Analysis

Topic: Official Prescription Program
Sponsor: Representative DeWeese
Committee: Health Policy
Date Referred to Committee: 11/30/99
Date of Analysis: 4/27/00

Position
The Department of Consumer and Industry Services supports the bill.

Background
In 1988 the Michigan Legislature enacted the Triplicate Prescription Program. The law was part of an anti-crime package and required that all Schedule 2 drugs be written on the triplicate form. The law contained a 5-year sunset provision which required the Legislature to revisit the issue in 1993. The Legislature at that time decided to replace the program with the Official Prescription Program. The new program substituted a single sheet official prescription form for the triplicate form then in use. The new form debuted in 1995. The purpose of both the triplicate and official prescription programs was to reduce diversion of Schedule 2 prescriptions.

Content of the Bill
The bill amends the Public Health Code to repeal the Official Prescription Program in the Department of Consumer and Industry Services. All references in the act to the Official Prescription Program and official prescription forms are deleted. The requirement that Schedule 2 controlled substances and androgenic anabolic steroids be dispensed only with a prescription is continued. However, only one prescription for a controlled substance included in Schedule 2 may now be included on a single prescription form and such prescriptions may not be refilled. A prescription form for a controlled substance may not be postdated.

The bill would create the Pain Management Education and Controlled Substances Anti-diversion Fund to replace the Official Prescription Program Fund. Money remaining in the Official Prescription Program Fund on the effective date of the repealer is transferred to the Health Professional Regulatory Fund. Money in the new Pain Management Education and Controlled Substances Anti-diversion Fund may be used only for pain management education for health professionals and prevention of diversion.

Argument(s) For
The medical profession, patient advocates and others argue that the Official Prescription Program deters physicians from prescribing Schedule 2 drugs for the treatment of many types of pain, particularly cancer. They argue that the program has a "chilling effect" on the prescribing of Schedule 2 drugs due to the fear of disciplinary action by the state board. Weaker drugs in lower schedules may be substituted. These drugs may be both less effective and less safe for the patient. There has also been a corresponding increase in the use of counterfeit scripts for Schedule 3, 4 and 5 substances.

The popularity of official or triplicate prescription programs has diminished in recent years. In 1993 Indiana abolished its triplicate prescription program and several years later replaced it with an electronic filing program. A bill establishing a triplicate prescription program in Maryland was defeated in 1994. Federal legislation introduced in 1990 which would have required all states to adopt multiple-copy prescription programs was also defeated.

Although the Official Prescription Program has reduced diversion, the financial cost of the program is significant. The program also generates huge amounts of paper. An estimated 50-60,000 prescriptions are received monthly, most of them in paper form. There are other alternatives which could prevent diversion and the state should explore them. For instance, Wisconsin has developed an interagency program which has produced a dramatic reduction in the diversion and abuse of prescription drugs. The Wisconsin model has reportedly been incorporated into the programs of the American Medical Association and a number of other states. In 1990 the Drug Enforcement Agency's Committee on Fraudulent Prescription Orders recommended seven diversion prevention measures for consideration by the states. Although official or triplicate prescription programs were one of the alternatives listed there were six others. The other alternatives listed included setting up professional awareness programs, forgery alerts, and nonreproducible prescription pads.

House Bill 5137 will make money which was previously used for regulatory purposes in the Official Prescription Program available for practitioner education and diversion programs. Missouri and Wisconsin have reportedly instituted effective programs to address diversion without placing additional regulatory limitations on appropriate prescribing. Wisconsin's program has been particularly praised in the literature and is based on coordination between health, licensing, regulatory and law enforcement agencies.

Argument(s) Against
The Official Prescription Program has been effective in eliminating counterfeit prescriptions, thereby preventing diversion of Schedule 2 controlled substances. It has been estimated that ten years ago over 100,000 counterfeit prescriptions were presented to Michigan pharmacists annually.

There has never been a documented example of inadequate cancer pain treatment by Hospice, patient right activists, patients or care givers. There is no evidence of the substitution of weaker drugs as alleged by proponents of the repeal. Recent surveys show an increase in the use of long acting pain medications and a decrease in the use of short drugs such as Demerol. This is a desirable outcome.

There is only anecdotal information about the so-called "chilling effect" of the Official Prescription Program and similar programs on physician prescribing. Official Prescription Program data has never resulted in an investigation or disciplinary action against a health professional.

Significant reductions in the prescribing of Schedule 2 controlled substances in Texas, Rhode Island, New York and Idaho have been recorded in states imposing official or triplicate prescription programs. A 1992 article reports reductions of 64% in Texas, 57% in Rhode Island, 54% in New York and 50% in Idaho.

Supporters/Opponents
The bill is supported by Hospice of Michigan, the Michigan State Medical Society, the Michigan Osteopathic Association and other pain management advocates.

Fiscal Impact
Revenue from $20 set aside for the Fund was over $1.1 Million in FY 1999. Total expenses were about $750,000. Fund balance at the end of FY 1999 was nearly $1.3 Million.

Administrative Rules Impact
The bill will not result in new administrative rules.