In 2009, as prescription opioid addiction rates soared, Oregon adopted a critical oversight tool meant to help address the crisis: prescription drug monitoring. The database of prescriptions could identify patients who were doctor-shopping and notify prescribers. Or it could alert oversight authorities to questionable prescribing practices by clinicians.
But Oregon was one of the last states to adopt the tool. And since it was implemented 14 years ago, Oregon’s prescription drug monitoring program has lagged behind other states in terms of the type of data captured, who has access to it and how it is being used.
Now, despite Oregon having among the highest rates of prescription opioid addiction, state lawmakers remain slow to make improvements that Oregon Secretary of State Shemia Fagan says could make a meaningful difference in the battle against opioid addiction.
“It’s really time to act to strengthen our toolkit for fighting the opioid epidemic.”–Ian Green, audit manager for the Oregon Secretary of State’s Office
In 2018, a report by the Secretary of State’s Audits Division highlighted a dozen critical points for improvement of the program, including requiring prescribers to register and use it and creating periodic report cards on prescriber activity. The changes required action from both the Oregon Health Authority, which manages the program, and the Legislature.
Over the next four years, Oregon fully implemented only four of those recommendations, prompting urgent calls from Fagan for more action.
“I will just say, that’s not good enough,” she said last June. “It is not. Legislative changes are needed to implement most of the outstanding recommendations.”
While fentanyl and synthetic opioids have increasingly driven overdose deaths, some state lawmakers hope to improve the prescription drug monitoring program. In the current legislative session, three bills seek to expand the Oregon Health Authority’s oversight and increase the rigor of the program.
But other recommendations are still going unaddressed, including those that raise concerns from legislators and advocates around patient privacy.
While legislators hesitate, however, the auditors who championed the improvements five years ago say the stakes are only getting higher.
“Frankly, Oregon has fallen behind,” said Ian Green, audit manager for the Oregon Secretary of State’s Office. “It’s really time to act to strengthen our toolkit for fighting the opioid epidemic.”
A public health, not a law enforcement tool
In the fight against the opioid crisis, the prescription drug monitoring program is useful in a few ways. When considering a prescription for a patient, a prescriber can check the system to see if that patient has recently received a separate opioid prescription or other medications that can be dangerous in combination with opioids. Pharmacists can also check before filling a prescription.
Limited individuals and groups have access to the data to help hold providers accountable for prescribing and dispensing drugs responsibly. They include medical directors, who oversee medical practices at hospitals and clinics, and the Prescribing Practice Review Subcommittee, housed within the state Prescription Drug Monitoring Program Advisory Committee, which is composed of doctors, dentists, nurses and a couple of members of the public.
If they spot questionable prescribing patterns, they can target the prescriber or pharmacy for outreach and education.
Some states embraced prescription drug monitoring programs as a law enforcement tool: According to the U.S. Centers for Disease Control and Prevention, the federal Drug Enforcement Administration originally funded the development and operation of most of them.
However, Oregon created its monitoring program with the prime focus on public health.
“The Legislature established the (prescription drug monitoring program) as a means for improving provider collaboration and patient outcomes, but the program is not a law enforcement, regulatory or insurance tool,” an Oregon Health Authority spokesperson said in a written statement.
In 2018, when then-Gov. Kate Brown declared the opioid crisis a public emergency, the Secretary of State’s Office conducted an audit of the system to determine whether it could be more effectively leveraged to tackle the crisis.
At the time, Oregon reported the highest prescription opioid abuse in the country, according to the National Survey of Drug Use and Health. Oregon teens reported the sixth-highest substance abuse in the country, the audit reported, and Oregon’s seniors led the nation in hospitalizations for opioid-related issues such as overdose, abuse and dependence.
Auditors spoke with stakeholders of all kinds across the state, including program staff, prescribers, members of licensing boards and staff from the Oregon Pain Commission.
They found significant shortcomings. For example, 33% of required prescribers weren’t actually registered with the program, and many of them weren’t checking the system regularly. Some of the dozen recommendations auditors made in that first report were within the Oregon Health Authority’s power to implement, but many others were dependent on legislative changes.
The drug monitoring program’s staff acted on a few of the recommendations, increasing efforts to enroll prescribers and creating quarterly prescriber report cards and reports to medical directors, which allowed for more transparency around prescriber practices.
But in the four years that followed, many more of the recommendations — about eight of them — were only partially implemented or not implemented at all.
Legislators and auditors say the COVID-19 pandemic played a role in the legislative inaction, as distribution of personal protective equipment and vaccines and dealing with crippling hospital staffing shortages catapulted to the forefront of public health priorities.
But the pandemic amplified the drug crisis, too. Deaths from all opioid-related overdoses, including prescription, synthetic opioids and heroin, substantially increased from fewer than 400 in 2019 to more than 600 in 2021, annual data from the OHA showed.
