Pennsylvania this week is at last going to launch what is frequently described as one of the most effective public policy tools to rein in out-of-control opioid overdose rates.
Starting Thursday, the statewide prescription database will allow medical providers to check for evidence that their patients may be abusing or selling drugs - getting the same oxycodone scripts from multiple doctors and filling them at different pharmacies, for example. The benefit of knowing is so obvious that 48 other states already have databases accessible to health practitioners.
Don't expect miracles. In fact, many who work in the field, including those involved with Pennsylvania's initiative, agree on two things: Lives will be saved in the long run as fewer prescriptions are written and troubled patients are treated earlier. But some people may die if their prescriptions are cut off before treatment is available and they end up buying drugs on the street.
Although research is limited, evidence suggests that the saves will far outnumber the losses over time.
For physicians, a database query that reveals a patient has been doctor-shopping may put them in an uncomfortable spot if they can't quickly find treatment for the patient.
"If we can't get them into rehab then obviously we are not going to be prescribing a narcotic," said Montgomery County cardiologist Scott E. Shapiro, explaining that knowingly abetting an addiction would be unethical. "The patients don't have a choice. They have to feed their addiction; it's their only out."
On the street, buyers can find pills as well as cheaper, stronger heroin, which also is an opioid. Pills are consistently formulated, but heroin varies. It also may be mixed with fentanyl. Philadelphia officials warned Friday that fatal overdoses involving the synthetic opioid rose 600 percent between 2013 and 2015, and accounted for more than a third of drug deaths during the first half of 2016.
Although fentanyl, unlike heroin, is a prescription narcotic, few opioid addicts got their start on it. Most sought medical help for pain and were prescribed Percocet or OxyContin. As their tolerance built, higher doses or stronger drugs prevented excruciating withdrawal symptoms.
Rising overdose fatalities over the last decade have led states to repurpose what are known as Prescription Drug Monitoring Programs, or PDMPs. Most, including Pennsylvania's, had been limited to law enforcement use.
Public health officials saw an opportunity to give doctors critical information that a patient may not have mentioned. Benzodiazepines, for example, are frequently prescribed by psychiatrists for anxiety. But taken with opioids - typically prescribed by another doctor or dentist for pain - they dramatically increase overdose risk.
Every state's PDMP is different. New Jersey's program, updated last year, requires that every practitioner able to prescribe controlled substances register with the system. It then mandates that they check histories before prescribing a narcotic to a new patient for the first time and quarterly thereafter, as well as if they believe that drugs are being abused.
Pennsylvania does not require registration or ongoing checks but it does mandate querying the system (which requires registration) when first writing a script for a new patient and if abuse or diversion is suspected. The state is encouraging more frequent checks, as is the Pennsylvania Medical Society.
Peter Kreiner, who directs a federally funded PDMP research center at Brandeis University, pointed to innovative ways that states use the data. Kentucky examines the top 2 percent of prescribers, and has a small investigative team that forwards some cases to the state medical board.
In California, logging in to the database opens a dashboard that automatically alerts physicians about patients who may be at risk. Nevada dispatches trained workers to the homes of some patients. They try to convince them to seek treatment but the prescription records they present, Kreiner said, are an "implicit threat that we have this information that we could turn over to law enforcement."
Lauren S. Hughes, a deputy secretary at the Pennsylvania Department of Health who is overseeing the PDMP, said she anticipated that physicians who didn't check it themselves would receive letters about patients with risky patterns of drug use.
Aetna, the giant health insurer, announced earlier this month that it had begun sending similar notices to 931 physicians nationwide who were among its top opioid prescribers. Pennsylvania was home to 136 "super-prescribers" - those within the top 1 percent of prescribers in their specialty - more than any other state.
The Pennsylvania PDMP will contain far more data than the insurer has. Pharmacists are required to electronically submit records of every controlled substance dispensed within 72 hours.
Most opioids are prescribed by dentists and physicians with specialties in emergency medicine, primary care, and pain management. A query of the database should take "two to three seconds," Hughes said. The record for each patient will show names, dosages, and dates for each substance prescribed and filled, along with the name and address of the prescriber and pharmacy, and method of payment.
If a worrisome pattern appears, it generally will be up to the doctor to decide what to do. Some may refer patients to pain specialists, who are in short supply. Some may try to convince them to stop seeing multiple doctors.
"These are not easy conversations," said Chris Echterling, a family physician at WellSpan Health, based in York, Pa. "It is rare that the person says 'I need help' and the physician says 'Great, we will get you in someplace this afternoon.' "
Echterling's advice for doctors whose patients won't listen to their counsel: "at least offer them naloxone," the emergency overdose-reversal drug.
Shapiro, the Montgomery County cardiologist who is also president of the Pennsylvania Medical Society, pointed out that, even now, physicians often can't find treatment for patients who seek help. "We have to tell them to come back in 48 hours. And those are the people who go out and die," Shapiro said.
Both doctors strongly support the new program. So does Gary Tennis, secretary of the state Department of Drug and Alcohol Programs, which has a supporting role with the PDMP.
Tennis said there were short-term spikes in heroin deaths in other states that launched databases without enough treatment available. He said Pennsylvania is in slightly better shape: 15 percent of people in need of treatment receive it, he said, vs. 10 percent nationally.
Tennis is optimistic about the longer term, as the database, new prescribing guidelines, and other actions lower the number of prescriptions written for opioids, meaning fewer addicted patients needing treatment.
A study published last month in the journal Health Affairs found a small decline in overdose deaths from prescription painkillers after states implemented PDMPs.
No strong research has confirmed the short-term increase in heroin deaths that is widely projected. Overdose patterns are notoriously complicated to discern, as the arrival of fentanyl mixed in with heroin shows.
Corey Davis, who grew up in Pennsylvania and is now based in Los Angeles, studies how public policy affects overdose rates. He thinks PDMPs, as one tool among many, are a good idea, but not as significant as some believe.
"The most important thing is the decision of whether the doctor makes that first opioid prescription," said Davis, who works for the Network for Public Health Law.
"If you're having a tooth out, you shouldn't get 30 Vicodin," he said. "You should get three."