September Physician Focus: Is Marijuana Medicine?

Posted in Medical Marijuana, Medicine, Physician Focus on August 28th, 2014 by MMS Communications – Be the first to comment

Despite a ban by the Federal government, little clinical research into its effectiveness as a medicine, and lack of approval by the Food and Drug Administration, the use of marijuana for medical purposes has been approved by 23 states and the District of Columbia as of August.

In Massachusetts, voters in 2012 overwhelmingly approved a ballot question allowing the use of marijuana by patients with “debilitating medical conditions.” The vote represented a declaration of medicine by plebiscite, a major departure from the nation’s structured way of creating, testing, and approving medications through well-controlled, sanctioned clinical trials and review and approval by the U.S. Food and Drug Administration.

As the regulatory process of overseeing the marijuana program proceeds and marijuana dispensaries prepare to open in the Commonwealth, the September episode of Physician Focus examines a basic question: Is marijuana medicine?

Guests for the show are two physicians who presented at the MMS’s recent CME course on medical marijuana in June: Alan Ehrlich, M.D. (photo, center), Senior Deputy Editor of DynaMed, a clinical reference tool created by physicians that examines medical articles for clinical relevance and scientific validity, and Kevin Hill, M.D., M.H.S., (right), Director of the Substance Abuse Consultation Service in the Division of Alcohol and Drug Abuse at McLean Hospital in Belmont. Hosting the program is John Fromson, M.D., (left) Chief of Psychiatry at Brigham and Women’s Faulkner Hospital in Boston.

The three physicians examine the current evidence surrounding marijuana, the risks of using the drug, what conditions marijuana may help, and what patients should know about the drug if they are considering using it for medicinal purposes.

Physician Focus is available for viewing on public access television stations throughout Massachusetts. It is also available online at www.massmed.org/physicianfocus, www.physicianfocus.org,  and on YouTube.

Ebola Outbreak Underscores the Benefits of Preparedness

Posted in preparedness on August 26th, 2014 by MMS – Be the first to comment

Paul Biddinger, MDBy Dr. Paul Biddinger

The Ebola outbreak currently befalling several West African countries is the most serious outbreak to date.

The outbreak has claimed over 1400 lives, has yet to be contained, and has certainly generated much anxiety, especially among health care workers. While there is no doubt that the Ebola outbreak is serious, it is also important to know the facts about the disease in order keep the threat from Ebola in perspective.

Experts agree that Ebola is not likely to become a pandemic.  In contrast to other viruses such as influenza, SARS and MERS, Ebola is spread only through direct contact with the blood or body fluids from an infected person or animal, not through the air.

Additionally, the virus is only transmitted when patients are symptomatic, making control of the virus more manageable. Unfortunately, the current outbreak is happening in some of the poorest countries in the world with the fewest number of doctors, and in cities with much larger concentrations of people than in previous occurrences, which has made the current situation very difficult to control.

Even though Ebola is unlikely to pose a widespread threat in the U.S., it is still very important that clinicians know what to look for and how to manage the virus. Since the initial symptoms are nonspecific, it is essential to obtain a detailed travel history from all patients and additionally ask about potential exposures to infected persons or animals. Early recognition that a patient may be infected with Ebola is critical in order to implement appropriate isolation and personal protective measures.

Understandably, there has been confusion about which facilities can care for patients who may be infected with Ebola. In the modern world, a patient who has been infected with Ebola could present to any hospital.

Therefore, all hospitals must be prepared to recognize potential suspect cases, isolate patients, and teach staff how to properly don and doff personal protective equipment.  Because lab testing and other issues may be complex, hospitals should review the available CDC guidance on how hospitals can safely manage patients with Ebola.

The Ebola epidemic underscores that preparedness efforts are needed every day, and are crucial to responding to any threat to the public health system. The best thing we can do is use this opportunity to review our infection-control measures, strengthen our capacity for detecting and managing infectious disease, and continue to engage the community in proper prevention and containment practices.

