Drug Abuse

Curbing opioid abuse: A little time can go a long way, experts say

Posted in Drug Abuse, opioids on October 5th, 2015 by MMS – 3 Comments
Wilson Compton, MD

Wilson Compton, MD

By Debra Beaulieu-Volk, Vital Signs Staff Writer

Speakers at Friday’s Opioid Misuse and Addiction Summit at MMS Headquarters each brought varied backgrounds and expertise, but they all had one mission in common: to talk strategy about how to effectively aid patients suffering from addiction and prevent new dependencies from forming.

All experts, including keynote speaker U.S. Attorney Loretta Lynch, emphasized the importance of a collaborative, multi-faceted approach to conquering the chronic disease of addiction. A secondary theme that emerged surrounded the notion of time.

Physicians are not widely reimbursed for spending extra time talking with or on behalf of patients, panelists noted. But with the devastating magnitude of opioid addiction and drug-related deaths, the stakes are too high not to invest more in certain critical moments.

Change the “quick fix” culture

One place to start, experts agreed, is in reducing the amount of prescription opioid medication in our environment. Many who misuse these pills obtain them not from doctors, but from friends and family members, with and without their knowledge, noted Wilson Compton, MD, MPE, Deputy Director of the National Institute on Drug Abuse. These pills would be harder to access if doctors prescribed them less often and in smaller amounts when they do, and if patients were better educated about how to store and dispose of unused medications safely. View Dr. Compton’s slides. (.pdf, 11 pages)

Curbing painkiller prescriptions will require a change in the United States’ current “quick fix culture,” said Maura Healey, Massachusetts Attorney General, noting that prescribing of opioids has grown exponentially in the last 15 to 20 years.

Pressed for time, it has become normalized for physicians to reach for a prescription pad rather than exploring alternative treatments to chronic pain. Thus dynamic must change, experts urged, with special attention paid to patients identified as high-risk for dependence.

Take advantage of the PDMP

Law enforcement officials pointed to the utility of the state’s prescription drug monitoring program (PDMP) as a tool to identify and thwart doctor-shopping. “The tool is right there. PDMP is a great opportunity to hit that one little button and find out what else has been prescribed,” said George Zachos, Chief of Medicaid Fraud Unit and Massachusetts Assistant Attorney General. “If the physicians and pharmacists are using [the PDMP] properly, it should never get to us.”

Identifying a potential case of addiction, diversion, inappropriate prescribing, or other misuse is, as with all elements discussed, just a piece of the puzzle. Most physicians and pharmacists don’t currently have the tools to take the next step and have difficult conversations with patients, panelists noted.

Engage and educate patients

But the common practices of firing the patient or simply refusing to prescribe perpetuate the problem, not just failing to address underlying addictions but upping the chances patients will turn to heroin to self-medicate. Rather, experts advise using the opportunity to engage patients and offer or refer treatment for substance disorders as soon as possible.

When patients aren’t motivated to get help for addiction, physicians should communicate similarly to how they would with someone not managing his or her diabetes, said Sarah Wakeman, MD, leader of an initiative to address opioid addiction at Massachusetts General Hospital. “Often people are ambivalent. It’s our job to tip those motivational scales,” she said. “There are opportunities when people very much do want help, which is why having help immediately available is so important.”

There are times, of course, when the benefits of opioid treatment outweigh the risks, and a prescription is helpful and appropriate for the patient. But many, if not most, devastating addictions begin with a legitimate short-term prescription, experts noted. Therefore, physicians and pharmacists should be sure not to miss this critical opportunity to educate patients, according to Nancy Coffey of the U.S. Drug Enforcement Administration. She told physicians and pharmacists: “Take the extra 10 seconds to advise patients, ‘This is powerful. Treat it that way. Put it where no one will have access.”

