Confused about Control

I'm confused about Ambien. I don't love it as a sleep aid, but it works for some of my patients, so I do prescribe it.

What's confusing to me is not the confusion it causes some of the people who take it, even the ones who mistake it for synthroid. What's confusing to me is its status as a controlled substance.

It seems to me that some pharmacies allow refills, others don't. Some will allow you to order refills on the phone, others won't. Some will require a cover for a phone order.

The most recent time I had to mail in the cover, I asked the pharmacist what exactly the deal is with Ambien, and he told me that it's a Schedule IV substance and as such, is controlled.

The weird thing was that before I called it in, I checked the PMP registry, even though I wasn't sure I needed to, and none of my previous ambien prescriptions showed up. I told the pharmacist this, and he said some doctors have complained that no information ever shows up for them. But this is the first time it's happened to me. Mostly, when I check for benzos and ritalin and whatnot, I see all the prescriptions I've written.

Well, this puzzle sent me into research mode. And this is what I found (on the DEA site):

(a) No prescription for a controlled substance listed in Schedule III or IV shall be filled or refilled more than six months after the date on which such prescription was issued. No prescription for a controlled substance listed in Schedule III or IV authorized to be refilled may be refilled more than five times.


Okay, so I can write for 5 refills of Ambien, and the prescription is good for six months.

What about calling in a prescription?

(e) The prescribing practitioner may authorize additional refills of Schedule III or IV controlled substances on the original prescription through an oral refill authorization transmitted to the pharmacist provided the following conditions are met:

(1) The total quantity authorized, including the amount of the original prescription, does not exceed five refills nor extend beyond six months from the date of issue of the original prescription.

(2) The pharmacist obtaining the oral authorization records on the reverse of the original paper prescription or annotates the electronic prescription record with the date, quantity of refill, number of additional refills authorized, and initials the paper prescription or annotates the electronic prescription record showing who received the authorization from the prescribing practitioner who issued the original prescription.

(3) The quantity of each additional refill authorized is equal to or less than the quantity authorized for the initial filling of the original prescription.

(4) The prescribing practitioner must execute a new and separate prescription for any additional quantities beyond the five-refill, six-month limitation.

No problem, even with up to 5 refills.

So what's the problem? It seems to me that it's a lot of work for the pharmacist. I left out a bunch of stuff on the link, which you can check out yourself, but there's a lot of initialing that needs to be done, and recording of names, etc. Is the real problem that pharmacies don't want to be bothered with the paperwork (HAH! Tell me about paperwork!), or that they're not clear on the details?

Even more puzzling, here's a link to Schedule IV meds, also from the DEA site. Zolpidem is down at the bottom, with the other "Z"s, (ZZZZ for sleep). But what else is on the list? Let's see, alprazolam, clonazepam, diazepam, lorazepam, a veritable cornucopia of benzodiazepines.

Now, I'm not advocating for a benzo prescribing free-for-all. There are good reasons to keep it contained. But if I am writing for benzos, do I and my patients really need to be inconvenienced?

Can I write refills for benzos? Can I phone in benzos with refills, and without a cover? Is this one of those lies that's perpetuated so benzo prescribing doesn't go haywire? And if so, why not just change the law to what everybody thinks it is anyway?

Am I missing something here? What gives?

I-STOP 2.0

Here's an update on I-STOP, the NY State law that's intended to better control drug diversion. Basically, it describes exceptions to the requirement to check the Prescription Monitoring Program Registry (PMP), including prescribing in a hospice, or actually administering the controlled substance. It also describes the requirements for assigning a designee to check the PMP for you.

To review, starting on August 27th, if you prescribe a schedule II, III, or IV substance, you need to check the PMP registry no more than 24 hours prior to writing the prescription. You need to document that you checked it (yes, more required documentation imposed by an external source), or you need to document why you didn't check it, such as a power outage.

For reference, see this post for a slightly wonky description of how to access the PMP registry.

And here are lists of:

Schedule II Drugs
Schedule III Drugs
Schedule IV Drugs

And here are some songs with the word "stop" in the title:

Stop in the Name of Love
I'll Stop the World and Melt with You
Don't Stop Believin'
Can't Stop Fallin' Into Love
Can't Stop This Thing We Started
Don't Stop Me Now
Who'll Stop the Rain
Bus Stop
Don't Stop
Don't Stop Til You Get Enough
Nothing's Gonna Stop Us Now
Stop Your Sobbing
Stop

E-Rx F/U and Confession

This is a practical follow-up to my recent post, Erx Me.

I went through the E-Rx validation process at Practice Fusion. It involved submitting a very simple form, along with my medical license and government issued ID. The instructions were a little confusing, because it asked for a valid medical license, so I wasn't sure if that meant a copy of the license, or the registration, which has the valid dates. I live-chatted with them, and they were immediately responsive, and told me I could use either, and they would verify the dates.

It was a bit difficult to find the right place to submit it, but I got there, eventually. I apologize but I don't remember exactly how I found it.

