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Wednesday, May 6, 2009

Ask your doctor, and she may ask about you

There's a bit of a flap going on in Salem about a Senate bill that would establish an electronic pharmaceutical database in Oregon of all prescriptions for a large number of drugs of a type that are deemed ripe for abuse. These are the drugs listed on Schedules II, III, and IV of the federal drug law.

Some people I know and admire support this measure. The folks who treat heroin addicts without hooking them on methadone tell me that there's been a rise in methadone-related deaths lately. They attribute this in part to patients getting multiple methadone prescriptions for pain from different doctors, without the doctors realizing that the patients are playing them off each other. A prescription registry, it is suggested, would alleviate that problem, not only with methadone, but with other drugs as well. Doctors could check out a patient's prescription collection before adding to it

My civil liberties buddies, on the other hand, are screaming that the registry isn't necessary, that it will include far more information than is called for by legitimate needs, that too many drugs are going to be covered (including common shrink pills like Xanax, Ambien and Valium), that it will invite all sorts of snooping on innocent Oregonians, that too many people (including every pharmacist in the state) will have access, that there's no patient notice or remedy for security breaches, and that the crazed druggies who are currently shopping for prescriptions are going to find some other way to get their buzz on anyway.

It's an interesting debate. The optimal solution probably lies somewhere between no registry at all and the massive one that's being proposed -- under the current bill, the prescriptions being tracked would apparently run into the millions each year. If people are getting heavy stuff like speed or opiates, then sure, keep tabs and let the doctors have access. But every mother's little helper? Pharmacy clerks all over the state getting to surf around through the data? And no meaningful recourse if your privacy is illegally violated? No way.

Comments (26)

Well if there is one thing we should have learned by now is that increased regulation seems to have only a minimal effect in curbing drug use or addiction. Seems like too much of a privacy risk for the return.

I ran across this news report the other day. How timely.

I think the basic idea of a registry is good, but until the internet is completely secure (if ever) it's too risky and so are medical records stored in cyberspace.

Those who have done nothing wrong have nothing to fear. Except, of course, those with a health issue or a sexual orientation of some kind.

The bigger issue is standardizing medical records and formats a la Microsoft, WalMart and GE are trying to do.

I can see a big benefit in using aggregate data (eg a cum report on how all users of XYZ drug are reacting and side effects without individual user identifiers.) However, the privacy issue is going to be big in this also.

My civil liberties buddies ... are screaming that the registry isn't necessary, that it will include far more information than is called for by legitimate needs, that too many drugs are going to be covered (including common shrink pills like Xanax, Ambien and Valium)

So in a day-and-age where Big Pharma can advertise restricted Rx drugs on television like it's a breakfast cereal, where the cost of dealing with Rx drug abuse has overtaken abuse of "black market" street drugs, where the FDA is funded by Pharma companies-- you don't want to take this precaution because of privacy concerns?

So should we extend that argument to PHRs and other electronic health records? Do we have to stay with paper records at the doctors office forever?

I also find it ironic that the drugs that you mention are a few of the most abused. It's 2008 and I can get a Valium Rx filled 10 times in the metro area-- that is ridiculous. How else do we solve the problem?

Let's see: Robbing and maybe killing a pharmacist for a fix, burglarizing homes for drugs OK. Getting illegal affordable drugs through duping a Dr. not OK.
Legislation of inconsequential morals in dire times OK.Giving up privacy for what?
We amerikans really know how to prioritize the important issues.

Let's see: Robbing and maybe killing a pharmacist for a fix.

Um, haven't you seen the "No Oxycontin Sold Here" signs at Rx stores? This already happens.

burglarizing homes for drugs OK.

If someone wants to track down legal Rx narcotics users there is much easier ways to do it then hacking medical records systems. Why not just B&E into a doc office or make friends with a receptionist?

The rest of your comment is Greek to me.

But I do agree that privacy and security should be primary concerns of any medical records system (that's why there's already a lot of regulation in place, HIPAA, etc). But if we are going to solve the health care problems in the US then computerized health records are a given.

Prescription records with any given pharmacy are already held in a digital format with Fred Meyer, Rite Aid, Walgreens and the like. They maintain servers that can be hacked just like any other server can be hacked. How the proposed database presents more of a risk of a privacy breach than already exists is lost on me.

A central registry that helps make controlled substances truly controlled sounds like an excellent idea that is long overdue.