Related Content from the Opioid Summit

Narcan offers immediate life-savings, opportunity to engage addicts long-term

Posted in Drug Abuse, opioids on October 5th, 2015 by MMS – 2 Comments

L to R: Sarah Wakeman MD, Jeffrey Baxter MD, Ruth Potee MD, and DPH Commissioner Monica Bharel, MD.

By Debra Beaulieu-Volk, Vital Signs Staff Writer

“We need to keep patients alive long enough to treat them,” Sarah Wakeman, MD, of Massachusetts General Hospital, told attendees of the MMS’ Opioid Misuse and Addiction Summit held last Friday.

A key tool in the state’s arsenal to make addiction recovery possible, experts agreed, is the overdose-reversal drug naloxone, better known by its brand name Narcan. Timely administration of the drug is credited with saving 5 million lives throughout the Commonwealth, according to Monica Bharel, MD, Massachusetts’ Public Health Commissioner.

Although treating acute respiratory emergencies due to overdose is just one piece of the opioid epidemic puzzle, it allows “an opportunity to engage a person who is battling the disease of addiction,” Bharel said.

According to expert panelists, positive steps toward optimizing this opportunity in Massachusetts include the following:

  • The creation of standard orders to make naloxone available at pharmacies without a prescription, not just for patients using opioids but also to secondary individuals such as patients’ family and friends.
  • Distributing naloxone toolkits as standard equipment on law enforcement toolkits. Massachusetts has been a groundbreaking leader on this front, said U.S. Attorney Loretta Lynch. “They can’t always be there [to respond to an overdose], but we can take steps to ensure law enforcement is prepared,” she said.
  • Maintaining reasonable cost to supply and replenish supplies of the drug to first responders and hospitals. “We never want cost to be a barrier to somebody’s ability to access lifesaving medication like that,” stated Maura Healey, Massachusetts Attorney General.
  • Ensuring people carrying Narcan, in either injectable or nasal form, receive proper training. Ideally, at-risk patients or caregivers would receive initial administration instructions in the physician office where the drug is prescribed, followed up with training by a pharmacist filling the prescription, provided that a private consultation area is available, experts said.

Although many overdoses occur when victims are alone, having medication such as Naloxone available is similar to keeping a fire extinguisher in one’s home, said Samuel Penta, RPh, senior investigator with the MA Board of Registration in Pharmacy. “You may never need it, but it will be there if you do,” he said.

Of course, immediate lifesaving doesn’t ensure a person’s long-term freedom from addiction. But use of modalities including medically assisted treatment, behavioral therapy, and other resources can begin as early as a trip to the emergency room, physician experts said.

“This puts the onus on the healthcare system,” Wakeman said. “We don’t have to wait for people to hit bottom. We have treatments that work and need to stat them as soon as possible.”

Related Content from the Opioid Summit

AG Lynch: Cooperation Between Law and Medicine Key to Opioid Fight

Posted in Drug Abuse, opioids on October 2nd, 2015 by Erica Noonan – 2 Comments

By Erica Noonan, Vital Signs Editor

WALTHAM — U.S. Attorney Loretta Lynch said collaboration and cooperation among law enforcement and medicine is the key to progress in battling the epidemic of opioid addiction.

She delivered the keynote address at Friday’s Opioid Misuse and Addiction Summit at MMS Headquarters, a gathering of hundred health care leaders, physicians, law enforcement officials, substance abuse experts, pharmacists,  and patients.

“This is a vital public health issue that was for far too long seen only through the lens of law enforcement,”  she said. “As physicians, you see the true human cost of these addictions.”

She described the four points of the White House approach: enforcement, disposal, monitoring, and education. “We are disrupting the distribution channels… and building cooperation and communication between agencies, and integrating DEA (efforts) with other agencies.”

Because prescription drug abuse is a common precursor to abuse of heroin, a federal multi-agency Heroin Task Force will bring a plan to Congress by years end, Lynch said.

