Colorado state auditors released a report on Monday identifying significant deficiencies and oversight issues within the state’s decade-old Prescription Drug Monitoring Program.
The program and corresponding database for medical providers was established in 2008 by state lawmakers to electronically track and monitor prescriptions to help prevent abuse, allow medical providers to review patients’ prescription histories, and help law enforcement and regulatory boards investigate medical providers or individuals acting in bad faith, according to the report.
“The General Assembly established the PDMP to help improve patient care, detect illegal activity, and prevent prescription drug abuse and misuse,” Kate Shiroff, legislative audit supervisor in the Office of the State Auditor, said in a written statement. “Unfortunately, this audit showed that the program is not working as it should to achieve these goals.”
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State auditors found that of the 1.4 million Colorado patients with opioid prescriptions in 2018 and 2019, nearly 8,700 patients each received prescriptions from 10 or more medical providers, a practice commonly referred to as “doctor shopping.” Approximately 1,200 of the patients each received opioid prescriptions from 15 or more medical providers.
The audit, which was conducted from January 2020 through February 2021, also found 85 medical professionals each had written more than 3,000 opioid prescriptions in 2018 and 2019, which is 26 times higher than the average prescriber. The trends indicate the potential presence of “pill mills,” referring to facilities that prescribe more opioids than a patient needs without investigating their medical history, according to state auditors.
The overprescription of opioids by medical providers in the U.S. has been a major driver in the upward trend of overdose deaths in the past two decades, from about 8,400 in 2000 to more than 50,000 in 2019, according to the Centers for Disease Control and Prevention.
Since the program’s formation, overdose deaths from prescription opioids have risen by 76% in Colorado
The auditors found that PDMP staff did not identify and follow up on problematic trends or make referrals to law enforcement or regulatory boards, as they are statutorily required to do.
Since the program was formed, overdose deaths from prescription opioids have risen by 76% in Colorado, from 246 deaths in 2008 to 433 in 2019, according to the report.
Since 2014, Colorado law has required pharmacists to submit data on all dispensed controlled substances to the PDMP database, and it has required Colorado prescribers and pharmacists to query the PDMP database to help monitor prescription drug use. But providers are still not using the database.
Auditors found that 18% of Colorado’s approximately 35,000 prescribers were not registered to use the PDMP database, as required by state law, and that most pharmacies did not submit their data in a timely manner, according to the report. It is unclear whether providers comply with the state requirement to query the database before issuing a second opioid prescription because the state does not collect this information, according to the audit report.
In addition to containing prescription history, the PDMP database provides medical providers and pharmacists monthly patient alerts to inform them when a patient is receiving multiple prescriptions during a given time period.
Key audit recommendations to improve Colorado’s Prescription Drug Monitor Program
State auditors made five detailed recommendations to improve the performance of the monitoring program, all of which PDMP agreed to implement between 2022 and 2024. Some recommendations will require lawmaker approval.
- Improve the effectiveness of the PDMP by working with the General Assembly on statutory changes that would require prescribers to query the PDMP database before prescribing each opioid.
- Enforce the requirements that prescribers and pharmacists register to use and query the PDMP database.
- Enforce statutory limits on opioid prescriptions and develop enforcement mechanisms for noncompliant prescribers.
- Ensure pharmacies comply with rules to timely submit data on prescriptions to the PDMP database.
State Rep. Janice Rich, a Grand Junction Republican, said she’s disappointed that the Department of Regulatory Agencies and the PDMP have not “done their job” to hold providers or patients who are acting in bad faith accountable.
“It is disappointing to read something like this,” she said. “That they know about this, and haven’t done anything about it.”
Rich, who is the House minority caucus chair, is especially upset to see how much “doctor shopping” has been occurring.
“This whole thing about the PDMP was to stop that,” she said. “And so that’s why I’m really disappointed in DORA for allowing that to go on. And it happened in 2018 and 2019, and here we are in 2021 just now hearing about this.”
She said she’s unsure if she will bring a bill next legislative session to address the concerns outlined in the state audit. “But I would certainly support whoever decides to,” she added.
Rich ran a bill that is awaiting Gov. Jared Polis’ signature that expands the prescription drug monitoring program to track all prescription drugs prescribed in the state. But the bill comes with the caveat that it will only be implemented “if there is sufficient money in the prescription drug monitoring fund from public and private sources to fund the expansion.”
Bill would mandate that prescribers check the state database
For Robert Valuck, the director of the Center for Prescription Drug Abuse Prevention at the University of Colorado Anschutz Medical Campus, nothing in the state audit report comes as a surprise. He’s been “knee deep” in the topic since 1986 and helped craft the legislation that created the PDMP.
His center houses the Colorado Consortium for Prescription Drug Abuse Prevention, which includes an 850-member state task force that was created by then Gov. John Hickenlooper in 2013 to coordinate the state’s opioid crisis response.
Though the issues outlined in the state audit report aren’t news to him and are problematic, he says the report needs to be taken in context.
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“It’s very difficult to say that this specific patient has a problem, or that that doctor is a problem. That’s very difficult to do without opening a case, and looking at the situation,” Valuck said. “It could be a pain doctor that’s legitimate, or it could be a pill mill that’s not legitimate. Either of those is possible.”
DORA only investigates cases when a formal complaint is filed, according to Valuck, or if a law enforcement agency acquires a subpoena to access specific case information.
The Department of Regulatory Agencies did not respond to multiple interview requests for more information about the process.
Valuck wants medical providers to check the state’s database more frequently to identify if a patient might be “doctor shopping,” but he understands that it’s not always feasible to do so (though a bill awaiting Polis’ signature would mandate it).
“There’s no real enforcement or real mechanism for it,” Valuck added. “And it’s also difficult if the prescriber has to leave their workflow and go over to a different computer system, log in and check the PDMP. It takes time, takes an average of about five minutes to do that, and the doctor’s only got 12 minutes with a patient. So how are they going to spend half of their time checking a database that only comes back with a problem for about 1 or 2% of people?”
“The mandate will help, that will get more doctors checking it, and more of those co-prescribing things will get caught, and then stopped, which is good,” he added. “Lives will be saved because of it, I’m convinced. But, you know, we still have a long way to go.”
One recommendation within the audit report gives Valuck pause, though as a coalition member he tries to stay neutral on potential legislation and focus on his education efforts.
The recommendation, which would require legislative change, would give law enforcement more access to the database to investigate potentially problematic cases. Valuck said historically, their coalition and the majority of state lawmakers have opposed similar efforts.
“The tool has always been designed and meant to be a clinical tool in Colorado,” he said. “Different law enforcement agencies have come into the legislature and said, ‘Hey, we would like PDMP access. And they’ve always been turned away and told, ‘No you can’t have it, get a subpoena, get a court order, then you can look at it.”
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