Haven't we learned a dam thing from the war on drugs? We keep chiseling away at our rights...all in a vain attempt to keep people "safe" from WHAT, I ask you? Themselves? From drugs? Since when does writing a law down on paper, passing it and spending an enormous amount of money enforcing it-- stop ANYONE from doing ANYTHING they really want to do?

These databases take away more of our rights to privacy and dignity and control over our own bodies....and they will do absolutely NOTHING to keep us safe. When it's too hard to get these drugs from doctors, people who want them WILL find a way to get them through other avenues...or the will turn to other drugs like Heroin and methamphetimines....and with illegal drugs comes crime, violence and LOTS OF MONEY.

It's not just those who are "doing wrong" that get caught up in this mess...its innocent doctors, sick patients and people in pain--and what do we GAIN? WE gain more big brother survelliance and we LOSE good doctors because they are too scared of "who's watching" to treat people they way they were taught to and they way they need to. Would you work in a field where every thing you do is gone through with a fine tooth comb and making a simple mistake can cost you your livelihood and your freedom? Especially when you went into that field, intending to help people?

Why don't we just take the constitution and write a big clause that says "this only pertains to you if you don't need healthcare and you've never even TRIED drugs."

>Haven't we learned a dam thing from the war on drugs?

Yes, we've learned that trying to control the drug problem from the demand side doesn't work. So now we are going after the supply side (Sudafed behind the counter, Rx registration, etc)

>safe from WHAT, I ask you? Themselves? From drugs?

In a word: yes.

>Since when does writing a law down on paper, passing it and spending an enormous amount of money enforcing it-- stop ANYONE from doing ANYTHING they really want to do?

Well, because if ANYONE wanted to get 10 refills of Valium on a single day then the Walgreens Pharmacy will type in info and find out that you've already had your Rx filled at Freddies.

>These databases take away more of our rights to privacy and dignity and control over our own bodies....and they will do absolutely NOTHING to keep us safe.

I think you should be more worried about the credit report agencies than Rx registrations databases. Also you might want to look into an agency called the NSA. Lots of reasons to wear a tinfoil hat these days, but I don't think Rx registration is one of them.

>When it's too hard to get these drugs from doctors, people who want them WILL find a way to get them through other avenues...

Some will, but many won't. It's like closing the offshore corp loophole before you reform the tax code. You have to patch up the huge hole in the wall before you fix the gate.

Also, this rampant abuse of Rx filling is what fuels underage abuse of these drugs. By ending this practice we are LIMITING the drugs available to our youth.

>or the will turn to other drugs like Heroin and methamphetimines....

The guy popping Ritalin recreationally is really going to go score an 8-ball if they can't get their pills anymore? Really?

>and with illegal drugs comes crime, violence and LOTS OF MONEY.

Well, unfortunately the "legal" drugs (illegally obtained) cause more damage then the street drugs in US. So I'm not sure where this is going...

>It's not just those who are "doing wrong" that get caught up in this mess...its innocent doctors, sick patients and people in pain--

Huh? How can this system hurt legal users of Rx medications?

>and we LOSE good doctors because they are too scared of "who's watching" to treat people they way they were taught to and they way they need to.

The WHOLE POINT of this is to keep people on the dosages that their MD prescribed and no more. So I'm not sure why this is such an anti-doctor measure in your mind.

I'm of mixed mind on this - I take fairly heavy doses of Methadone for post-surgery cancer pain & it allows me to live a pretty normal life, no "high" at all, and it takes care of most of the pain. Every couple of months with Doctor's permission I stop 'cold turkey' to see if the underlying pain has increased or diminished - the withdrawal is the worst kind of miserable, but not fatal (and the underlying pain hasn't diminished.) My doctor has her patients sign a contract to get all scripts filled at one designated pharmacy, but that could obviously be breached easily. If the registry would help legitimate Doctors avoid DEA harassment, it would be good, & I don't think it would seriously increase third-party theft (I had some pills stolen by a 'friend of a friend' visiting, & that was a hassle).

The big conclusion from my experience is that a lot of the Drug Treatment Industry is perhaps unnecessary - just put the addicts on Methadone (cheap as dirt - 1000 5mg pills for under $70 retail) & slowly wean them; they can live normally, & do just about anything not requiring extended deep concentration. If they transgress, put them in a cell & let them go cold turkey - after one experience like that, they'll think twice. It may seem harsh, but it would make a deep impression. The other thing is education - kids have got to be taught that you have to build up Methadone doses very gradually. If you took my dose, you'd be dead in hours. (A skell on TriMet saw me taking the pills & told me "if you take too many, you'll breathe real fast & get real high." Thanks, I'll remember NOT to do that.)

