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Source: Dickson Herald

Date: 4-Feb-2007

Author: Jennifer Brooks

It takes 15 prescriptions and an oxygen tank to get Amy Wilson through the week.

There are pills for her diabetes, pills for her high blood pressure and pills to control the autoimmune disease, polymyositis, that is attacking and weakening her muscles and lungs. The 48-year-old Antioch woman is just one of the many desperately ill Tennesseans who are driving the state's sky-high rate of prescription drug use.

Tennesseans use more prescription drugs than any other state in the nation — an average of 17.3 prescriptions for every man, woman and child, according to a new study by BlueCross BlueShield of Tennessee.

The state's prescription drug spending topped $7 billion in 2005, according to the insurer's latest report. The national average is 11.3 prescriptions per person.

That figure includes everything from people who take dozens of pills per day to people who take a single prescription but refill it every month and are recorded as taking 12 prescriptions that year.

"Anybody that's taking the number of pills I am is doing it because they have to," Wilson said. "Nobody wants to take 15 pills. I dread it."

State low on health scale

By most accounts, Tennessee is an unhealthy state, full of unhealthy people, who may be using an unhealthy amount of prescription drugs.

Tennessee ranks 47th nationwide in the health of its residents. It has some of the nation's highest rates of drug-resistant infections and accidental drug overdoses. Prescription narcotic abuse is a growing problem. And the state has an imperfect system for tracking prescription trends and intervening to counsel doctors who may be over-prescribing to their patients.

"We are over-prescribing. That much is clear," said Dr. William Schaffner, an epidemiologist and chairman of preventive medicine at the Vanderbilt University School of Medicine. "It's not that the doctors in all the other 49 states are getting it wrong and we're on the right track. ... It's a matter that has puzzled us for some time."

Over-prescribing an issue

But despite years of evidence that Tennessee's prescription rates are far outside the national norm, no one can agree on the reasons why.

Some blame TennCare and its generous prescription drug benefits. The 2005 figure reflects the first year the state made a concerted effort to clamp down on prescription benefits.

Terry Shea, director of pharmaceutical services for BlueCross, points out that the state's prescription drug rates did decline from the previous average of 18.1 prescriptions per person.

In August of 2005, the TennCare Pharmacy Program began limiting the majority of enrollees to just five prescriptions per month, only two of which could be brand-name drugs. Those limits were relaxed somewhat in 2006.

There are also widespread concerns about the way Tennessee monitors and educates its physicians. Some parts of the state, particularly rural and eastern counties, have much higher rates of prescription use than others.

In Morgan County, near Knoxville, BlueCross found a 4,853-day supply of Schedule II narcotics had been prescribed for every 1,000 of its members, while the statewide average was a 1,000-day supply.

Drug enforcement officials keep a close eye on doctors and pharmacies that may be dispensing drugs for illicit use — such as the recent arrest of Williamson County Sheriff Ricky Headley and a Crieve Hall pharmacy owner on prescription drug fraud charges.

But there is equal concern about doctors who may be over-prescribing to their patients with the best of intentions — giving patients antibiotics because patients expect them when they come in with the flu, or writing a prescription for a pill patients may have seen on TV for a condition they think they might have.

The most commonly prescribed drug in Tennessee is hydrocodone, a narcotic that accounts for 2.8 percent of all the prescriptions in the state, according to the BlueCross study. Rounding out the top 10 were Lipitor, which treats high cholesterol; Nexium, which treats heartburn and indigestion; Alprazolam for anxiety; Levothyrxine, for thyroid problems; the blood pressure medication Lisinopril; Zyrtec allergy pills; the diuretic hydrochlorothiazide; Azithromycin, an antibiotic; and the diabetes treatment Metformin HCL.

Database to track doctors

Drugs save lives, but too much of a good thing can be costly in more ways than one.

Tennessee has some of the highest rates of antibiotic-resistant diseases in the nation, according to the Centers for Disease Control.

Its rate of accidental poisonings is also 26 percent higher than the national norm — a statistic the BlueCross study pins partly on bad drug interactions and patients confused by large amounts of drugs. And the Institute of Medicine estimates that accidental drug overdoses in Tennessee hospitals alone cost the state $791 million annually.

"Getting too many prescription drugs is as bad as not getting enough," said Bill Cecil, director of health policy research for BlueCross and one of the authors of the new study.

There has been a concerted effort in recent years to improve prescription monitoring in the state. The Tennessee Department of Health has launched a Physician Prescribing Task Force to study the prescription habits of the state's doctors.

The Tennessee Board of Pharmacy's new Controlled Substance Database will help regulators track doctors and pharmacies that seem to be dispensing suspicious quantities of prescription narcotics and other controlled substances.

The Tennessee Medical Association has identified over-prescriptions as one of its top priorities. It has received a federal grant to study the state's prescription drug patterns. It also is working to formalize controlled substance monitoring in the state.

State Rep. Joey Hensley, a practicing physician who battled the proposed cuts in the TennCare prescription program, believes that Tennessee's prescription rate simply reflects its large population of poor, sick and elderly residents.

"It's not necessarily a bad thing," Hensley said. "To me, that high number means we have a high number of sick people. I'm certain there are physicians who over-prescribe, but I don't think that a big percentage of doctors do."

While doctors and academics and public officials debate the state's prescription problem, Wilson keeps doing what she has to do to survive. She particularly dreads Mondays, when she takes the drug methotrexate to help her weakened system fight off infections. It's a harsh drug, developed to help cancer patients, and she knows how horrible it will make her feel.

"You just do what you have to do," she said. "If taking all these drugs means I can live at home, instead of going into a nursing home, that's what I'm going to do."