A recent four-state drug bust netted 220 arrests, including 22 physicians and pharmacists, she said. National drug drop-off programs have grown in popularity and effectiveness; the past nine events collected more than 5 million pounds of medication.

“We do have reasons for optimism. We can strengthen families and save lives,” said Lynch. “This is about mending the basic fabric of our communities.”

Related Content from the Opioid Summit

MMS, Medical Schools, Governor Join in Opioid Abuse Battle

Posted in Department of Public Health, Drug Abuse, opioids, Public Health on September 3rd, 2015 by MMS Communications – Comments Off on MMS, Medical Schools, Governor Join in Opioid Abuse Battle

MMS President Dennis M. Dimitri, M.D.

Taking another step in the battle against opioid abuse in the Commonwealth, the Massachusetts Medical  Society, along with representatives from the state’s four medical schools, met yesterday with Governor Charlie Baker and Commissioner of Public Health Monica Bharel, M.D., to discuss a physician-led approach in developing training and best practices for medical students on pain management and safe opioid prescribing.

Providing physicians with additional training on opioids was part of the comprehensive set of 65 recommendations released in June by the Governor’s Opioid Working Group. Yesterday’s meeting was a collaborate effort by the Governor, the Department of Public Health, and the state’s leading physicians to develop that recommendation.

MMS President Dennis M. Dimitri, M.D. described the meeting as one filled with a “spirit of cooperation and positive energy about what we can do working together” to continue the battle against opioid abuse.

Continuing medical education on opioids and pain management has been a prime focus of MMS in its efforts to help curb opioid abuse. In May, MMS issued its Opioid Therapy and Physician Communication Guidelines, offering evidence of best practices for prescribing and made its continuing medical education courses on opioids and pain management free to all prescribers. These courses have been accessed more than 3,200 times.

In a press conference following the meeting, Governor Baker said he was “pleased with the quality of the dialogue” and saw the meeting as the first of several discussions with physicians about their role in addressing the opioid epidemic. “Everybody’s got a role to play,” said Baker, “and we can’t move fast enough” in the fight.

DPH Commissioner Bharel said the meeting resulted in agreement to develop core competencies to educate future doctors on safe prescribing and pain management.

In offering the physicians’ perspective, Dr. Dimitri said physicians constantly face the “challenge of patients with ongoing pain, but the pressure of time, inadequate systems to help the physician and patient deal with pain, and the lack of alternative methods of pain relief covered by insurance put physicians in a tight box” where options to relieve pain were limited and the choice of opioids seemed the most appropriate one.

Dr. Dimitri added that doctors now recognize the impact of the number of opioids in the community and that too many have been allowed to be prescribed. Pledging MMS support of the Governor’s effort, Dr. Dimitri said “we’re very glad to participate in this process.”

MMS commitment to the effort was evidenced by the presence at the meeting of its top three officers – Dr. Dimitri, President-Elect James Gessner, M.D., and Vice President Henry Dorkin, M.D. – and Executive Vice President Corinne Broderick. The medical schools were represented by Karen Antman, M.D., Dean of the Boston University School of Medicine; Harris A. Berman, M.D., Dean of the Tufts University School of Medicine; Terence R. Flotte, M.D., Dean of the University of Massachusetts Medical School; and Todd Griswald, M.D., Director of Medical Student Education in Psychiatry at Harvard Medical School.

Selected press coverage is available here: Boston Herald, MassLive.com/The Republican, WCVB-TV.

The President’s Podium: Being Part of the Solution

Posted in Drug Abuse, Health Policy, opioids, Public Health on July 31st, 2015 by MMS Communications – Comments Off on The President’s Podium: Being Part of the Solution

by Dennis M. Dimitri, M.D., President, Massachusetts Medical Society

 In October 2Dr. Dimitri1_edited013, the Trust for America’s Health rated Massachusetts as one of the top six states for developing  strategies to curb prescription drug abuse. Despite that ranking, the Commonwealth recorded more than 1,000 deaths from opioid overdoses in 2014, a jump of 33 percent from 2012.

