Auditors found indications of doctor and pharmacy shopping, including one person who filled nine prescriptions in a 30-day window at four different pharmacies.
They also found more than 1,000 likely incorrect birth dates for people in the system, and prescribers writing prescriptions without licenses, though representatives with the state Board of Pharmacy said auditors didn't take into account everything that could have led to their findings.
The Montana Prescription Drug Registry went into effect in 2012. It is administered by the Board of Pharmacy, which is under the Montana Department of Labor and Industry. The cost for the registry over the last seven years has been about $1.8 million, and it's now primarily funded by fees paid by prescribers and pharmacists.
The registry tracks medications that are prescribed and dispensed within the state or to Montana residents. It had been voluntary until the most recent state Legislature passed a bill to require every person who is licensed to prescribe or dispense prescription drugs to register. That takes effect this fall. Previously, the registry had been used by about 54% of those who were eligible.
The registry is mainly used by medical providers and pharmacists to search a patient's medical history to learn about their past and current prescriptions. It has a secondary use by law enforcement officers, who obtain subpoenas.
The registry could also be used to flag people who are shopping around for multiple doctors and pharmacies in order to obtain and potentially misuse or divert medications.
Auditors, however, found the Board of Pharmacy does not review or analyze the data in the registry to find those potential abuses. State law allows for that type of proactive use, but does not require it.
The system instead relies on doctors and pharmacists to “make their own conclusions” about a patient’s records, according to the audit.
Auditors tended to qualify their findings in the report by saying that other problems within the registry — such as a lack of oversight or review of the accuracy of information put into the system — could skew outcomes.
Still, they raised concerns about records showing 4,410 patients who went to four or more pharmacies or prescribers in a 30-day window, and 8,814 who did the same in a 60-day period. That type of behavior could indicate doctor or pharmacy shopping to misuse or abuse prescription drugs.
In one example, a patient got nine prescriptions for high-strength opioids from four doctors in a 30-day window, and filled the prescriptions at four different pharmacies in Kalispell, Helena, Spokane and Whitefish. In a single day, the person had two prescriptions written for OxyContin from two different doctors.
In another case, a person got 11 prescriptions from nine prescribers in a 30-day stretch and filled them at five pharmacies.
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Auditors also found concerns with missing and nonsensical data, as well as inconsistencies in data reporting. The department disputed some of how auditors interpret their findings.
In some cases, the auditors found more than 1,000 dates of birth for patients in the registry that were “unreasonable." Four records had dates listed in the future, 231 had invalid dates like 01/01/0001, 50 had birthdays before 1900 and the rest had dates before 1912, which the auditors found unlikely to be accurate.
Marcie Bough, executive officer of the Board of Pharmacy, told lawmakers on the Legislative Audit Committee that met Tuesday not all those incorrect dates represent something wrong. Pharmacists, Bough said, would use nonsensical birth dates for things like animal prescriptions, which can be distributed from regular pharmacies.
The audit found several potential issues related to prescription dates and refills, such as inaccurate tracking of the number of refills a patient received or prescriptions being refilled for longer periods of time, or more frequently than they should be.
Bough said data sometimes don't present a full picture of a medical situation.
"Just because the data shows a threshold has been hit doesn't necessary mean there’s anything wrong with those prescriptions," Bough said.
Since the board does not review or validate incoming prescription data, it’s impossible to tell whether what auditors found shows abuse of prescription drugs, problems with data provided or a mix of both, according to the audit report.
The pharmacy board has already addressed many of the issues raised in the audit, said Kathleen O’Leary, deputy commissioner of the Department of Labor and Industry. Other issues will be addressed as the board moves to an updated registry system, which it received money to purchase in the 2019 legislative session.
The new system should help the board identify possible cases of use and misuse in a more proactive way, wrote labor Commissioner Galen Hollenbaugh in a response to the audit. The report says using the registry that way would also make the state eligible for increased grant funding.
The abuse of prescription drugs is a major problem in Montana, with the Department of Justice estimating one in 10 state residents are either dependent on or abusing drugs, including prescription medications.
O’Leary told lawmakers Tuesday drug overdose deaths in the state have dropped in recent years, from 9.4 per 100,000 people in 2006 to 4.2 per 100,000 in 2016.
“We’re not saying that the registry alone accounted for that decrease, but it’s just one of the many tools used across the state to deal with this epidemic,” O’Leary told the committee.