The instructions said it could take 7 business days to complete the validation process, or more if they were particularly busy. I got confirmation the same day.

So, thus far, overall, Yay! for Practice Fusion.


I also tried to register for I-STOP. But I have a confession to make. I terminated my membership in the APA a year ago. I felt that they were just extorting money for CME, and that my money was better spent on something like UpToDate. Also, they implemented the MOC PIP program, which I find unacceptable.

But I still seem to get emails from the NYSPA, which is how I found out about I-STOP. Of course, since my membership expired, I can't log in. So I wasn't able to register through the NYSPA site for I-STOP.

Well, after some fumpfing around online and fuming at the idea that I might have to rejoin the APA for something that is required by law, I discovered that I didn't need to register through their site. In fact, I didn't need to register at all, since the Prescription Monitoring Program can be accessed through the NYS DOH portal. And I already have an account there, since that's how I order my prescriptions.

The instructions  for finding it were moderately helpful. You log in, click on the "Applications" tab at the top, click on the letter "P", and then scroll down to the PMP Registry. That part was easy, once I found the right instructions. As a bonus, the link to order new prescription pads is right below it.

I was then instructed to click on the green "+" sign to the right of the link, to add this to my favorites. I did so, several times, and my favorites still says it has nothing in it.

Summary: It's pretty easy to get started with E-prescribing through Practice Fusion, and you don't need to register for the Rx monitoring program through NYSPA.

Just FYI.

Erx Me

In case you thought you were done with big practice changes, s/p CPT, DSM-5, think again.

"Starting August 27, 2013, all physicians who prescribe Schedule II, III and IV controlled substances will be required to consult a new online state registry designed to track the prescription and dispensing of controlled substances."

This is from the NYSPA's comment on the new I-STOP law.

Here's a good I-STOP resource, from the Medical Society of the State of NY.

From what I can tell, starting on August 27th of this year, when we write prescriptions for controlled substances, we will have to open up our laptops or ipads or whatever, right there with the patient, and check that the patient is not up to any funny business with his meds.

I'm assuming this because of the phrase, "real time", which is supposed to be defined in regulation.

So, here you are, in your office, and you look up the patient on the registry, and you say, "Mr. Patient, it seems you've been diverting your meds, so I can't write that prescription for you. Have a nice day."

I don't know. The level of monitoring is getting out of control. It's like legislative OCD. And it carries such righteous indignation. We're going to purge the country of the evil of prescription drug abuse. Yeah, okay. It's a problem. But it doesn't have to be the Spanish Inquisition.

And it's one more way the government is insinuating itself into the room with the patient. Others include implying the psychiatrist is not doing a good job unless the patient is filling out checklists, and requiring patient reviews (see this post).

But that's not all. Starting on December 31, 2014, ALL prescriptions will need to be submitted electronically.  I was trying to figure out how to implement this, and I know, from risk management classes, that electronic medical records are a no-no, since, even if you can guarantee security (and really, you never can), if the data is stored in the cloud, you don't know who owns it. So I figured there're going to be some problems with e-rx's, and I called my carrier to find out if they have any advice about potential pitfalls, etc. They didn't have a lot of information, but referred me to the AMA's website, for  A Clinician's Guide to Electronic Prescribing, which was actually not that easy to find through the site, and I ended up googling it.

What WAS relatively easy to find was their e-prescribing learning center, where you can learn about how great e-rx is, and how it will solve the age-old problem of illegible prescriptions. You can also learn about how much it will cost you to implement and maintain your e-rx system. In fact, it'll walk you through a series of questions to help you determine which system is best for your practice. And then it will give you a list of e-rx systems that meet your needs.

I tried it, and I answered all questions on the "no frills" end, i.e., I don't want any advanced features, I don't want an EMR to go with it, etc. It came up with 3 recommended systems:

Relayhealth Escript at $600, no demo available
Care360 Physician Portal 2008.3, at $240, no demo available, and
InfoScriber, version 115, at $600, no demo available

Now, I didn't try to look this up, but I'm willing to bet that the AMA has financial connections with all these systems, and any others it spits out. It certainly didn't refer me to Practice Fusion, which is free, comes with an, also free, EMR which you don't have to use if you don't want to, and is ranked #1 for both e-rx vendors, and EHR based e-rx vendors, by the Black Book Rankings.

Bottom line: I signed up for Practice Fusion (no, they're not paying me to write this), and I'm in the process of being verified for the e-rx (apparently, you have to do that). I'll let you know how it goes.

As I was writing this, it occurred to me that once we start e-prescribing controlled substances, we'll be taking diversion of these substances out of the hands of individuals who have to hustle to get hold of a one-month supply of meds, and placing it in the hands of anyone savvy enough to hack the system. Who could do that? Oh, I don't know, maybe a large scale crime organization, or your average computer science major at MIT. Goodbye, diversion in dribs and drabs, hello big-time diversion.