Today, our state has developed an even firmer resolve in response to this epidemic.

Governor Charlie Baker and Attorney General Maura Healey have made this public health crisis a top priority. The Governor’s Opioid Working Group released an action plan in June that I believe is a smart, comprehensive approach to a complex problem. From the physician’s perspective, the plan has much to like. It reframes addiction as a medical disease, and recognizes the physician’s critical concern: “to ensure access to pain medication for individuals with chronic pain while reducing opportunities for individuals to access and use opioids for nonmedical purposes.”

The plan also supports initiatives that physicians have urged for some time and embrace wholeheartedly: more drug take-back days (an effort the Drug Enforcement Administration is also reviving), increases in the co-prescribing and bulk purchasing of the life-saving drug naloxone, more treatment programs, eliminating insurance barriers to treatment, and improvements in the state’s Prescription Monitoring Program.

The monitoring program is especially significant. The Centers for Disease Control describes such programs as one of “the most promising state-level interventions” to improve prescribing and protect patients at risk.

Changes in the monitoring program will make it easier for physicians to use, and compatible with those in other states. One key improvement: reducing the time for pharmacy reporting of opioid prescriptions from two weeks to 24 hours. This will provide better “real time” information on patient prescriptions and less “doctor shopping” by patients.

Another good sign: government is allotting more resources to fight the epidemic. The new state budget includes $111 million for substance abuse services, and the Governor has requested another $27.8 million in supplemental spending for treatment and prevention. U.S. Health and Human Services has also announced a $100 million effort for medication-assisted treatment, and Massachusetts will share in that program.

Creative new approaches have come from law enforcement as well. Gloucester’s Angels Program has enrolled nearly five dozen people into treatment since it began June 1, and the program has led to similar efforts in other communities.

For our part, the Massachusetts Medical Society has reached out to all prescribers with our Opioid Therapy and Physician Communication Guidelines, offering evidence of best practices for prescribing.

In May, we made our continuing medical education courses on opioids and pain management free to all prescribers, and since then, nearly 2,500 health professionals have taken one or more courses in the first two months. To meet demand, we have added nine courses since last year, when only 400 completed such courses in a comparable period.

We are reaching out to patients, focusing on the critical areas of proper storage and disposal of medications with a dedicated website and an upcoming radio public service campaign that will continue through the end of the year.

The American Medical Association is also taking action, concentrating on physician education in prescribing opioids, use of monitoring programs, and promoting access to treatment and naloxone.

But physicians – and all prescribers – can do better. More than half of enrolled prescribers don’t routinely use the prescription monitoring program, and most patients say their doctors don’t discuss the risks of addiction when prescribing pain medication. One of the best things prescribers can do is raise patient’s awareness of the risks of addiction and their responsibility to properly store and dispose of their medications.

Let’s also remember the public has a critical role to play. More than 75 percent of those 12 and older who use pain relievers for nonmedical reasons are using drugs prescribed to someone else, whether obtained free, purchased, or stolen. As White House Drug Policy Director Michael Botticelli told our membership, the prescription opioid problem is, in one sense, “an epidemic that starts in the medicine cabinet.”

The Opioid Working Group declared that “strong partnerships” will be required to curb this abuse. Many groups are rising to meet the challenge, and physicians have made the commitment to be part of the solution as well. As those closest to the patients, as the ones who prescribe their medicines and treat their pain, we can do no less.

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

Governor’s Opioid Task Force: A Smart, Comprehensive Approach

Posted in Drug Abuse, opioids on June 22nd, 2015 by MMS – Comments Off on Governor’s Opioid Task Force: A Smart, Comprehensive Approach

By Dennis M. Dimitri, MD
MMS President

Dr. Dennis Dimitri 300 ppiWe welcome today’s report from the Governor’s Opioid Working Group. It is a smart, comprehensive approach to an extremely complex problem, and we pledge to pledged to continue to work with public and private officials to combat the opioid overdose epidemic.