Paul Biddinger, MD, is chair of the Massachusetts Medical Society’s Committee on Preparedness. He is vice chairman for Emergency Preparedness in the Department of Emergency Medicine at Massachusetts General Hospital, and director of the Emergency Preparedness and Response Exercise Program at the Harvard School of Public Health.

The President’s Podium: Reclassification of HCPs Reasonable

Posted in Drug Abuse, Health, opioids, Regulation on August 22nd, 2014 by MMS Communications – Be the first to comment

By Richard Pieters, M.D., President, Massachusetts Medical Society

The announcement today by the U.S. Drug Enforcement Administration that it is reclassifying hydrocodone combination products (HCPs) to a Schedule II drug – those substances with accepted medical uses deemed to have the highest potential for abuse and harm – is a reasonable step in the fight against prescription drug abuse – and long overdue.

The reclassification does raise important concerns for physicians and patients alike about access to appropriate treatment. Patients may have to make more visits to providers and pharmacists.  Physicians may have to write more prescriptions for shorter durations, and some physicians may prescribe alternative drugs that may be less beneficial or have adverse effects.

The Massachusetts Medical Society shares those concerns.  Physicians – always aware of the need to balance the alleviation of pain and the risks of addiction – recognize that patients who experience severe pain will always require treatment and should be able to get appropriate care and relief.

I have previously written about the challenges of prescription drug abuse, noting that the problem is severe, that addiction is a major public health problem that needs prevention and treatment, and that physicians must be part of the solution at the same time as the care and treatment of our patients remain paramount.

DEA has recognized the critical concern of physicians in issuing its new rule, by clearly stating that it “does not intend for legitimate patients to go without adequate care” and that “controlling HCPs as a schedule II controlled substance should not hinder legitimate access to the medicine.”

Further, DEA recognizes the role and responsibility of the physician in caring for his or her patient: “When a practitioner prescribes a medication that is a controlled substance for a patient,” it writes in its new ruling, “it must be because he/she has made a professional medical determination that it would be medically appropriate for the patient’s medical condition to treat with that specific controlled substance.”

The DEA’s reclassification of the most frequently prescribed opioid in the United States (nearly 137 million prescriptions for HCPs were dispensed in 2013), at the same time acknowledging physician concerns and professional judgment, is a sensible action in the face of a nationwide public health emergency of prescription drug abuse.

The complete DEA rule on the reclassification of HCPs is available here.

The President’s Podium appears periodically on the MMS Blog, offering Dr. Pieters’ commentary on a range of issues in health and medicine. 

Commentary: Baseball, Youth, and Smokeless Tobacco

Posted in Health, Public Health on August 22nd, 2014 by MMS Communications – Be the first to comment

By Richard Pieters, M.D. and Anthony Giamberardino, D.M.D.

Versions of the following joint commentary by the presidents of the Massachusetts Medical Society and the Massachusetts Dental Society, calling attention to the dangers of smokeless tobacco, were published in several newspapers across the Commonwealth during July and August. 

Richard Pieters, M.D.

The headlines first came with baseball Hall of Famer Tony Gwynn. His all-too-early death at 54 was attributed to the long-term use of smokeless tobacco.  Now it’s former Red Sox pitcher Curt Schilling, who revealed August 20 that he was diagnosed in February with mouth cancer.  “I do believe without a doubt, unquestionably,” said Schilling when making his condition public, “that chewing [tobacco] is what gave me cancer…I did it for 30 years. It was an addictive habit.” His physician agreed.

Many of us who grew up with the game are used to seeing players chewing tobacco, but a new generation of children watching in the stands and on television may be seeing smokeless tobacco used for the first time. They are the ones most influenced by what baseball players do both on and off the field. And that behavior by professional athletes can be more powerful in shaping behavior than any advertising campaign by the tobacco industry.

Anthony Giamberardino, D.M.D.

Although cigarette smoking in the United States continues to decline, a report from the U.S. Centers for Disease Control and Prevention (CDC) indicates that the use of smokeless tobacco has held steady over the past nine years.  CDC says that 14.7 percent of high-school boys, and 8.8 percent of all high-school students, reported using smokeless products in 2013.

