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A conversation with CSRS administrator William D. Bronson
The NC Department of Health and Human Services implemented the Controlled Substances Reporting System (CSRS) two years ago to monitor outpatient dispensing of prescription controlled substances on a statewide basis. The system is authorized by a 2005 state law, which clearly states the CSRS's purpose: To "improve the State's ability to identify controlled substance abusers or misusers and refer them for treatment, and to identify and stop diversion of prescription drugs in an efficient and cost-effective manner that will not impede the appropriate medical utilization of licit controlled substances."
The law requires all outpatient dispensers of controlled substances in North Carolina to regularly report prescription data to the CSRS. Eligible prescribers (medical practitioners must hold either a valid DEA registration or a valid pharmacist's license to view data) may register for access to the system, for the purpose of viewing individual patients' prescription profiles.
Since the system went live in July 2007, more than 4,200 physicians, physician assistants, nurse practitioners and other prescribers have signed up to access CSRS data, and that number is growing every week. Recent changes authorized by the NC General Assembly would eliminate tight controls that make it unlawful for prescribers to discuss a patient's CSRS prescription profile with other clinicians. This change, which the NC Medical Board requested after licensees brought their concerns about the system to its attention, should make it easier for prescribers to use CSRS data in planning and coordinating treatment for their patients. The Board appreciates the gracious cooperation of Sen. William R. Purcell, MD, who agreed to amend his bill to include the requested changes.
NCMB Public Affairs Director Jean Fisher Brinkley recently spoke with William D. Bronson, who oversees the NC Controlled Substances Reporting System. They discussed how clinicians can use the system to greatest effect.
Q & A
Under what circumstances might a physician check a patient's prescription profile with the CSRS?
They should be doing it to provide care to an established patient. It is not intended to be used as a means of deciding whether to take on a potential patient who's coming in.
What information would a query to the CSRS on a particular patient return?
It would indicate the date a prescription was dispensed, the amount dispensed, whether it was a refill or a new prescription, the number of refills, the pharmacy where it was dispensed and the practitioner who wrote the prescription. It will also indicate the patient's name and address.
How should physicians and other prescribers be using this data?
To provide better care for their patient, not to exclude patients. If the data reveal that the patient may be seeking large quantities of controlled substances or seeking prescriptions from multiple providers, then the practitioner should discuss this with the patient and offer help.
Are you aware of situations where prescribers are using data obtained through the system to "fire" a patient?
Yes, not only to fire a patient, but to exclude. We've heard of a couple of situations where a pain management specialist decides that a patient is doctor-shopping and, based on what he sees in the CSRS, decides not to take on that patient. That is not an appropriate use of the system. We've also heard of numerous cases where, based on the data, physicians have dismissed an established patient. I don't mean to suggest that they can't or shouldn't do that. But there's a right and a wrong way to do it. It's complicated. First, we've had several instances where the data has been wrong and the patient has been right and the physician hasn't believed the patient. And potential harm may come to the patient when a physician decides to exclude them. The fact that they've been labeled or branded as a doctor-shopper follows them and then other physicians decide not to take them on.
What would be a preferable response?
If a patient is starting to see different doctors, the physician can establish an agreement or contract with the patient that he only sees one physician or that he notify and get approval from his physician to see another physician. If that contract is violated, you don't need to throw the patient out. It may be an opportunity to expand the care. Maybe refer that patient to more specialized care or to a substance abuse program, that kind of thing. Would you dismiss a cardiac patient for not following his or her diet? Ultimately you're going to have some patients who are ripping off the system and playing games, and then, after you've tried to intervene and refer them for care and all of those things you've attempted, and documented and sat down with the patient and talked about have failed, then it's OK to dismiss them.
But it shouldn't be the first action you take.
Correct. You may be able to use the data to take a different approach. For example, an emergency room doctor who checked on a patient may say, 'I don't want to give this person an opiate. I'm going to give them something else because they’ve gotten a lot of opiates.' It can be useful in deciding what kind of treatment you're going to provide.
What if a patient claims that the information the CSRS has on them is not accurate?
Believe them. Sit down and discuss it with the patient. Either the doctor or the patient can contact us and we can help sift through what is accurate and what is inaccurate in the system. Don't just assume that it's a doctorshopper and because he's an addict, he's lying. He might be, but he might not be. We've had too many occasions where either there's been a mistaken identity or the dispensing pharmacy has loaded up the wrong DEA number so the wrong prescriber is on there, or other things like that. Give the patient the benefit of the doubt, at least the first time. Then inform the patient you are going to follow them very closely.
Could you go over the protocols for accessing the CSRS? Who is authorized, within a medical practice, to access the system?
The prescriber or dispenser. Period. Only the person with that log on, not their nurse, not their office manager, not another prescriber. Each practitioner in the office has to have their own login. Currently,
that's all that's permitted under the law. There's another practice I see doctors doing that is unlawful, and that is calling up the police. You can't do that. You cannot release this data to the police.
Is there anything else you'd like to mention that you feel is important for physicians and other prescribers to understand about the CSRS?
We would eventually like to see this become a standard of care in prescribing controlled substances. Our hope is that checking the system becomes an accepted part of practice. A physician would not be doing his or her best if they didn't check the system. The other message is that this needs to be seen as a tool and not as the gospel truth. It's one piece of the puzzle just like an X-ray or a lab test or anything else. And it should be used in combination with all the other stuff. Physicians should not be relying on it as a standalone item when making patient care decisions. We hope this tool can assist
a physician in providing appropriate care for the patient, including a referral for treatment if indicated.
If you're using the system, tell your patients you're doing it. Don't do it behind the patient's back. Practices can post a sign in their waiting rooms that says, 'We use the Controlled Substances Reporting System when prescribing controlled substances.' That will chase the riffraff out of their offices. Also, to help prescribers become more comfortable with confronting patients -- prefer to call 'carefrontation'-- would suggest learning more about SBIRT, which stands for Screening, Brief Intervention and Referral for Treatment. This is now a billable service. You can learn more about SBIRT by visiting www.samhsa.gov which is the Internet site for the U.S. Substance Abuse & Mental Health Services Administration.
Sign up to use the system
Clinicians who want to check a patient's controlled substances prescription profile must register for access with the NC Controlled Substances Reporting System. To qualify, you must be authorized to prescribe or dispense controlled substances for the purpose of providing medical or pharmaceutical care for patients.
How do I sign up for access?
Download and complete a short enrollment application from the CSRS website. Please note that the form must be notarized and mailed with a copy of a photo ID and signed copy of a privacy statement to the CSRS. Approved applicants will be notified via e-mail, typically within two weeks.
Once I get access, who in my practice may use my login to query the CSRS database?
Because of strict confidentiality provisions in the law, only the registered practitioner may access the system. The law prohibits other members of the practice from using it.
How often is the database updated?
State law requires outpatient dispensers of controlled substances to report prescription data to the CSRS at least twice a month, on the 15th and the 30th, so it may take up to three weeks for a prescription to show up in the system. A bill recently passed by the General Assembly would require dispensers to report no later than seven days after the prescription is dispensed, starting January 2, 2010.
What if I have concerns about accuracy of the data, or a patient questions its validity?
Contact John Womble or William D. Bronson at the Division of Mental Health, Developmental Disabilities and Substance Abuse Services, Drug Control Unit at 919-733-1765, Monday through Friday between 9 a.m. and 5 p.m.).
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