Computerized Prescribing and Pain Medications

As part of the government initiative to modernize health information recording and exchange , doctors and health care providers are encouraged (with financial incentives) to prescribe medications using the computer.  This “e-RX” system allows you to send prescriptions to the patients’ designated pharmacy right from your computer screen with a few clicks and turns of your computer mouse controls. The only medications you are not permitted to prescribe are narcotics, controlled substances and pain medications with narcotic contents.

At the same time this initiative is occurring, there is a massive crackdown in the State of Florida on prescribing medications for pain. Sloppy legislation in Tallahassee by the State Legislature led to the opening and growth of “pill mills.”   Drug addicts and suppliers from all over the country routinely travelled to Florida to obtain massive quantities of prescription medications from these fraudulent facilities staffed by criminal physicians. The medications ended up on the streets causing numerous drug and alcohol related deaths around the country.

The “sloppy” Florida State Legislature then attempted to rectify the problem by passing new rules and regulations that closed the “pill mills” with the help of the police and drug enforcement authorities but has frightened the legitimate physician population into not being willing to prescribe for legitimate chronic pain. Their actions included updating physicians’ online profile with the state licensing agency to declare whether you write narcotic scripts for chronic pain or not.  If you reply “yes” you are apparently placed on a list of “chronic pain” prescribing doctors that the public can access as well as the criminal elements looking for doctors to write scripts for cash.

At the same time legislation now requires doctors to take specific courses to prescribe some of the newer pain delivery products necessitating the physician to leave their practice to train on the use of the new medications. The result is that legitimate neurologists and anesthesiologists are shying away from seeing chronic pain patients less than 65 years of age even if they have been referred and have legitimate needs for pain medications.

This brings me back to computerized prescription ordering. If you are trying to track narcotic prescriptions, why prevent the doctors from using the computer to prescribe controlled substances?   What is easier to track and trace, a computerized order or a hand written prescription?   It would seem that computerized record keeping through electronic order entry would be the preferred method of tracking narcotic prescriptions.

Pharmaceuticals – Pads, Pens and Prescriptions

It has become stylish to trash doctors for accepting lunch, pens, pencils, pads or even samples from representatives of pharmaceutical companies.  The theory is that pharmaceutical marketing raises the cost of prescription medications to patients and the health care system. Once the patient gets started on a new medication, which costs more than generic products in the same medication class, they stay on the more expensive medicine. Ethics experts consider a discussion with a pharmaceutical representative unprofessional and unethical.

In certain states it is now illegal to receive any gift (I.e., a pen, paper, samples, etc.) from a pharmaceutical representative including a discussion of the new product line over lunch in your office provided by the pharmaceutical company for your staff.  Purists claim we should be learning about new products from the scientific medical literature.  Let me join the chorus of those who say this is pure nonsense.

Physicians are trained to be independent thinkers and evaluators. For thirty years of private practice I have taken the position that, unless I am dealing with an orphan drug for a lethal disease, I want the product out on the market in my community for at least a year before I will prescribe it to my patients. Let someone else’s patients be the community guinea pigs. After a year of reflection, evaluation, reading about the community experience and discussion with my colleagues, I will try the samples if the drug offers distinctive advantages over existing products.

Where do the pharmaceutical representatives fit in?  They let me know there is something new out there and they tell me why they think it is different and improved over existing products. That is the introduction that piques my interest in beginning my due diligence into the product with its benefits and risks.  I do not know how the rest of my colleagues treat new products but I am willing to bet their inquiries are similar. To think that because someone brings me a pen or a tuna fish sandwich for lunch I will give my cherished patient their new product without doing a background check first is an insult to my professionalism and my colleagues.

Articles and reviews in medical journals are outstanding for reviewing data on a product. The journals would be have far more credibility if they hadn’t compromised years ago and started selling full page glossy ads to pharmaceutical companies to cover their costs.  Reading about a product is not the same as using it. I give the analogy of two mechanics trying to service an automobile by reading the auto manual. Both are similarly inexperienced but one has a master mechanic at his side to guide him through the pitfalls. They both can read the manual but the one with some hands-on experience and guidance figures it out much quicker and with much less aggravation than the mechanic just using the written material.  New pharmaceutical samples give me an opportunity to gain some experience with the product without my patient incurring expenses. If the medication does provide a distinct advantage to the existing products I have helped my patient in my field trials. If the medication doesn’t live up to the billing then I do not use it again!

I have tried the computerized on line drug “detailing,” provided by pharmaceutical companies to replace human representatives, but frankly once you log in they don’t cover the material in a quick and timely fashion like our experienced drug representatives do. I don’t want to spend 15- 30 minutes online listening to the companies’ educational spiel. I want the “Cliff Notes” version as the basis for me beginning my investigation.

I am additionally tired of hearing lecturer’s at my CME courses disavow all relationships with pharmaceutical companies before beginning their lecture on a topic. I still believe that most speakers present a fair and objective viewpoint of the topic they are asked to speak about. Their presentation is only one piece of data for me to review and consider before I add that product to my repertoire or reject it.

The same “ethical” physicians attacking pharmaceutical advertising are using generic products with absolutely no knowledge of their true safety, efficacy or even their nation of origin. The last time I looked at this question I was told generic products had to have at least 80% of the “bioavailability” of the brand product. The actual research is done by the generic pharmaceutical company with the data submitted to the FDA for their review. Isn’t that like letting the fox into the chicken coop and asking it to maintain order?  Where are the double blind studies showing the efficacy of each generic as compared to the brand name product?  Where are the certified lab studies showing that with similar performance efficacy there are similar blood and tissue levels of the active agent and similar adverse effect profiles?

I think it’s high time that physicians and legislators realize it’s all about the money with insurance companies looking to keep their pharmaceutical costs down at all costs with as little investment in research and development as they can get away with.  I will continue to break bread with the pharmaceutical reps willing to bring in a lunch to my office staff while discussing a new product. I will wait a year for the new products to exhibit their benefits and risks in my community on someone else’s patients before I use them. I will perform my due diligence before subjecting my patients to a new product but I will not for one second feel any less professional for having accepted a pen or a pad or a bagel from a pharmaceutical representative while discussing a new product.