In short, the information is in some computers already. I don't like centralization in general, but if it would leave the Docs free to practice medicine instead of filling out DEA paperwork, OK. (I've also agreed to random urine screenings, to make sure I'm taking the meds & not selling them. Again, no big deal. But I still don't see the allure of Methadone. I went to college in the early 70s & have some experience in these matters, but M has no recreational value if you're in pain. Maybe it's different if you are not.)

PS - TV Dr. House is my new Hero, but if he took all that Vicodin, I think he'd have no Liver left. And his wacky experience on Methadone in one episode didn't fit my experience. Maybe there is a greater variation. He uses his cane on the wrong side, too. But chacun a son gout...

Still another example of why we should have a single payer health care system in the United States of America!

Anyway, this measure is just another elaborate tort shield (expressed in the bill as "immunity from civil liability") for the pill-pushing industry. This bill would also just amp up the black market for fake IDs and increase criminal activity as desperate drug addicts tenaciously engage in bolder actions to satisfy their uncontrolled and irresistible cravings.

You can't save everybody from their own self-destructive behaviors when it comes to substance abuse.

Meanwhile, the rights to privacy and access to justice of everyone else are subject to a different dark market's invisible hands. And worse.

There's easier ways to solve this perceived problem.

Big Medicine, the AMA, Big Insurance, Big Pharma, and their lawyers, need to look in the mirror and each other and deal with this medically, as healers and their helpers, and intermodally within the strictures of HIPPA -- -- and other existing regimes, rather than run to the state capitals and foist another set of complex and expensive regulatory structures on the backs of faultless taxpayers.

Wonder who's sitting in the wings waiting to scoop up the Oregon "private entity" operation of the "monitoring system" and the creation of the software program, etc., etc., etc.?

You would think that after all of the catastrophic economic implosions still ongoing in the public sector, that there wouldn't be any more money to loot from the treasuries. No sense. No shame. Good grief!

Now let's see....where'd I put my soma?

Wow, urine testing to make sure you DO have drugs in your system! Never heard of that twist before, but it makes perfect sense.

Anyway, this measure is just another elaborate tort shield (expressed in the bill as "immunity from civil liability") for the pill-pushing industry.

IANAL, but I think the shield in question is limited to the information, it's not a tort shield against folks hurt by Big Pharma's business practices.

From the PDF: "Provides certain immunities from civil liability relating to reporting or use of information."

I know. "use of the information" not in "good faith" blah blah blah.


The point I was trying to make is that I think rather than being a tort shield against someone who takes a boner pill and dies of a heart attack, they are trying to shield from liabilities related to storing and providing the information in question, which seems reasonable to me.

Again, I'm not a lawyer and I'm curious if my impression of this bill is wrong.

You're in the ballpark, Gener, but there are other civil wrongs besides physical injury or death -- that's what I'm referring to, and what they're also trying to hide from. There's a spectrum of civil wrongs, including outrageous ones, and many in which one's "good faith" is irrelevant, except as this new law would create a new excuse for wrongdoers. Here's a partial list of some of the wrongs that would be improperly shielded by this bill: invasion of privacy, invasion of privacy (false light), HIPPA violations, negligence, gross negligence, reckless disregard for the rights of another (a negligence enhancer), interference with contractual relations.....

Add to that list the additional wrongs that could be perpetrated by "system operators" or "software vendors/technicians" and it gets wide-ranging in the threat to everyone's right to privacy. Imagine the effects of the stress of such a transgression against a very ill person who is on meds, struggling to survive cancer or the like.

The permutations of all of this are enormous -- and astronomically expensive -- and unnecessary.

Me wonders if almighty Gener is a Big Pharma stockholder?

I would hope that pharmacists have at least a shred of professional ethics.

The IRS, sadly, has dealt with this issue for years: its incredibly tempting for IRS folks to check up on their neighbors or celebrities. IRC 7213 is the answer: unauthorized disclosure to any person (including yourself as I remember) means $5k fine, up to 5 years imprisonment and you lose your job.

I'd suggest a similar deal for the pharmacists: unauthorized disclosure, including browsing, gets you $5k fine, up to 5 years imprisonment and you lose your pharmacy license. If its so important to the medical community, they'll swallow the restrictions; if not, it couldn't have been that important.

Chris, unfortunately that suggestion doesn't even get to first base because it provides even less actual prevention protection than the paper thin Prevention From Abuse orders in Family Court, to compare with a common sense example of the (non)deterrent effects of such legislative artifices. Shreds of professional ethics of any profession are exactly that -- shreds.

