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Why Federally Mandated Electronic Prescribing for Controlled Substances will Benefit Public Health

Today, 35 states have passed mandates for electronic prescriptions for controlled substances with the aim being to reduce the risk of stolen or forged prescriptions and to prevent patients from ‘doctor shopping’ between states.

Although 2022 has brought on a greater sense of normalcy, the past few years have distracted us from one of the most overlooked epidemics plaguing healthcare: prescription drug abuse.

Before Covid-19 diverted attention away from this problem, President Trump signed on to the SUPPORT for Patients and Communities Act of 2018, instating sweeping legislation for initiatives to address the opioid epidemic. The bill, among other initiatives, requires electronic prescriptions for controlled substances (EPCS) for any covered part D drug. Although the official start of the mandate was delayed two years to January 1, 2023, the importance of this federal intervention cannot be emphasized enough as we plan for the year ahead.

The rise of substance use disorders: An epidemic

In 2021, there were 107,622 lives lost to drug overdoses – a big jump from 2020’s already staggering 91,799 deaths. But what’s especially shocking about many of these deaths is how so many individuals developed substance use disorders to begin with. If we look back at opioid abuse alone, nearly 80% of heroin users reported using a prescription opioid before heroin. This statistic is just one example of how controlled substances – if not carefully monitored and prescribed – can lead to misuse and addiction.  To fully understand how we’ve gotten to this point, it’s important to consider the issues that come with paper prescriptions.

The paper script problem

The pharmaceutical landscape has changed dramatically over the past several decades. Around 30 or 40 years ago, prescription blanks (the pads of Rx paper designated for hand-writing prescriptions) were everywhere – stuffed in desk drawers, in pockets, on countertops, laying on a nurse’s station. There was zero security. If someone stole a prescription pad, it would be hard to miss. Back then, drug diversion – the theft of medication intended for patients within a healthcare setting – wasn’t widely discussed.

But sure enough, there were red flags everywhere. Pharmacists started to pick up on the way diverters would look at a prescription blank left out in the open – which essentially served as a blank check for drugs. Eventually we talked to physicians about the importance of securing their blanks, but compliance was low. In the years that followed, there was an attempt to make paper prescribing more secure, but the efforts weren’t enough to outsmart diverters. And frankly, there were hardly any regulations to enforce change.

It is not difficult to imagine the diversion that happened across the nation and the subsequent widespread consequences of addiction that have since rippled through society. Today, we are still cleaning up this mess. But with federal regulations in our line of sight, there’s certainly hope.

Combatting addiction with EPCS

Recognizing the depth of this problem over a decade ago, many local governments started implementing state mandates for EPCS. The biggest change this posed for health systems was the transition away from paper to a greater reliance on technology. However, this change paved the way for prescribers to send prescriptions directly to pharmacies electronically, in turn establishing IT infrastructure that will now be required on a federal level. Around ten years ago, there were limited technologies on the market to do this. However, more developments and products have come out since, and the healthcare industry now has many options to seamlessly facilitate electronically prescribing.

Today, 35 states have passed e-prescribing mandates, with the aim of the mandates to reduce the risk of stolen or forged prescriptions and to prevent patients from ‘doctor shopping’ between states. As of 2021, 74% of e-prescribers in the U.S. are enabled for EPCS. However, the problem still exists on a national level, with many states still writing paper prescriptions for controlled substances. Alabama, for example, has no state mandates in place and just 37% of prescribers are enabled for EPCS.

While change on this scale always requires an adjustment, health systems that have implemented EPCS have experienced significant benefits. There’s now much better visibility into the physician-specific patterns of prescribing controlled substances, thanks to the electronic medical record (EMR). The data and auditing capabilities are much more robust, allowing health systems to identify diversion and act or remediate sooner.

Above all, EPCS enhances accountability and creates room for improvement in prescribing. Providers can make better informed decisions for patients when they are able to look at all the data on how many controlled substances an oncologist prescribes, for example, compared with how much a psychiatrist prescribes and whether additional opioids are medically necessary or appropriate. In the past, prescribing was about treating and controlling pain. Today, it’s more about treating the specific problem and reducing the quantity of drugs that are prescribed. If we’re able to prescribe less, there’s a reduced chance of addiction.

What to expect in 2023

Currently, the law only requires EPCS for prescriptions for Medicare part D patients. However, most states that already have mandates require electronic prescribing for all controlled substances regardless of payer status – and it’s not far off to assume this trend might evolve for new states complying with federal EPCS. Further, a new federal bill introduced in 2023, the EPCS 2.0 Act, if passed, would effectively require all controlled substances to be electronically prescribed.

Rural communities might feel the most pressure from these changes, as many still rely on paper scripts. Financial constraints could also have an impact. On the other hand, patients can receive their medication faster than ever before with EPCS – no need to pick up paper from the doctor and then drop it off at a pharmacy. Although any transition is hard, we’ve all been primed for it with the pandemic (especially healthcare). There may be a long road ahead, but as overdoses climb and drug diversion persists, one thing is clear – it’s time for change.

Photo: uchar, Getty Images

Jason Potts is an experienced clinical pharmacist with an extensive background in clinical pharmacy and informatics working in academic medical centers and community hospital systems. He received his Bachelor of Science at Colorado State University and his Doctor of Pharmacy at Pacific University after which he pursued his Critical Care Pharmacy specialization at UMass Memorial Hospital. Jason continued his career at Billings Clinic where he served as Critical Care Lead Pharmacist for 8 years. While at Billings Clinic Jason also displayed a passion for the overlap of clinical work and information systems, working extensively to find ways to improve clinical efficiency through EHR integration. Jason is currently a Clinical Workflow Specialist at Imprivata, where he advises on the clinical practice of healthcare IT security.

Dana Darger, RPh is the Director of Pharmacy at Monument Health Rapid City Hospital, the Director of Pharmacy at Monument Health Custer Hospital and the System Director of Inpatient Hospital Pharmacy for Monument Health. He is a 1979 graduate of the College of Pharmacy at South Dakota State University and has spent his career working in rural health in South Dakota. He currently serves as the chairman of the South Dakota Medicaid Pharmacy and Therapeutics and the President of the South Dakota Pharmacists Association.

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