The CDC further states that smokeless tobacco contains 28 carcinogens, which can cause gum disease, stained teeth and tongue, a dulled sense of taste and smell, slow healing after a tooth extraction, and, worst of all, oral cancer.

Smokeless tobacco is not harmless. According to the National Institute on Drug Abuse, it delivers more nicotine than cigarettes and stays in the bloodstream longer. Clearly, tobacco use is both a serious medical problem, as well as an oral health problem.

In a letter to baseball commissioner Bud Selig following the death of Tony Gwynn, nine leading health care organizations, including the American Medical Association and the American Dental Association, stated, “Use of smokeless tobacco endangers the health of major league ballplayers. It also sets a terrible example for the millions of young people who watch baseball at the ballpark or on TV and often see players and managers using tobacco.”

Oral cancer continues to be a serious problem in the U.S. More than 30,000 new cases are diagnosed each year, and the five-year survival rate is only around 50 percent. While a batting average of .500 would be considered outstanding in baseball, 50/50 odds aren’t very good in the game of life.

The connection between oral health and overall health is well documented. What happens in the mouth can affect the entire body. Physicians are now being trained to examine the mouth and to work with dentists to make patients more aware of the importance of oral health as it affects their overall health and well-being.

Programs such as the Massachusetts Dental Society’s Connect the Dots, in which physicians and dentists work together in the community, and the Massachusetts Medical Society’s establishment of a Committee on Oral Health mark the beginning of a growing relationship between physicians and dentists to promote oral health in the Commonwealth.

But oral cancer isn’t the only health risk from smokeless tobacco. Users have an increased risk of heart disease, high blood pressure, heart attacks, and strokes.

Many health issues are preventable, especially those related to tobacco use. The medical and dental professions can play a key role by providing education and screening for oral cancer.

Major league baseball players have an important opportunity to contribute to this educational process by aiding in prevention efforts, particularly aimed at impressionable young people. For the past four years, the Massachusetts Dental Society, in partnership with NESN and the Boston Red Sox, has produced TV campaigns on the dangers of smokeless tobacco.

The Massachusetts Medical Society and the Massachusetts Dental Society are committed to reducing tobacco use in all its forms and welcome the continued participation of the Red Sox and all of major league baseball. In 2014, chewing tobacco continues to be as much a symbol of baseball as the actual action on the field.

For the health of our children, shouldn’t this image of our national pastime now be considered past its time? The cases of Tony Gwynn and Curt Schilling should serve as a warning to us all.

Richard Pieters, M.D., a radiation oncologist at the University of Massachusetts Memorial Medical Center in Worcester, is president of the Massachusetts Medical Society. Anthony Giamberardino, D.M.D. practices general dentistry in Medford and is president of the Massachusetts Dental Society.

 

Update: AMA Seeks Physician Input on Sunshine Act Portal

Posted in Uncategorized on August 19th, 2014 by Erica Noonan – Be the first to comment

The AMA has extended its deadline until noon on Friday, August 22, for physicians to share their experiences with CMS’ Sunshine Act Open Payments system while trying to register.

The responses will help strengthen AMA’s advocacy on this topic.     calendar_icon

Go to the survey here, or email your comments to OpenPayments@ama-assn.org.

The portal reopened last week after glitches and reports of errors earlier in the month.

CMS still plans to open the system to the general public on Sept. 30, but that the deadline for physician registrations has been extended to Sept. 8.

We’ll keep you updated on any changes to that schedule.

Sunshine Act Portal Reopens for Registration

Posted in sunshine act on August 15th, 2014 by MMS – Be the first to comment

The Centers for Medicare and Medicaid Services says that the physician portal for the Sunshine Act’s Open Payments system has now reopened, and is now accepting registrations.

The portal was shut down for more than a week following reports of significant errors with physician data, and the extreme difficulty some physicians were having when trying to register.

CMS’ last comment was that it still plans to open the system to the general public on Sept. 30, but that the deadline for physician registrations has been extended to Sept. 8. We’ll keep you updated on any changes to that schedule.

Important Note

The AMA is asking physicians to take a brief online survey to report their experiences while trying to register. The responses will help strengthen AMA’s advocacy on this topic.

