Drug Abuse

The President’s Podium: Reclassification of HCPs Reasonable

Posted in Drug Abuse, Health, opioids, Regulation on August 22nd, 2014 by MMS Communications – Comments Off on The President’s Podium: Reclassification of HCPs Reasonable

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. 

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 on The President’s Podium: Tracking Prescription Drug Abuse

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. 

 

AMA President: A Prescription for Opiate Abuse

Posted in Drug Abuse, opioids, Public Health, Uncategorized on June 20th, 2014 by MMS Communications – Comments Off on AMA President: A Prescription for Opiate Abuse

Attention and activity directed at the persistent problem of opiate abuse are continuing to increase in the Commonwealth, as policymakers, regulators, legislators, and public health officials propose solutions and programs to address the epidemic.

The latest effort is a collaboration of five New England Governors, who announced on June 17 a unique agreement to work together across state borders to address the problem of opiate abuse, focusing on the monitoring of prescriptions and increasing addiction treatment.

The agreement prompted a thoughtful piece from American Medical Association President Robert M. Wah, M.D. Published online in The Boston Globe on June 18,  Dr. Wah offered a five-point prescription to fight prescription drug abuse, emphasizing treatment and prevention.

The piece adds to the perspective of Massachusetts physicians, previously expressed by MMS Immediate Past President Ronald Dunlap, M.D.  in April in newspapers across the Commonwealth.

Most important, Dr. Wah’s commentary raises the physician’s voice on a critical national issue, offers the assistance of the nation’s leading physician organization in working with governors and legislatures to reduce prescription drug abuse, and demonstrates that physicians seek to be part of the solution.

Opiate Abuse: The Physician’s Perspective

Posted in Drug Abuse, opioids on April 10th, 2014 by MMS – 1 Comment

DSC_0003 Dunlap 4x6 color 300 ppi_editedBy Ronald W. Dunlap, M.D.
President, Massachusetts Medical Society

Across Massachusetts, lives are being wasted. State Police have recorded nearly 200 deaths from drug overdoses since November, but the actual number could be even higher, as figures from the largest three cities – Boston, Worcester, and Springfield – are not included in the totals.

The Commonwealth is not alone. The Centers for Disease Control states that death from drug overdose is now the leading cause of injury-related death in the U.S. While drugs like heroin remain a prime cause of such deaths, CDC’s most recent figures show that most – 60 percent – of the more than 38,000 annual drug overdose deaths in the U.S. are related to pharmaceuticals. And of those, 75 percent involved opioids or prescription painkillers.

Thus Governor Patrick’s declaration last month of a public health emergency regarding heroin and opioid addiction was appropriate and welcome.  Physicians share the Governor’s concern and support his goal of reducing opiate abuse.

His directive that first responders carry Naloxone is something we have long supported.  The $20 million commitment for treatment is a good initial response to increase help for addicts. His focus on youth is desirable, with teen prescription drug abuse jumping 33 percent since 2008 according to the Partnership at Drugfree.org.

His ban on a new form of hydrocodone should be the subject of legitimate discussion about its use and potential impact in clinical practice and its addiction potential. A balance must be achieved so that patients can truly benefit from its ability to control chronic pain. Opioids are important therapies to treat acute pain after trauma or surgery, as well as to manage chronic pain, including end-of-life care.

Those who follow the drug abuse issue point to physicians as part of the problem. We write too many prescriptions, they say, and are too quick to fulfill patient requests for painkillers. Balancing pain management and potential overprescribing is an area of constant physician concern.  The treatment of pain is complex and individualized for each patient, and the addictive potential of any medicine that could be harmful gives any caring physician pause. And while some physicians have been found to prescribe painkillers for financial gain, these outliers represent a tiny portion of the physician population and should rightfully pay the consequences for violating ethical and clinical standards.

Physicians are not standing on the sidelines. We have had multiple discussions about solutions to the problem with legislators, patient advocates, and other professionals that prescribe pain medications, as well as with representatives of the Department of Public Health and the Board of Registration in Medicine.

Twenty years ago, the Massachusetts Medical Society helped to establish the Prescription Monitoring Program. We have consistently provided input into the program. It remains the best tool we have to combat prescription drug abuse. An accurate and accessible database can provide data on all prescriptions, including prescriber, dispenser, and patient usage. It can alert regulators to physicians who might be overprescribing or patients who might be “doctor shopping” for controlled substances.

We support the automatic enrollment of all prescribers and dispensers and call on them to participate fully in the program.  We also believe improvements to the program, such as establishing real-time information and integrating the program into electronic health records, will enhance monitoring and reduce diversion of drugs.