While prescription opioid-related overdoses and deaths make up fewer than 200 of those deaths annually, OHA data showed that they nevertheless increased in 2021 after steadily declining for several years. On a national level, Oregon became less of an outlier in its rates of prescription opioid abuse among people 12 and up: The rates of several states surpassed the Beaver State in 2021, according to National Survey on Drug Use and Health data.
A few months after the blistering 2022 follow-up report to Oregon’s 2018 audit, Green and Kip Memmott, audits director for the Secretary of State’s Office, presented an update to the Joint Committee on Legislative Audits in December.
Their presentation elicited strong reactions from the legislators in that committee. Several expressed an eagerness to move forward with the remaining recommended improvements.
“I really hope we would … collectively come up with kind of an omnibus bill that addresses these issues,” said Rep. Greg Smith, R-Heppner, at that time. “To me, this looks like common sense.”
Smith and Rep. Nancy Nathanson, the Eugene Democrat who co-chaired the committee, did not respond to two emailed requests for interviews on what follow-up efforts the committee members made after hearing the presentation from Green and Memmott.
Some action, ongoing hesitancies
Rep. Bobby Levy, a Republican from Echo, introduced a bill in January that would address one of the most pressing recommendations from the audit about the prescription drug monitoring program.
House Bill 2642 would require all prescribers to check their patient’s prescription history before prescribing any drugs tracked in the program. The intention is to increase vigilance against doctor-shopping and potentially dangerous prescription combinations.
At the time the first audit made that recommendation, Oregon was one of only nine states that did not have such a requirement enshrined in law.
Levy cited broad concerns about addiction in Oregon as reasons for filing her bill: rising numbers of fentanyl overdose and her concerns about the implementation of Measure 110, which decriminalizes possession of small amounts of drugs including heroin and meth.
“I could go on and on,” she said in an email. “We are not doing enough. We need to look everywhere a drug addict can get their choice of fix. This is just one of the ways.”
Another measure, House Bill 3258 filed by Rep. Tawna Sanchez, D-East and Northeast Portland, would require the program to begin tracking federal Schedule V drugs. Drugs in the classification contain limited amounts of certain narcotics, such as codeine.
Both Levy’s and Sanchez’s bills have been referred to the House Committee on Behavioral Health and Health Care. Only Levy’s bill has been scheduled for a public hearing, on March 27.
A bill from Sen. Sara Gelser Blouin, D-Corvallis, has stirred up more reaction, however. That measure, Senate Bill 559, would require veterinarians to register with the monitoring program, another recommendation from the audit. That has sparked opposition from veterinarians around patient privacy and other concerns.
The Oregon Veterinary Medical Association asked the Legislature to take “a deeper look to determine the prevalence of veterinary drug shoppers and to clarify the degree to which veterinary prescriptions impact the human opioid epidemic.”
Similar concerns about privacy of patient data have made Oregon’s legislators balk at pursuing recommendations to allow regulatory bodies and law enforcement more access to drug monitoring data.
Currently, Oregon law requires a warrant for law enforcement to access prescription drug monitoring data, and health licensing boards only get access if they have an open investigation into a medical provider. By contrast, a majority of states allow for proactive reports to be made to health licensing boards, which can lead to additional training and intervention outside of any discipline, Green said. And 21 states allow for reports on suspicious prescribing to law enforcement, according to the Secretary of State Audits Division.
The Oregon audit asserted that allowing law enforcement more open access to the data can save agencies time and money during investigations.
Green said concerns about patient privacy are “certainly legitimate.” But the Legislature could, for example, ensure that proactive reports could focus solely on prescribers and not patients.
“The worst of the worst of the pill mills,” Green said.
But others still harbor doubts. Kelly Simon, legal director for the American Civil Liberties Union, said the potential for law enforcement abuse of increased access to prescription drug monitoring data is too high a price to pay. It is an issue the ACLU has successfully litigated before, in an instance when the Drug Enforcement Agency sought access to information from the database without a probable cause warrant.
“Warning flags go up for me when I hear about proactive sharing of private health information with law enforcement,” Simon said. “Oregonians consistently say drug use is a public health issue for us, not a criminal issue … I think Oregon’s statutory protections that require law enforcement to get a warrant is exactly the right standard.”
Amid all of the urgent needs presented by the pandemic, Sen. Deb Patterson, chair of the Senate Health Care Committee, said changes to the prescription drug monitoring program have “not been a topic of conversation that I’ve been privy to … I’m still on the learning curve.
“The OHA does cooperate with all law enforcement requests with a court order and board requests related to investigations,” the Salem Democrat said. “To date, the Legislature maintains (the prescription drug monitoring program’s) primary purpose is to support safe prescribing decisions.”
Kaylee Tornay - InvestigateWest
Kaylee Tornay has been documenting stories in Oregon and California since her high school journalism days in Bend, Oregon, covering the progress of the water polo team. A graduate of the University of Oregon, she braved the rains of Eugene with her notebook before moving on to cover wildfire mitigation and dangerous highways in the forests and vineyards of Southern Oregon and Sonoma County. Reach her at [email protected].