Go to the survey here, or email your comments to OpenPayments@ama-assn.org. The deadline for responding to the survey is Monday, Aug. 18.

 

With Portal Plagued by Problems, AMA, MMS and Others Urge Sunshine Act Delay

Posted in Pharmaceutical Industry, Regulation, sunshine act on August 5th, 2014 by MMS – Be the first to comment

penThe American Medical Association, Massachusetts Medical Society, and 110 other state and specialty medical societies today asked the federal government to delay the public release of information about payments and other transfers of value to physicians from the pharmaceutical and medical device industries.

In a joint letter to Marilyn Tavenner (.pdf), administrator of the Centers for Medicare and Medicaid Services, the groups said that because of an “overly complex” registration process and a condensed time frame, it is “effectively impossible” for physicians to review and dispute reports by the August 27, 2014 deadline.

The reports are scheduled to be released to the public by Sept. 30, 2014. The letter recommends a release date of March 31, 2015. “This process must be streamlined and physicians must be given adequate time to review and dispute their reports,” the letter states.

The reports are mandated by the Physician Payments Sunshine Act, which was enacted in 2010. The report this year will cover activities from Aug. 1 to Dec. 31, 2013.

The joint letter also asked the CMS to:

  • Explicitly direct industry manufacturers to label as “disputed” any unresolved disputes between physicians and industry, even after the physician’s appeal is rejected by the manufacturer. CMS has no plans to mediate physician-industry disputes, even though physicians are already reporting significant errors in the data.
  • Exempt manufacturers from reporting about funding for continuing education activities when the manufacturer does not know the name of program faculty and other participants before the event. Current regulations require reports if industry learns of the identities before or after the event. “Our organizations are concerned that this would have a significant chilling impact on CE [continuing education], which runs contrary to the public interest,” the letter states.
  • Exempt medical textbooks, journal article supplements and reprints from public reporting. The letter states that these publications “represent the gold standard in evidence-based medical knowledge and provide a direct benefit to patients.”

ABIM Responds to Certification Change Concerns

Posted in MOC on August 4th, 2014 by Erica Noonan – Be the first to comment

Earlier this week, the American Board of Internal Medicine  issued a     written response to all internal medicine physicians, addressing concerns   about recent changes to Maintenance of Certification, or MOC, requirements.

ABIM acknowledged “a palpable level of anger among internists and internal medicine subspecialists” and said it plans to alter some of its policies and processes, as well as its requirements.

Read more on the NEJM Knowledge + blog.

 

August Physician Focus: Advance Care Planning

Posted in End of Life Care, Palliative Care, Physician Focus, Uncategorized on July 31st, 2014 by MMS Communications – Comments Off

Physicians are increasingly recognizing the importance of advance care planning – preparation for the end-of-life -  and as the subject gains more public attention, more patients are being motivated to talk about the issues.

The August edition of Physician Focus shares the physician’s perspective on this topic with two members of the Massachusetts Medical Society’s Committee on Geriatric Medicine.

Eric Reines, M.D., (photo, center) a geriatrician with Element Care in Lynn and chair of the committee, and Beth Warner, D.O., (right) a consultant geriatrician with Cooley Dickinson Health Care in Northampton and committee member, join host and primary care physician Bruce Karlin, M.D. (left) to discuss the basics of advance care planning.

Among the topics of conversation are the importance and advantages of planning, when it should begin, how to start the process, and the physician’s role in the process. Healthcare proxies, medical orders for life-sustaining treatment, and hospice and palliative care are also included in the discussion.

Physician Focus is available for viewing on public access television stations throughout Massachusetts. It is also available online at www.massmed.org/physicianfocus, www.physicianfocus.org,  and on YouTube.

The President’s Podium: Tracking Prescription Drug Abuse

Posted in Department of Public Health, Drug Abuse, opioids, Public Health on July 17th, 2014 by MMS Communications – Comments Off

By Richard S. Pieters, M.D., President, Massachusetts Medical Society

The Centers for Disease Control’s just-released state-by-state report on opiate abuse has cast a bright new light on this serious and potentially deadly problem.