Other actions should also be considered. As the respected CommonWealth Magazine has noted, no hard data exists on the state’s opiate problem. We need better and updated information. We must learn more about the source of these drugs:  How many are stolen, taken from home medicine cabinets, obtained illegally from street dealers or out-of-state sources, or bought on the internet? Answers to these questions will help target preventive efforts.

Pharmaceutical companies must play a role in assessing any discrepancies between the manufactured supply of medicines and actual patient demand, as their market studies usually include these estimates.

Drug take-back or return measures can be expanded. The Medical Society, for example, has advocated for legislation requiring pharmacies to have a “take back and disposal” policy for unused and expired medications.

We must also recognize the patient’s role. In the final analysis, the drugs are in the patient’s hands, and responsible use, storage, and disposal are absolutely critical. More patient education is a must.

Prescription medications are some of medicine’s best therapies, and yet they’ve become the root of one of today’s biggest public health problems. The Governor’s declaration has properly elevated opiate abuse to a public health priority; his call to action should represent just the beginning of a sustained analysis and long-term effort for solutions.

This article appeared as a commentary in several Massachusetts newspapers this week.

DPH Proposes New Regulations for Prescription Monitoring Program

Posted in Department of Public Health, Drug Abuse, Regulation on February 15th, 2013 by MMS – 8 Comments

Rules May Apply to All Physicians and Prescribers

The Department of Public Health this week presented draft regulations to the Public Health Council to implement changes to the state Prescription Drug Monitoring Program (PMP).

The draft regulations spell out the requirements for review of 12 months of prescribing history in the PMP database by all fully licensed physicians and other professionals for new patients and those who have not been seen in the past 12 months. This requirement appears to be proposed for any patient encounter, regardless of the likelihood of prescribing being indicated.

While there are some exceptions to the requirement listed and more possible in future guidelines, the MMS had hoped the proposed regulations would be more reflective of the demands of clinical practice than the initial draft has proven.

The MMS has engaged the DPH in discussions around the proposed regulations and on recent changes to the drug control registration program done without regulations or public comment and which require submission of email addresses and certification of compliance with the PMP requirements as a condition of receiving a state registration.

The MMS recognizes that limitations of the state database system and federal grant requirements for adherence to specific patient privacy protections have probably had an impact on the DPH in its decisions.

Physicians who cannot meet the new requirements are urged to contact the Department for a waiver of the email requirement. MMS government relations staff is interested in your experiences if you have been subject to a registration recall in 2013. We are also interested in your experiences with the PMP database .

A meeting with DPH staff on the proposed regulations and MMS’s concerns with changes to the drug registration process is scheduled for early March. The MMS continues to investigate options in responding to these initiatives.

There will be a public hearing on the regulations March 22. A final vote is likely at the April Public Health Council meeting.

Physicians are urged to review the proposed regulations and the DPH vision for the PMP program. Future MMS communications will provide more details.

– William Ryder, Esq.

November Physician Focus: Youth Substance Abuse II

Posted in Drug Abuse, Physician Focus, Public Health on November 1st, 2012 by MMS Communications – Comments Off on November Physician Focus: Youth Substance Abuse II

Sometimes a subject is worth another look, and November’s Physician Focus does just that with youth substance abuse.

The numbers show just how serious the problem is:  By the time of high-school graduation, eight in ten teens have reported using alcohol, four in ten smoking marijuana, and almost one in ten taking prescription drugs for nonmedical reasons.

“Teen substance use is very common,” says Sharon Levy, M.D., M.P.H., (photo, right) Director of the Adolescent Substance Abuse Program at Boston Children’s Hospital. “That makes it difficult for us to know how serious the problem is, or what to do about it, until we have more information such as the results of a screen or a full assessment.”

Dr. Levy, who specializes in adolescent substance abuse and development and behavioral pediatrics, continues the conversation on youth substance abuse begun in the July episode of Physician Focus.  In discussion with host and primary care physician Mavis Jaworski, M.D., (photo, left)  Dr. Levy points out ways parents can talk with their children about substance abuse, how parents might spot a problem, the role of the primary care physician in addressing abuse, and the services and treatment options provided by the Adolescent Substance Abuse Program at Boston Children’s Hospital

Physician Focus is available for viewing on public access television stations throughout Massachusetts.  To view online, visit www.physicianfocus.org. The program is also available on iTunes at www.massmed.org/itunes.