And, I think its unacceptable dereliction of duty for the medical industry to foist the main burden of the performance of this proposed statewide system on the backs of the pharmacists (and a tapped-out state treasury with diminishing revenues).

Plus, as Jack mentioned earlier in making one of his points for discussion: "And no meaningful recourse if your privacy is illegally violated? No way."

Code Black!

SB 355 should be euthanized.

Physicians heal thy own system.

For starters, usual kevin is correct: a great deal of prescription data is already being sent over data networks. Many docs can dispatch a prescription to most any pharmacy right from their EMR, and the pharmacy may well receive the script before the patient leaves the office. So to the extent you're worried about information security, this is not really going to put a lot of new information out there... though it will open new paths to the data, those new paths will be controlled reasonably well if HIPAA applies. (Which it most likely will.)

HIPAA has recently grown some fangs, by the way - the stimulus bill contained some very interesting changes. Among these is a data breach notification requirement that is very aggressive... as aggressive as California's rules. If some clinic or pharmacist or clearinghouse leaks data, they're going to be in for a world of public hurt.

Anyway, though I am not myself a medical professional, I do talk to several on a regular basis. I know from their (de-identified) stories that prescription shopping is a real and active problem. (Think meth abusers whose kids take meds for ADHD.) This proposed system may or may not be a great solution, but the legislature did not imagine the problem.

Me wonders if almighty Gener is a Big Pharma stockholder?

Me wonders if KISS belongs to a militia.

A reader writes:

Did you read the Washington Post blog (and now elsewhere) posted on your comment section about the breach of the PMP database in Virginia? Hackers claim to have deleted the entire records but have a copy of over 8 million Virginians and 36 million prescriptions. This is personal medical information. Oh, and apparently it has some value since they are asking for $10 million in ransom. Yes, there's a lot of data out there on all of us but that doesn't mean we should create more database of personal identifying and medical information, store it one place and spend just enough to make it run but easily hackable. (Oregon BOP says they can pay for an out-of-state vendor for just $200,000.) A few other quick points:

Names are identical or similar (5 million or more prescriptions a year according to BOP) and this system has no protection for misidentification and the resulting problems it can raise for an individual (denial of timely medication). SB 355 provides that you can "ask" the BOP to fix the problem, but they have no obligation to act, and you have no remedy to make them fix the problem (that is if you can afford to get a copy of your own report since BOP plans to charge you for it and you can only get it 1 x every 6 months). So, if you are wrongly identified, it may be like the no-fly list -- you can't get off the list.

Although our doctors must comply with HIPAA, the BOP (and the vendor it will use) are not "covered entities" under HIPAA so any protections that consumers have arising from HIPAA (and obligations by the custodians of this information to care for it properly under HIPAA) are gone when it's given to BOP.

The issues for us is does the risk to the 98% (or so) law-abiding Oregonians who will be entered on this database, managed (or mismanaged) by a government agency that has no experience in running such a system (and is not consumer-based) outweigh the benefit to possibly identifying drug seekers and abusers? We think not. You may get at one problem (albeit identifying abusers but still no treatment) but you create a whole new one!

And so fabulous: You go to your doctor and he/she identifies you as a drug abuser b/c you are addicted. And then what happens? Treatment? But there's no $ or beds for that. So, if we are going to raise $1 million in licensing fees from pharmacists and providers, is this how we want to spend it? We know we have drug abuse and addiction -- I say spend it on treatment already needed and wanted.

Let's recognize this bill for what it truly is: a private industry liability protection system paid for by the taxpayers, with immunity provided to the private industry, while those same taxpayers who are wronged by system malfunctions and abuses are denied redress and access to justice.

The Biz (insurance) is using drug-zombie terror tactics to fear-monger and extort acquiescence from reflexive legislators and well-meaning social workers who will try anything that the public will pay for. It's a sucker play, though, intended to get Oregon to sign away basic citizen rights for the benefit of the insurance industry.

Let them pay for it themselves. Don't be grifted!

P.S. -- The public money would be better spent on things like 21st century programs for at-risk children (& family) and their teachers and other helpers, to teach children (& family) life skills, and providing support and encouragement and things for them to have and do year-round, instead of letting them spin off into ennui, misdirected anger, fear, despair, dropping out, and following paths that lead to illegal drug abuse and the anti-social and self-destructive behaviors that correspond.