Saying that an “increase in painkiller prescribing is a key driver of the increase in prescription overdoses,” CDC noted that prescribers wrote 259 million prescriptions for painkillers in 2012, and that 46 people die from prescription overdoses every day. That prompted CDC Director Dr. Tom Frieden to capture the paradox: “All too often, and in far too many communities, the treatment is becoming the problem.”

Massachusetts ranked in the top 10 in prescribing long-lasting painkillers, but 41st in overall prescribing of opioids.  Rankings, however, are only a reference point, as volume itself is insufficient to indicate whether overprescribing or under prescribing is occurring.  And rankings matter little when counting the human toll: in Massachusetts alone, 688 residents died from opiate overdoses in 2012, and more than 200 additional lives have been lost since November 2013, according to the Massachusetts Department of Public Health (DPH).

Multiple responses are under way in the Commonwealth: The Governor has formed an Opioid Task Force, the legislature has filed bills, DPH launched Opioid Overdose Education and Naloxone Distribution Program, and police and fire departments are now carrying naloxone.

Regionally, five New England governors agreed to collaborate, and nationally, the U.S. Senate has announced the formation of a Prescription Drug Abuse Working Group.

Physicians are adding their voices as well. MMS immediate past president Dr. Ronald Dunlap offered his perspective in April, and American Medical Association President Dr. Robert M. Wah, following the New England governors’ announcement in June, shared a five-point proposal to combat prescription drug abuse.

The CDC is focusing attention on overprescribing by healthcare providers, and while others continue to see physicians as part of the problem, thefts from pharmacies and diversion from families and friends remain major contributors to the problem, as is the influx of heroin into Massachusetts and New England.

A critical need in responding to this crisis is getting better data. We should know the sources of the drugs – how many come from prescriptions, how many from thefts, how many are diverted from home medicine cabinets – to develop responses.

Better data is available through the state’s Prescription Monitoring Program (PMP), a program MMS helped to establish more than 20 years ago.  It’s one of the best tools we have to track prescription use, and one CDC urges all states to use.  The experiences of New York and Tennessee are testimony to the effectiveness of such programs.

In Massachusetts, however, the program has yet to fulfill its promise.

A well-run PMP has four purposes: (1) identifying patients who get schedule II and III prescriptions from multiple doctors; (2) identifying prescribers who inappropriately write many prescriptions or write prescriptions for high dosages; (3) providing a clinical review of those patients and prescribers, to determine what interventions might be necessary; and (4) facilitating research in discovering trends, practices, and problems.

To achieve the program’s full benefit, two things must occur: (1) the PMP must allow all prescribers and dispensers access to up-to-the-minute data on individual patients, and (2) the state must reform its structure to devote resources to the clinical analysis of data and to streamline outreach to providers.

Further, a re-energized medical review board, created as part of the original PMP but subsequently reduced in its role, will give an added boost to the effort.  The board can determine patterns of abuse, propose needed interventions, and should be charged with responsibility for referral of such activity to licensing boards or law enforcement authorities.

For the individual clinician, the monitoring program should be a tool seamlessly incorporated into clinical decision making, but it should never impede appropriate patient care.  One of the most difficult tasks for physicians in patient care is balancing the alleviation of pain and the risks of addiction, and we must recognize that patients who experience severe pain will always require treatment and should be able to get relief.

An improved PMP, with real-time data, with all prescribers participating, and with accurate and timely data analysis, should be regarded as the cornerstone of our collective efforts to address prescription drug abuse.  It’s time for that to happen, and physicians stand ready to help.

Addiction is a major public health problem that needs prevention and treatment. Prevention requires the use of all pain management tools, including such methods as physical therapy and acupuncture. We should use the PMP as a starting point to engage other stakeholders to develop a comprehensive strategy for chronic pain management, with the hope of less need for opioids and thus less addiction. Such actions should also lead to more compassionate and enlightened treatment of addiction.

The President’s Podium appears periodically on the MMS Blog, offering Dr. Pieters’ commentary on a range of issues in health and medicine.