We appreciate that the working group addressed many of the issues we have discussed with the Governor Baker, Attorney General Healey, Secretary Sudders and their staffs. We agree that because of the opioid crisis, we need a different approach to the prescribing and management of opioid medications. That is why we’ve taken a proactive approach to the issues, and launched a comprehensive program to educate physicians, other prescribers and the public last month.

We especially support the recommendations to improve the state’s online prescription monitoring program; increasing access to naloxone by encouraging it to be co-prescribed with opioid medications; allowing the partial filling of opioid prescriptions without additional co-payments; expanding education for prescribers and the public; expanding access to intervention and treatment; and taking steps to destigmatize addiction.

Our program to fight opioid overdoes, called “Smart Scripts MA,” was launched in May 2015. It has three components:

Prescribing Guidelines: The guidelines are designed to help physicians make the right decisions for their patients. They were developed by a task force of physicians from a broad range of specialties, and derived from similar work conducted in other states and by several state and national medical specialties.

The guidelines first emphasize that physicians and patients should discuss family and personal histories of substance abuse disorders and behavioral health concerns, before the prescription is written. The guidelines also encourage patients and physicians to mutually develop agreements that outline the expectations and goals of the treatment, along with the conditions for continuing opioid therapy after initial treatment.

Free Education in Pain Management: The MMS has made its online medical education courses in pain management available free to all prescribers until further notice. Five courses are currently available; several more courses will be published later this week, and more courses are planned for later this year. These courses are available for Continuing Medical Education credit. Physicians have been required to obtain CME credits on this topic as a condition of licensure and re-licensure since January 2012.

Public Education Program: The MMS has also launched a public education program to inform patients and their families about the safe storage and proper disposal of their opioid medications, in an effort to reduce the supply of medications in the community. According to the CDC, more than 80% of people who abuse prescription drugs are using medications that were prescribed for someone else. Safe storage and disposal will reduce or eliminate this source of misused prescription medications.


Bold Steps to End the Opioid Epidemic – The Physician Contribution to the Solution

Posted in Drug Abuse, opioids on May 21st, 2015 by MMS – 5 Comments

Dr. Dennis Dimitri By Dennis M. Dimitri, MD
President, Massachusetts Medical Society

An epidemic of opioid use and the associated overdose deaths has been slowly building across the nation and Massachusetts for the last decade, and has now reached a crisis point. It is affecting nearly every city and town in the Commonwealth. In some communities, the crisis is unprecedented.

State officials estimate that more than 1,000 Massachusetts residents died of opioid overdoses last year – 33% percent more than in 2012, and nearly three times more than in 2000.

A Harvard School of Public Health survey found that nearly 4 in 10 state residents personally know someone who has abused prescription pain medications.

While the total numbers may be startling, we should also remember that each individual overdose death has a human face. Each tragedy has changed a family forever. It has to stop, and the time for action is now.

Physicians must step forward immediately to do everything we can to help bring this devastating problem under control. How can we do this? It starts with education.

According to the Centers for Disease Control and Prevention, more than 80% of people who misuse prescription pain medications are using drugs prescribed to someone else. These drugs are most often obtained from a friend or relative – for free, purchased, or stolen.

This tells me that there are too many doses of opioid medications in circulation. By limiting this supply and ensuring that opioids are available only to patients who truly need them, we can make a big impact on the Commonwealth’s opioid crisis.

That is why the Massachusetts Medical Society is launching a comprehensive campaign to educate prescribers and the public about the safe and responsible prescribing and handling of these medications.

