help get substance users away from opioids and into treatment. So why aren’t prescribers using it?

By Rose Hoban

A bill on today’s Senate calendar at the General Assembly makes it easier for family members to get their hands on a drug that can reverse an opioid overdose in seconds.

By all accounts, SB734 is likely the pass the Senate easily and head to the House of Representatives for consideration.

State Health Director Randall Williams (center) presents to lawmakers at the Senate Judiciary 1 Committee meeting last week. With him were SB 734 sponsors Buck Newton and Gladys Robinson.
State Health Director Randall Williams (center) presents to lawmakers at the Senate Judiciary 1 Committee meeting last week. With him were SB 734 sponsors Buck Newton and Gladys Robinson. Photo credit: Rose Hoban

Advocates are praising the measure, but they say the legislature could do more to reduce the epidemic of drug overdose deaths in North Carolina and that lawmakers have one tool on hand they’ve been unwilling to use: compelling doctors to use the state’s controlled substances reporting system when they write a prescription for any narcotic.

It’s a move that research has shown to help reduce doctor shopping by people seeking the drugs and to get more people referred to drug-treatment programs.

Despite the CSRS being in place for more than a decade, only one in five of North Carolina’s more than 45,000 doctors, physician assistants and nurse practitioners is even registered in the system; only about half of those who’ve signed up use it.

And the biggest opponents to mandatory use of the system are doctors themselves.

Full vials

It’s all too common to hear stories of patients being prescribed vials filled with more pills than they could ever need.

“You can talk to almost anyone who can tell you that, ‘I went to the dentist to have my tooth out and he gave me 60 Lortab,’ or, ‘I went to have my arthroscopy and the doctor gave me 50 hydrocodone,’” said state Health Director Randall Williams.

He told lawmakers during a committee hearing last week that 77,000 of every 100,000 North Carolinians are prescribed narcotic pain medications annually.

Screenshot of the provider portal for the Controlled Substances Reporting System.
Screenshot of the provider portal for the Controlled Substances Reporting System

And research published this winter showed that even after patients who were on long-term pain therapy overdosed on opioids, 91 percent of them received additional prescriptions for the drugs from their physicians.

But even Williams stopped short of recommending lawmakers make CSRS use mandatory.

The deference infuriates Donald McDonald, who is the program director for Recovery Communities of North Carolina. He also serves on the state’s new Prescription Drug Abuse Advisory Council, where he’s advocated for making CSRS use mandatory.

“All the arguments about the CSRS have been about not interrupting the work flow in the physician’s workday, to make it as easy as possible,” McDonald said. “The Department of Health and Human Services has spent a tremendous amount of time on this system trying to make it as highly functional, as smooth as it can possibly be.”

It’s not just advocates who are calling out physicians for how their prescribing habits have helped drive the opioid epidemic in the U.S. No less than CNN’s Sanjay Gupta published a column last week taking doctors to task.

Most of the blame, Gupta wrote, “belongs on the shoulders of the American doctors themselves. I am a practicing neurosurgeon, and this is not an easy thing to acknowledge.”

‘Would ya? Could ya?’

A report produced by the Injury Prevention Research Center at UNC-Chapel Hill in 2013 found that the largest barrier to the CSRS’ effectiveness is that too few physicians actually use it.

State statistics show only 21 percent of prescribers have registered, despite the legislature passing a law in 2013 that allows for staff in doctors’ offices to enter and retrieve the data.

Yet, the state’s physician organizations continue to resist making use, even registration, mandatory.

“The N.C. Medical Society has been supportive of the CSRS since its inception, and over the years we have been working to make it easier for physicians to use and to ensure the information is meaningful,” Elaine Ellis, a spokeswoman for the Medical Society, wrote in an email. “We will continue to work with legislators to come up with productive ways to improve the CSRS and encourage our members to use it.”

Ellis also pointed to an op-ed that ran last fall in the News & Observer by Robert Schaaf, the Medical Society’s president at the time, in which he appealed to physicians to use the system “to protect the public and our patients.”

“[The North Carolina Medical Board] has long advocated that licensees register and use CSRS, but currently does not have a formal position on mandatory prescriber use,” wrote board spokeswoman Jean Fisher Brinkley in an email. “Board staff are evaluating different approaches to mandatory use and expect to develop model legislation to offer the NC General Assembly.”

Brinkley wrote that the board was concerned that any mandatory requirement “make[s] sense and isn’t unduly burdensome.”

McDonald said the board needs to be bolder, beyond simply ”encouraging.”

He pointed out that since the inception of the CSRS, more than 5,000 North Carolinians have died from prescription opioid overdoses. He said he got so frustrated at one point that he posted a comment on the Medical Board’s website.

“Right now, it’s more like, ‘Please, fellas. Would ya? Could ya?‘“ he said. ”If this were a response to Ebola, you wouldn’t be having these conversations.”

Bill looms

Last year, lawmakers filed a bill that would have made it a felony for physicians not to register or use the CSRS when “prescribing or dispensing a controlled substance.”

The bill went nowhere, but Rep. Craig Horn (R-Weddington) said his patience is running out. Horn has publicly proclaimed his willingness to push doctors harder.

“I hope to never have to make it mandatory, because we’re going to make the system so user friendly and doctors are going to fully embrace the importance of its use,” Horn said. “But I’m not so naive as to think that it’s going to happen anytime soon.”

Horn doesn’t have an opponent this November, so he’ll be back at the legislature for another two years.

“I’m going to be keeping a very close eye on participation, and if participation doesn’t improve significantly – not just sort of, but significantly – then I will be one that will support that we mandate its use,” Horn said, noting he thinks he can get the votes.

“I’m interested in improving the system and quickly,” he said. “How many dead bodies do I have to stack up in front of you before you’re gonna do something?”

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