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PRESCRIPTION FOR AN EPIDEMIC

Drug Firms Battle Rule on Prescription Forms

Law: 'Triplicate' system hurts sales, is resented by doctors as inhibiting care. But police say it deters forgery.

August 19, 1996|DAN WEIKEL | TIMES STAFF WRITER

Printed on bank note quality paper, they measure about 8 by 5 inches. Each bears a number. Doctors and dentists are required to sign them. Copies go to the state. They are called "triplicate" prescription forms, and never has a pad of paper so small ignited so much political heat. Law enforcement officials contend that triplicates help them track pill-pushing doctors, deter prescription forgery and put a dent in drug abuse.

Physicians call the forms an intimidating intrusion into their practices and into the privacy of their patients, possibly inhibiting some doctors from providing needed medications.

Pharmaceutical companies, meanwhile, see triplicates as a threat not only to patients but to profits because of the precipitous drop in sales of drugs once triplicates are required.

For years these powerful forces have collided in state after state. Along the way, both the rhetoric and campaign contributions have flowed.

"Triplicates have been the single most divisive element in the attempt to deal with prescription drug abuse," said Bonnie B. Wilford, director of the Pharmaceutical Policy Project at George Washington University in Washington. "The divisions are so deep I know people who won't even talk to each other over the issue anymore."

Wilford said she watched 10 years of work unravel as the triplicate controversy plowed a rift in the National Steering Committee on Prescription Drug Abuse. The panel, which was organized after a White House conference in 1980, had dissolved by 1990.

"The American Medical Assn. opposed them. Law enforcement wanted them," she said. "It was the 500-pound gorilla that sat in the middle of all our discussions. It drew the energy right out of the committee."

Triplicate prescriptions are used for Schedule II drugs, a ranking under state and federal law for medications with a high potential for abuse. The category includes amphetamines, barbiturates, codeine, morphine, methadone, methylphenidate or Ritalin, and synthetic opiates, such as Dilaudid and Demerol.

When a triplicate is issued, a copy goes to the doctor, the pharmacy and the state agency that monitors controlled substances. By looking for odd sales patterns, regulators say they can ferret out drug dealing professionals, prescription thefts and people who trick physicians and pharmacists into prescribing them drugs.

Today, no more than 10 of the 50 states have triplicate programs because of intense political opposition from medical societies, drug companies and patient advocates.

Opponents offer a variety of criticisms--all countered with equal fervor by advocates. Among the most enduring and potent complaints is that doctors will prescribe weaker, less effective drugs to avoid having state authorities looking over their shoulders.

"The head of the AMA once said the war on drugs should not become a war on patients and their doctors. I'm afraid it has become just that," said Harvey L. Rose, a Sacramento-area physician at the forefront of the effort to change state policy related to prescribing narcotics.

The California Medical Board prosecuted Rose in 1981, alleging gross negligence and incompetence in prescribing powerful pain relievers. Though the charges were sustained, the case was dismissed on appeal because the state lost his trial transcripts.

Rose likes to point to the case of Tracy Temp, a 29-year-old athlete and college student from Contra Costa County who committed suicide after pain from an immune system disorder rendered her an invalid. In her note, she complained about her doctor.

"I only wish you knew how horrible it was to hear your detached voice going on about doses and the federal drug people," Temp wrote. "I can't stand to live with this constant replay on pain, and you're worried about someone. . . . I think you want me to go to another office so you won't look bad."

Research from Brandeis University in Massachusetts shows that where triplicates are mandated, doctors have, in fact, shied away from using the most powerful narcotics for broken bones, muscle or joint injuries and ill-defined pain. According to the study--an analysis of 40,000 office visits to 1,500 doctors--prescriptions for cancer patients were unaffected.

Researcher Linda Wastila cautioned that she did not try to gauge the quality of care.

Other studies indicate that, after triplicates are required, states generally experience a 30% to 50% drop in the prescribing of Schedule II drugs. Though the research does not prove that the quality of care suffers, triplicate opponents say they believe patients are not getting the most appropriate medication.

"Triplicates result in the use of less effective and more risky drugs," insisted David E. Joranson, a research director at the University of Wisconsin-Madison Medical School. "Many doctors say they don't even keep the forms in the office."

The Counterattack

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