In October of 2003, Jimena Barreto lost control of her Mercedes, running into and killing Bob Pack’s 10-year-old son Troy and 7-year-old daughter Alana. Barreto was under the influence of alcohol and prescription painkillers. She had been doctor-shopping, going from one physician to another to get multiple prescriptions for the drugs she craved.
Pack questioned how authorities could not have noticed someone obtaining an exorbitant amount of pain pills, and wondered why there was no system in place to monitor such action. He later learned that the state of California does have a Prescription Drug Monitoring Program, the Controlled Substance Utilization Review and Evaluation System (CURES). Pack also learned that CURES is both technologically inadequate and critically underfunded.
However, those shortcomings may soon be a thing of the past. State Senator Mark DeSaulnier (D-Concord) has introduced Senate Bill 809, which proposes funding measures to upgrade, operate and enforce the CURES program.
“It’s really frustrating for me because I’ve been at it for so long,” said Pack, who operates a mobile shopping application start-up in Danville. “I’m hoping this Senate bill finds its wheels and makes it through.”
The way CURES is supposed to operate is straightforward. Pharmacists are required to enter into the CURES database Schedule II through IV drugs that they’ve dispensed. Pharmacists, physicians who prescribe these drugs and law enforcement have access to the database. The purpose is two-fold: keep an eye out for patients that are doctor shopping, as well as doctors that are over prescribing dangerous, addictive pills.
Because of inadequate funding and outdated technology, the CURES program faces a number of shortcomings. Fewer than 13,000 out of a potential 200,000 subscribers are currently enrolled in the program. But even if everyone eligible were to sign up, the system as currently constructed would be unable to support them all, according to people familiar with CURES. And because of recent budget cuts, the program faces suspension as of July 1.
“It’s bare bones,” said Travis LeBlanc, special assistant attorney journal for the California Department of Justice. He said budget cuts have created delays in registering new users, updating the system, and supporting complicated queries to track doctor shoppers. “Bare bones means we have minimal employees working on it. They barely just keep the database up, that’s all they do. We’re dealing with a system that was created largely in the 20th century and we’re trying to use that now in the 21st century. There’s a lot of good reasons to invest in this, but bare bones is not good.”
Dr. Christy Waters, a psychiatrist with Kaiser Permanente, has been a member of the California Society of Addiction Medicine for 10 years. For the past six years, she’s acted as the chairperson of the CSAM’s Public Policy Committee. She characterized her recent interaction with CURES as being in “no man’s land.” She described the burdensome process of filling out an application, having it notarized, getting locked out of her account, and finding that no one is available to answer questions because of budget cuts.
“It really is a painful nightmare,” Waters said, noting that most physicians already have their plates full. “It just kind of limps along. It’s such an inadequate vehicle to do work that is so critically important.”
“The system itself from just a mechanical point of view doesn’t work very well,” Waters added. “But if you can log on, and you can get a hold of the information by logging on, then yes, it’s very helpful and it’s very effective.”
Senate Bill 809, co-written by DeSaulnier and Senate President Pro Tem Darrell Steinberg and sponsored by Attorney General Kamala D. Harris, promises to upgrade, fund and enforce the CURES program. A one-time tax assessment on health insurance plans and workers compensation insurers will fund software and hardware upgrades for the system. CURES would be maintained through an increase in licensing fees on medical professionals who prescribe or dispense Schedule II through IV drugs. The fee works out to about $2 for pharmacists and up to $10 for podiatrists, who pay the highest license fees. The bill also includes a tax on pharmaceutical manufacturers of Scheduled II through IV drugs to establish and support enforcement capabilities. The total cost of the bill in its first year is under $10 million.
Senate Bill 809 also includes a requirement for practitioners and pharmacists to register for CURES and consult the program, but the mandate would not take effect until the state completes the system’s upgrade in approximately two years.
“I think it’ll make a serious dent in prescription drug abuse, particularly the growth of it,” DeSaulnier said.
Pack’s story moved DeSaulnier, and this is his third attempt at getting legislation through to support CURES. The senator credits media attention to the effects of prescription drug abuse as one of the reasons why his current effort has a chance of being successful. He also cites the under $10 million price tag.
Aside from Pack’s story and others, DeSaulnier didn’t have to look far to find a personal connection to the plague of prescription drug abuse.
“My dad had substance abuse problems,” DeSaulnier said. “He was an alcoholic. He used prescription drugs, both antidepressants and pain killers, and he ended up committing suicide, so I have an interest from that personal perspective.”
Jon Roth, the Chief Executive Officer of the California Pharmacists Association, describes CURES as currently situated as “suboptimal.” He wants to see a database that is accurate and can combat patients altering identification, and will also not mistakenly deny patients who need pain medications.
Roth said that the CPhA supports SB 809, but doesn’t think funding options should be limited to fees on licenses. He is also concerned about what he called “uncoordinated enforcement activities” between the Attorney General’s office and the California boards of medicine and pharmacy.
“To me the principle of a prescription drug monitoring program is something we fully support,” Roth said. “We think pharmacists need to be part of the solution to prescription drug abuse in California.”
Waters echoed Roth’s concern with where the funding for SB 809 is coming from.
“We think everybody should be helping out, in particular we think the pharmaceutical companies should be helping out because they’re the ones that make the drugs,” she said.
However, Waters also supports a more robust, effective CURES program. She’d ultimately like to see the ability to share data with other states to track folks crossing state lines to fill prescriptions.
Dr. Itai Danovitch, Chairman of the Department of Psychiatry and Behavioral Neurosciences at Cedars-Sinai Medical Center in Los Angeles, describes CURES as “clunky” and “cumbersome.” He proposed a larger database that checks for any prescription conflicts, not just scheduled pain pills, to avoid any potentially negative interactions.
For now, Pack is optimistic that SB 809 will pass and a better funded, updated CURES will more effectively track those who doctor shop and physicians running pill mills.
“They’re equally bad,” Pack said. “They really go hand in hand.”