The campaign has three components:

  • Guidelines to help physicians make the right decisions for their patients
  • Free education resources for prescribers to help inform their judgments
  • Storage and disposal information for patients and their families

Prescribing Guidelines

We have reviewed guidelines already developed by many states and medical specialty societies on this topic. There has been a lot of good work done in the area already – it is, after all, a national epidemic. We are recommending this set of guidelines for use by all physicians.

They are not designed to micromanage care, but to provide guidance and information based on evidence that will improve the care of our patients and lessen the risks associated with opioid prescribing. At the same time we recognize that each patient is different, and in all cases, a prescriber’s sound clinical judgment is important. However, we also believe that several principles should govern the exercise of this clinical judgment.

First, the guidelines emphasize that physicians and patients should discuss family and personal histories of substance abuse disorders and behavioral health concerns, before the prescription is written.

Second, patients and physicians are encouraged to mutually develop agreements that outline the expectations and goals of the treatment, along with the conditions for continuing opioid therapy for chronic pain after initial treatment.

Third, there are exceptions for hospitalized patients, those in hospice and palliative care, and for those being treated for cancer. These patients have special circumstances that do not yield readily to hard and fast rules. Their care must be based upon the long held medical principles of relief of suffering.

We’re offering these guidelines with the hope that they will be adopted by physician practices throughout the state. We are also sharing them with the state Board of Registration in Medicine, in the event that the Board will consider incorporating them into its prescribing guidelines for physicians.

You can see the details of our recommendations here.

Prescriber Education

The Massachusetts Medical Society has long been a leader in providing continuing medical education to physicians and other clinicians about pain management. Today, we are announcing that we are making these pain management courses available to all prescribers – for free, until further notice. This includes not only our current suite of courses, but those currently in the pipeline that are due to be released in the coming weeks and months.

The urgent interests of the community are paramount, and we will remove as many barriers to this prescriber education information as possible.

Public Education

An effective first step to reduce non-medical opioid use is through education. Therefore, in an effort to curb the supply of prescription opioids in the community, we are partnering with the Partnership for Drug Free Kids and its Medicine Abuse Project to broadly disseminate information about the safe storage and proper disposal of opioid medications.

Most people are probably unaware that their medicine cabinets are attractive targets for those who would misuse opioids, and that they could be an unwitting supplier. Our education program will provide guidance on how to safely store and secure medications, and how to get rid of them when they are no longer needed.

In early June, our website will host all of these materials. We will make these materials available to anyone, including physicians, who wish to put them in their offices or share them electronically.

There is no more important public health issue today than the opioid epidemic. It is devastating communities, families, men, women, rich and poor, and most tragically, children and adolescents. It has to stop – and we are ready to do our part.

2015 Shattuck Lecture: CDC’s Dr. Tom Frieden on the Current and Future States of Public Health

Posted in Annual Meeting 2015, Drug Abuse, HIV, opioids, Public Health on May 2nd, 2015 by MMS Communications – Comments Off on 2015 Shattuck Lecture: CDC’s Dr. Tom Frieden on the Current and Future States of Public Health

Describing public health as the means that will “account for most of our health progress in the years to come,” Director of the U.S. Centers for Disease Control Dr. Tom Frieden spoke of the achievements and challenges in public health in delivering the 2015 Shattuck Lecture at the Massachusetts Medical Society’s annual meeting on Friday, May 1.

In a talk that was both entertaining and instructive and supported with statistical data, Dr. Frieden touched on a myriad of subjects, including antibiotic resistance, the opioid epidemic, the state of HIV care, tuberculosis, the impact of vaccines, the threats and improvements in cardiovascular care and hypertension, the continuing and new dangers of tobacco and nicotine delivery systems such as e-cigarettes, and the public health actions of a responsive government.

Among the highlights from his address:

On infection and the spread of drug-resistant bacteria: “The obsession to increase the population impact of our efforts is routinely complicated by infection, which could eventually undermine much of modern medicine. Our Antibiotic Resistance Initiative could reduce many infections over the next five years.”

