Hoping to stem the abuse of prescription painkillers, Minnesota regulators have sent letters to more than 2,400 health care providers warning of patients who may be “doctor shopping” to obtain drugs illegally.

The letters identify people who have obtained large quantities of drugs from multiple doctors and pharmacies. In the first 10 months of this year, the state Board of Pharmacy flagged about 194 patients.

The unusual step represents an aggressive new enforcement tactic by the state’s Prescription Monitoring Program. It also has triggered a debate over the privacy rights of patients and the risk of smothering doctors in paperwork.

The prescription registry was created five years ago for physicians to check whether their patients were visiting other doctors to obtain large amounts of pain pills, sedatives and other drugs of abuse. But doctors are not required to run a patient’s name through the database before writing a prescription for a controlled substance. And some 30 percent of Minnesota’s top 4,000 prescribers did not even have an account with the system in 2014.

“We would like to see more use of — and mandatory use of — the Prescription Monitoring Program by all prescribers,” said Jerry Kerber, inspector general of the Department of Human Services, which oversees health insurance for hundreds of thousands of Minnesotans using Medicaid and MinnesotaCare.

Kerber said the department found one person with 55 different prescribers for controlled substances.

“We are talking about people that are using the health care system in ways that are unfathomable to most of us,” Kerber said.

Records also showed two people who had made more than 130 trips to the emergency room in one year, which can be a strategy to get drugs from an unsuspecting physician. Often, these patients have mental illnesses but are not getting treatment.

But the executive director of the Pharmacy Board, which runs the registry, says the state shouldn’t require doctors to use it for every patient.

“We think [mandatory use] is going add a huge burden to health care professionals out there,” said Cody Wiberg. “We are still convinced that the vast majority of prescriptions are not issued for any nefarious reason. Most people aren’t doctor shopping.”

Surge in overdose deaths

Minnesota is one of 49 states with a program to monitor prescription drugs. Most are relatively new and reflect surveys showing an epidemic of prescription drug abuse, which by some estimates now exceeds the use of street drugs. Overdose deaths from prescription drugs exceeded heroin overdoses last year, according to the U.S. Centers for Disease Control and Prevention.

To improve the performance of Minnesota’s registry, Wiberg favors a law that would simply require all prescription writers to have accounts with the system. That way, a doctor will have access when needed.

A law that would have required doctors to register failed in the 2015 Legislature.

“It wasn’t the right time yet to force them to do it,” said Rep. Dave Baker, R-Willmar. “I wish providers would voluntarily see the need rather than the Legislature mandating it.”

Baker knows how addiction can spiral out of control. His son Dan died of a heroin overdose in 2011 at age 25. Dan’s drug use started with pain meds for a back injury.

“The pills got ahold of him,” Baker said. “The more you are on it the more your body will expect it and demand it.”

If the drug registry had been in place then, Dan’s doctor-shopping might have been detected, Baker said. “I absolutely believe that doctor shopping has gotten reduced because of this program,” Baker said. “I don’t know if it is stopping the problem. That is the biggest question.”

In the absence of mandates, Wiberg said mailing physician alert letters could increase the program’s usefulness. “Here’s an alternative that might make this program more effective than requiring use 100 percent of the time.”

But privacy advocate Rich Neumeister, who serves on the program’s advisory board, said the change sacrifices individual rights. “If the state is making a decision to tell things about people, the subjects of those alerts should have knowledge of that,” Neumeister said. “I don’t think the advisory board or the pharmacy board itself knows the implications of this stuff.”

‘One front door’

Still, there is early evidence that the provider alerts are having an effect. Of the 194 people flagged as possible abusers, 88 percent subsequently dropped off the list after the state notified their prescribers, according to Barbara Carter, the program’s manager.

The system can’t detect addicts who found other sources for drugs — through theft, fraud or using street drugs. But a survey of providers who received the alerts found that some patients had been directed to treatment and others had been tapered down to safe levels of medication.

“I’m not hearing complaints about it, and I think most providers and physicians are finding it useful,” said Dr. David Thorson, who represents the Minnesota Medical Association on the program’s advisory group.

As part of a larger effort, the Department of Human Services uses the database to identify those among the 1 million members in state health insurance programs who might be gaming the system to feed an addiction. “We are convinced that it is saving lives,” said Kerber.

The agency’s program requires patients, once identified, to use only one primary care doctor, one pharmacy and one hospital. “It does not deny them services, but assures that they are getting the services they need only through that one front door,” Kerber said.

Wiberg said the board will continue to push for legislation that would mandate registration by all providers. Thorson predicted that the requirement would eventually pass.

Sen. Kathy Sheran, DFL-Mankato, a supporter of the alert system, said it’s a useful experiment that the Legislature will continue to monitor.

“Maybe this is a lot of money and effort to get little in return,” she said. “But there is no way of knowing that until we really try it.”