That's actually one of the great societal benefits of The Arts, which are always the first things that bureaucrats, school boards, and politicians cut out and de-fund. (Bring back the public park concerts, Portland!)

And Oregon -- like other states -- just builds hires more paramilitary cops, builds more prisons, creates more classifications of crimes and capital punishment, and escalates prison terms, while it figures out ways to insure and shield the insurance industry, and to gin up more schemes to provide tax-breaks and other give-aways to selfish corporate greedheads who waste more money than most people even need to live comfortably. Now, about that Paulson stadium two-fer....

See what happens when you put sudafed behind the counter?
If the ID of legal users is a problem, shouldn't the records be maintained some other way without using names? I don't think we really want to tempt every pharmacy clerk with the power to find out if their local political leadership or the cop who wrote them up for running a red light takes an antidepressant.

This is the kind of crappy state you people wanted; this is the crappy state you people get. Living in here is like living in prison.


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Sara Varon - Bake Sale
Stephen King - 11/22/63
Paul Goldstein - Errors and Omissions
Mark Twain - A Connecticut Yankee in King Arthur's Court
Steve Martin - Born Standing Up: A Comic's Life
Beverly Cleary - A Girl from Yamhill, a Memoir
Kent Haruf - Plainsong
Hope Larson - A Wrinkle in Time, the Graphic Novel
Rudyard Kipling - Kim
Peter Ames Carlin - Bruce
Fran Cannon Slayton - When the Whistle Blows
Neil Young - Waging Heavy Peace
Mark Bego - Aretha Franklin, the Queen of Soul (2012 ed.)
Jenny Lawson - Let's Pretend This Never Happened
J.D. Salinger - Franny and Zooey
Charles Dickens - A Christmas Carol
Timothy Egan - The Big Burn
Deborah Eisenberg - Transactions in a Foreign Currency
Kurt Vonnegut Jr. - Slaughterhouse Five
Kathryn Lance - Pandora's Genes
Cheryl Strayed - Wild
Fyodor Dostoyevsky - The Brothers Karamazov
Jack London - The House of Pride, and Other Tales of Hawaii
Jack Walker - The Extraordinary Rendition of Vincent Dellamaria
Colum McCann - Let the Great World Spin
Niccolò Machiavelli - The Prince
Harper Lee - To Kill a Mockingbird
Emma McLaughlin & Nicola Kraus - The Nanny Diaries
Brian Selznick - The Invention of Hugo Cabret
Sharon Creech - Walk Two Moons
Keith Richards - Life
F. Sionil Jose - Dusk
Natalie Babbitt - Tuck Everlasting
Justin Halpern - S#*t My Dad Says
Mark Herrmann - The Curmudgeon's Guide to Practicing Law
Barry Glassner - The Gospel of Food
Phil Stanford - The Peyton-Allan Files
Jesse Katz - The Opposite Field
Evelyn Waugh - Brideshead Revisited
J.K. Rowling - Harry Potter and the Sorcerer's Stone
David Sedaris - Holidays on Ice
Donald Miller - A Million Miles in a Thousand Years
Mitch Albom - Have a Little Faith
C.S. Lewis - The Magician's Nephew
F. Scott Fitzgerald - The Great Gatsby
William Shakespeare - A Midsummer Night's Dream
Ivan Doig - Bucking the Sun
Penda Diakité - I Lost My Tooth in Africa
Grace Lin - The Year of the Rat
Oscar Hijuelos - Mr. Ives' Christmas
Madeline L'Engle - A Wrinkle in Time
Steven Hart - The Last Three Miles
David Sedaris - Me Talk Pretty One Day
Karen Armstrong - The Spiral Staircase
Charles Larson - The Portland Murders
Adrian Wojnarowski - The Miracle of St. Anthony
William H. Colby - Long Goodbye
Steven D. Stark - Meet the Beatles
Phil Stanford - Portland Confidential
Rick Moody - Garden State
Jonathan Schwartz - All in Good Time
David Sedaris - Dress Your Family in Corduroy and Denim
Anthony Holden - Big Deal
Robert J. Spitzer - The Spirit of Leadership
James McManus - Positively Fifth Street
Jeff Noon - Vurt

Road Work

Miles run year to date: 113
At this date last year: 155
Total run in 2016: 155
In 2015: 271
In 2014: 401
In 2013: 257
In 2012: 129
In 2011: 113
In 2010: 125
In 2009: 67
In 2008: 28
In 2007: 113
In 2006: 100
In 2005: 149
In 2004: 204
In 2003: 269

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