On clinical care working with public health: “The intersection of clinical health care and public health is one of the essential concepts that underlie public health, and all too often they are going in different directions. There’s a lot we can learn from each other.”

On the Ebola crisis: “We learned two big lessons from the Ebola crisis. Every country needs to have a core public health capacity and the world has to move faster with outbreaks and epidemics.”

On the role of government: “The appropriate role of government is getting people to make healthy choices, with free and open information, by protecting individuals from harm caused by others, and by taking societal action to protect and promote health. These are the public health actions of a responsive government.”

On the responsibilities of individuals, providers, and government: “Until we have a collective responsibility for health-inducing environments, we will continue to have challenges.”

On the main goal of the CDC: “The goal of the CDC is a safer U.S and a safer world, to prevent avoidable catastrophes, to detect threats early, and to respond rapidly and effectively.”

Slides from Dr. Frieden’s presentation are available here.

A video of the full talk is available here:

February Physician Focus: The Physician’s Perspective on Prescription Drug Abuse

Posted in Drug Abuse, Health, opioids, Physician Focus, Public Health on January 30th, 2015 by MMS Communications – Comments Off on February Physician Focus: The Physician’s Perspective on Prescription Drug Abuse

Health and governmental officials at all levels are struggling with solutions to what has become one of the nation’s most pressing public health problems: prescription drug and opiate abuse.

Addiction experts, public officials, and even some physicians, have pointed to the medical profession as one cause of the problem. Physicians write too many prescriptions, they say.  But the fact that more than three out of four people who misuse prescription pain medicines use drugs that are prescribed to someone else is one indication that the problem arises from more than a single cause.

The February edition of Physician Focus, with a discussion among three physicians knowledgeable about the treatment of pain, pain medications, and opioid abuse, offers the perspectives of physicians on prescription drug and opioid abuse.

Participating in this conversation are Richard Pieters, M.D., (center, photo) President of the Massachusetts Medical Society and Professor of Radiation Oncology and Pediatrics at the University of Massachusetts Memorial Medical Center in Worcester; Daniel Alford, M.D., (right) Director of the Safe and Competent Opioid Prescribing Education program at Boston University School of Medicine and the Director of the Clinical Addiction Research and Education Unit at Boston Medical Center; and Barbara Herbert, M.D., (left) Medical Director of Addiction Service at Commonwealth Care Alliance and President-Elect of the Massachusetts Chapter of the American Society of Addiction Medicine, who serves as host for this program.

All three physicians bring their personal experiences in treating patients with pain to the discussion. Among the topics they address are the physicians’ viewpoints on the causes of opiate abuse; the prevalence of pain as a medical condition; the elements of effective and safe pain management; the distinctions among different kinds of pain; what steps physicians and patients can take, both individually and collectively, to reduce the abuse of pain medicines; and how physicians view the use of the prescription drug Narcan to prevent deaths from overdoses.

Physician Focus, now in its 11th consecutive year of production, is available for viewing on public access television stations throughout Massachusetts. It is also available online at www.physicianfocus.org, www.massmed.org/physicianfocus, and on  YouTube.

Walgreens Expands Its “Good Faith Dispensing” Policy

Posted in Drug Abuse, opioids on December 22nd, 2014 by MMS – Comments Off on Walgreens Expands Its “Good Faith Dispensing” Policy

Presciption drugs and stethoscopeIn April 2013, Walgreens Pharmacy notified health care providers across the country of its revised policy for the dispensing of controlled substances.

The letter cited every pharmacist’s corresponding responsibility, along with physicians, to ensure that every prescription for a controlled substance “must be issued for a legitimate medical purpose.”

The letter said Walgreen’s pharmacists would start taking additional steps when verifying certain prescriptions for controlled substances. MMS has heard from several physicians inquiring about this policy.

