Dozens of states around the country are taking measures to reduce the number of deaths and amount of diversion or abuse of prescription opioid painkillers, such as by limiting prescribing or launching prescription monitoring programs, and now, by doing away with the iconic prescription pad in at least two states.

First Minnesota, in 2011, and now New York in 2016 have taken the step of requiring prescribers to use electronic transmission of prescriptions to pharmacies. The new law in New York has teeth: New York is the first state to back up that mandate with penalties for physicians who don't comply.1,2

As of March 27, 2016, prescribers in New York may write a paper prescription only in specific cases, such as for medical equipment or devices, or if a prescription must be filled by the patient in another state.

All other medication-whether hydrocodone or amoxicillin-must be prescribed via electronic transmission from prescriber to pharmacy. Physicians and hospitals have had a year to prepare for this step. The law was initially proposed to take effect in 2015 but was delayed, mostly because of software issues.

"There should really be no reason that a doctor shouldn't have had ample time to get it up and running," said Dr. Joseph R. Maldonado, president of the Medical Society of the State of New York.

The new state law known, as I-STOP, was passed in 2012 to curtail the growing problem of prescription opioid abuse. The acronym stands for Internet System for Tracking Over-Prescribing. The law aims to improve the prescription monitoring program (PMP) registry by monitoring all drugs prescribed to patients over a 6-month period.3

"Practitioners must have an electronic health record system certified by the US Drug Enforcement Agency (DEA), plus a 2-factor authentication process that meets DEA standards, such as fingerprint biometric authentication software," said Elizabeth Frost, MD, co-editor of Topics in Pain Management and professor of anesthesiology at Icahn School of Medicine at Mount Sinai in New York. "It is onerous."

At the New York State Health Department website, the program's home page has detailed information, including an FAQ document that is 11 pages long, as well as a brochure with just the basics about how practitioners can register with the state for a "Health Commerce System Account" that gives them access to the PMP.3

More controlled-substance prescriptions were written in the state from 2013 to 2014 (about 27 million) than there were residents (about 20 million), according to the State Health Department, as reported in the New York Times.2 In 2004, there were 341 opioid-related deaths in the state. In 2013, there were 1,227, the Times reported.

The first phase of the law was put in place in 2013-an online registry that a physician must check before prescribing a controlled medication. The registry lists all controlled substances recently prescribed to a patient, so that a physician can spot a pattern of abuse.

But just as drug abusers and diverters have "doctored" paper prescriptions to change the number of pills, the date, or the patient's name, the electronic registry can be gamed, such as by a patient purposely spelling his or her name wrong for the doctor.

Some physicians are concerned about potential complexities that would affect patients who do not know during their visit where they will have prescriptions filled, but prescribers are able to show a list to patients to have them choose a pharmacy.

Patients might also lose some flexibility in shopping for a better price or shorter waiting time. It is unclear how this will affect patients who live in areas where pharmacies don't keep a broad variety of medications in stock. Physicians may have to give up the paper and pen, but they can still call a pharmacist to see if the drug is in stock.

With the push to go digital over the past year, New York now leads the nation in the percentage of medical practitioners able to prescribe controlled substances electronically, according to Surescripts, the company that runs the network on which the prescriptions travel.

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