Rx monitoring effect on minorities questioned

As New York state moves this month to monitor all prescription drugs, researchers warn that efforts to combat drug abuse and diversion can have an unintended fallout on minorities' access to appropriate treatment.

A March 13 Archives of Internal Medicine study found that Medicaid patients living in predominantly black neighborhoods were 1.8 times more likely than those living in predominantly white areas to have appropriate benzodiazepine prescriptions discontinued. The study examined the seven years after New York in 1989 added the drug to its list of those monitored under its triplicate prescription program. Patients in majority Hispanic neighborhoods were 1.6 times more likely than patients in white areas to have their prescriptions discontinued.

Patients should have had prescriptions rejected only if they fell into a "problematic use" category defined, with the help of a clinical advisory panel, as a patient filling a prescription at two different pharmacies within seven days, using the drug for more than 120 days or using the drug at a dose more than twice the recommended maximum. Adding benzodiazepine, a potentially addictive anti-anxiety drug, to the list of monitored drugs nearly ended pharmacy hopping, but it also had a racially disparate effect on prescribing, the study said.

"I don't think physicians are saying, 'Here's a black person; I'm not going to give them what they want,' " said Sallie-Anne Pearson, PhD, the study's lead author. "It's probably not that overt, but there does seem to be the perception that black folks and Hispanic folks tend to be the ones abusing this drug."

Dr. Pearson said the perception was unfounded, as her study showed that "problematic use" of benzodiazepines was lower among blacks and Hispanics than whites before New York began monitoring the drug.

"These programs aren't a bad thing, but some of the fallout is a bad thing," Dr. Pearson said.

New York no longer uses the triplicate prescription program now that it and other states have moved to all-schedules, electronic prescription monitoring programs with financial help from the federal government. But Dr. Pearson said the study's findings are still relevant.

"It's still physician surveillance," she said. The effect on patient access to medication "is likely to be similar."

While the study does not propose how best to minimize PMPs' affect on legitimate access to prescription drugs, other experts in the field are studying the subject. Aaron M. Gilson, PhD, assistant director at the University of Wisconsin Comprehensive Cancer Center's Pain & Policy Studies Group, said state PMPs that monitor all prescription drugs are less likely to stigmatize a certain class of drugs, and physicians will feel less intimidated if health department officials, not law-enforcement authorities, oversee state programs.

Twenty-one states operate electronic PMPs, according to the National Alliance for Model State Drug Laws. Another six have passed enabling legislation but don't have systems up and running. An additional 11 states are considering legislation to authorize similar programs.

Though states are hurrying to combat prescription drug abuse by setting up PMPs, their effect is still largely unknown. The Office of National Drug Control Policy has argued that they are successful, repeatedly citing the statistic that in 2000 the five states with the highest number of prescriptions for oxycodone -- a potentially addictive opioid -- had no PMPs in place, while the five states with the lowest number of prescriptions had PMPs.

But Dr. Gilson said that is not an accurate indicator. "What [the DEA] is using to define the efficacy of a PMP is what I'd use to demonstrate that it's negatively affecting appropriate usage of medicines," he said.

Scott Fishman, MD, president of the American Academy of Pain Physicians, agreed. "How can lowering the number of overall prescriptions be the key to success?" Dr. Fishman said. "The key is to get prescriptions to people who need them and keep them away from the people who don't."

The AMA supported the National All Schedules Prescription Electronic Reporting Act, which passed last year but has yet to receive funds. In general, Association policy supports finding a balance between access to appropriate medication and preventing drug abuse.

New York State Health Dept. Commissioner Antonia C. Novello, MD, did not respond to interview requests.