Walgreens’ policy states: “Our pharmacists are required to take additional steps when verifying certain prescriptions for controlled substances. This verification process may, at times, require the pharmacist to contact you … information requested may vary, potential questions could include information about the diagnosis, ICD-9 code, expected length of therapy and previous medications/therapies tried and failed.”

According to an FAQ provided to the New Hampshire State Medical Society, Walgreens has emphasized that this new policy should not mean calls to prescribers on every, or even most, prescriptions for controlled substances.

Why did this happen?

Over the past few years, the Drug Enforcement Agency (DEA) has increasingly been looking at the problem of narcotics abuse in this country. While the DEA has investigated and prosecuted individual prescribers of prescription narcotics and synthetic opiates, the DEA is also looking at the distributors and dispensers of these prescription drugs.

The DEA has also been visiting states nationwide and presenting an intense power point lecture to help train pharmacists and remind them of their corresponding duty under federal regulations to ensure that each prescription for a controlled substance is issued for a legitimate medical purpose by each individual prescriber.

In response, Walgreens revised its policy on good faith dispensing of controlled substances, using in part “red flags” as determined by the DEA. Walgreens wants its pharmacists to be comfortable when they fill a prescription for controlled substances and the policy lays out suggestions on how to assure that the prescription is legitimate.

Where do things stand?

MMS has worked closely with the AMA in sharing information and gaining a perspective of this problem on the national scale.  The AMA, along with the national medical societies for family physicians, emergency physicians, anesthesiologists, and osteopathic physicians have been part of broad medicine-pharmacy meetings convened by the National Association of Boards of Pharmacy, with Walgreens, CVS, the National Association of Chain Drug Stores, National Community Pharmacy Association, PhRMA, DEA and other groups to identify “red flags” that stakeholders agree would warrant some sort of further review.  It is anticipated that this set will be reviewed by the stakeholders in Spring 2015.

Red Flags of Illicit Use, Doctor Shopping, and Diversion of Controlled Substances

For Physicians

  • Symptoms incompatible with reported injury
  • History of problems with no medical records
  • Patient reports being from out of town
  • Multiple accidents
  • Insistence on drug of choice
  • Requests drugs by their street names, e.g. “blues” “Ms”
  • Loss of prescription or medications
  • Failure to provide or go for medical testing
  • Taking more medicine than directed
  • Requests medicine refills early
  • Use medicines from multiple physicians or filled at multiple pharmacies (as seen on the Prescription Monitoring Program)
  • Use of medicines prescribed for others
  • Use medicines in combination with alcohol
  • Paying in cash or sometimes uses insurance and other times cash

For Pharmacists

  • Prescriptions for large quantities of a “cocktail” or “holy trinity” of opioids, benzodiazepines, and carisoprodol
  • Diagnosis of lower lumbar pain. DEA testified that 90 percent of the pill mill doctors use lower lumbar pain as a diagnosis code
  • Pattern prescribing. Prescriptions for the same drugs, the same quantities, coming in from the same doctor
  • Shared addresses by customers presenting prescriptions on the same day
  • Customers going to the pharmacy counter with dilated pupils and difficulty concentrating
  • Unusual physical distance between the doctor, the patient, and the pharmacy
  • Patients paying in cash or sometimes uses insurance and other times cash
  • Prescriptions done in a “factory-like” manner – no reason to prescribe 15mg and 30 mg oxycodone because 30mg tablets are scored down the middle
  • Use medicines from multiple physicians or filled at multiple pharmacies (as seen on the Prescription Monitoring Program)
  • Inordinately large quantity of controlled substance prescribed
  • Prescriptions refilled at inconsistent intervals based on quantity
  • Use of street drug name by either the patient or the prescriber
  • Suspicion of forged or altered prescription
  • Suspicion of forged or altered identification or refusal to provide

What should you, the prescriber do?

If you or your patients have difficulties filling prescriptions for controlled substances at any pharmacy please contact the MMS Physician Practice Resource Center at (781)434-7702 or pprc@mms.org.