CHICAGO - When a new patient comes into Dr. Shawn Jones' office in Paducah, Kentucky complaining of pain and asks for a specific drug without talking about other symptoms, Jones gets suspicious.
"The first thing they say is they're in horrible pain and they need pain medicine," said Jones. "The other thing that gives it away is they want to tell you what works - they tell you they want Percocet. They don't talk about their symptoms - they don't say, 'Oh, two weeks ago I hurt my back.'"
These are the types of red flags that can send Kentucky doctors to check a state database to see if a patient is "doctor shopping" for addictive painkillers.
Prescription drug abuse kills more people a year in the United States than cocaine and heroin combined, according to the Centers for Disease Control. A CDC report last year said 15,000 people died as a result of overdoses of prescription painkillers in 2008 - more than three times the number in 1999.
Kentucky is a hot spot. Nearly 1,000 people in the state died from prescription drug overdoses in 2010, or about three a day, ranking it among the top states for such deaths.
In America as a whole, about 12 million people aged 12 and older reported non-medical use of prescription painkillers in 2010.
Abusers and dealers typically get drugs by finding doctors willing to prescribe them, forging prescriptions, theft from pharmacies or individuals, or buying from "pill mills" - storefront clinics that sell painkillers for cash up front.
State databases such as one used in Kentucky are designed to address the first problem - to alert prescribers that someone may be abusing drugs or diverting them for illegal sale.
Forty-three states now have databases to keep track of who is getting prescriptions for powerful pain relievers such as oxycodone, Vicodin and Opana.
Pharmacists enter prescriptions for controlled substances into the database, so prescribers can see if patients are getting pills at multiple locations.
Another five states have passed laws to create databases, but have not yet implemented them. Missouri and New Hampshire do not yet have such laws, though they have been introduced in the legislatures, according to Sherry Green, CEO of the National Alliance for Model State Drug Laws. There is no national database, though more states are sharing information.
For some doctors, running a "PMP" - shorthand for a Prescription Monitoring Program report - has become as normal a part of seeing new patients as measuring blood pressure.
But the programs have not been without controversy, with a major issue being whether doctors should be required to check the database when prescribing addictive medicine, or whether this should be left to their discretion, said Green.
Some doctors have expressed fears that PMPs could breach patient confidentiality and interfere with needed treatment of pain or could be used against doctors who need to prescribe a lot of pain medicine.
Doctors also object to proposals they see as putting law enforcement above health care. Citing privacy concerns, the Kentucky Medical Association fought successfully against a provision that would have moved the state's database to the Attorney General's office, the state's top legal officer.
In Kentucky, fewer than a third of prescribers have an account with the state's PMP program. However, a new state law, which will take effect on July 12, makes it mandatory to run a PMP for a new patient getting certain kinds of medicine. Nine other states have passed laws that require doctors to access the PMP database under certain circumstances.
"Before we can ever address the prescription-drug problem ... one of the things we have to do is to make sure we have full use of the tools we have," said Van Ingram, executive director of the Kentucky Office of Drug Control Policy.
Enforcement is up to state medical boards and state systems vary. But most allow doctors and pharmacists to access information from neighboring states - something that helps address the problem of abusers driving over state lines to find a willing doctor.
Improved technology, with a push by the National Association of the Boards of Pharmacy, is helping more states share data.
Doctors and pharmacists who suspect a patient is diverting can alert police. "If you recognize someone is a doctor shopper, you report it to the state police diversion agent," said Sarah Melton, a clinical pharmacist in Virginia. "I have him on speed dial."
Another issue for doctors is time, so states are trying to increase database speed so that doctors can get information while a patient is still in the office. About a dozen states allow doctors to delegate people to look up information.
Many states allow law enforcement to access the system - in limited circumstances, and a case must already be under investigation for officials to run a PMP report.
"You can't just pick someone out of the phone book and run them," said John Burke, president of the National Association of Drug Diversion Investigators and commander of the Drug Task Force in Ohio's Warren County.
Doctors need to strike a balance between treating people who genuinely need pain medication, and making sure it doesn't go to people who don't, said Samuel Hughes Melton, the husband of Sarah Melton and the president of a Virginia health clinic.
He used a PMP report to discover that a long-time patient had picked up an opiate from another doctor, and had also obtained a prescription for benzodiazepine. The two can be deadly if combined.
"I was able to confront him in the exam room," Melton said."I was able to use that information and nudge him into treatment for substance abuse."
There is some evidence that the databases are leading to the prescribing of fewer addictive medicines.
According to a study by the emergency department of the University of Toledo's College of Medicine, doctors or pharmacists who reviewed state prescription drug data changed how they managed cases 41 per cent of the time.
The study found that 61 per cent prescribed either no opioid medications, or less than originally planned, while 39 per cent decided to provide more.
"I know a number of emergency-room physicians tell us how much they appreciate the system to discriminate between real patients with real injuries and those who just want drugs," said Danna Droz, the administrator of Ohio's PMP.
Jones, the president of the Kentucky Medical Association, said doctors and pharmacists needed more education on abuse and diversion, as abusers become more sophisticated at fooling professionals.
He said he once got a call from a pharmacist questioning a prescription for 90 Percocet pills - when the pharmacist knew Jones rarely prescribed more than 20 pills at a time.
The prescription was forged. Jones reported it to police and the phony patient was arrested.