 

Debate on Prescription Drug Bill Resolved; Goes to Governor for Signature

Posted in Drug Abuse, e-prescribing, Pharmaceutical Industry, Regulation on August 9th, 2012 by MMS Communications – 1 Comment

The Massachusetts House and Senate today resolved the debate over a proposed prescription drug monitoring bill intended to increase scrutiny of the way prescriptions are handled. The bill now goes to Governor Patrick for his signature.

According to State House News Service, the bill would limit the number of doctors who overprescribe medications that may be abused or illegally sold and would increase participation in the state’s Prescription Monitoring Program (PMP) by prescribers – a tactic that can be used to identify patients who might be engaged in “doctor shopping”  to gain drugs.

The compromise bill contains provisions that the MMS had advocated for: automatic enrollment in the Prescription Monitoring Program and a required check of the database only for new patients.  MMS had argued that automatic enrollment would increase registrations, currently numbering only 1,800 out of 40,000 some prescribers in the state, and that mandatory use of the system would negatively affect long-standing physician-patient relationships.

Under the bill, participation in the PMP by those who prescribe controlled substances would be mandatory, but enrollment becomes automatic upon license renewal – a provision that the Medical Society said would reduce administrative burdens on physicians and avoid a cumbersome process of paper applications. The bill also says prescribers would only be required to consult the PMP for new patients, and dropped a requirement that physicians check the database before prescribing painkillers to a patient for the first time –a condition the MMS had opposed, saying that any law should allow prescribers to use their professional judgment in treating a patient.

Among the bill’s other provisions as reported by the News Service: Medicaid patients who fill 11 prescriptions from four doctors or at four different pharmacies within 90 days would be put on a watch list; pharmacies would be prohibited from filling prescriptions for narcotics unless written by a doctor licensed and registered in-state, or in one of the five contiguous states to Massachusetts and Maine; a ban on the drug called “bath salts;” pharmacies and drug manufacturers must report thefts to local or state police and the Drug Enforcement Agency; prescriptions for controlled substances would have to be written by doctors on “secure,” tamper-proof prescription pads already required for Medicare and Medicaid patient; pharmacies will be required to sell drug lockboxes, but they will only have to advertise them near registers; the Department of Public Health will provide patient information on the dangers of Class II and Class III drugs; and a working group of physicians will be tapped to write a “best practices” guide for prescribing opioids.

 

July Physician Focus: Youth and Substance Abuse

Posted in Drug Abuse, Physician Focus, Public Health on July 2nd, 2012 by MMS Communications – Comments Off on July Physician Focus: Youth and Substance Abuse

Substance abuse by adolescents is a growing personal and public health  concern, and all too often it turns deadly. Such behavior accounts for almost 60 percent of accidental deaths among teens and poses significant risks to their physical and mental health as well as their success in school and later life.

The July episode of Physician Focus, Youth and Substance Abuse, takes an in-depth look at this issue with John R. Knight, M.D., Director of the Center for Adolescent Substance Abuse Research at Boston Children’s Hospital, Associate Professor of Pediatrics at Harvard Medical School, and one of the nation’s foremost experts on adolescents and substance abuse. Hosting the program is primary care physician Mavis Jaworski, M.D.

The topics of conversation include how alcohol and marijuana affect the teenage brain, why adolescents are at greater risk than adults with these substances, the consequences of abusing these substances, the growing incidence of prescription drug abuse, the warning signs and symptoms parents should look for, and steps to take to prevent these problems.

Physician Focus is available for viewing on public access television stations throughout Massachusetts. To view online, visit www.physicianfocus.org. The program is also available on iTunes at www.massmed.org/itunes.

 

MMS President: State Can Do Better On Prescription Drug Checks

Posted in Drug Abuse, Health Policy, Mass. Legislature on February 9th, 2012 by MMS Communications – 2 Comments

By Lynda Young
President, Massachusetts Medical Society

The Massachusetts Senate’s recent unanimous passage of a bill to expand the state’s Prescription Monitoring Program is well intentioned, addresses a serious and growing problem, but, like The Boston Globe editorial of February 8 that speaks to the issue, falls short of addressing the heart of the matter.

Since 1992 when the PMP was established (with Massachusetts Medical Society support), the Department of Public Health has electronically recorded every prescription for Schedule II drugs, and since 2010, every Schedule III through V as well.  DPH has had regulatory and statutory mandates to review those prescriptions to find doctor shoppers and prescribers who overprescribe.

Its efforts, however, have fallen short, as no meaningful data, such as cross referencing Schedule II prescriptions with overdoses in the PMP database, has been compiled.  Prescribers are already registered with the DPH, yet are not given automatic access to the database, so additional registration by physicians would only seem redundant.  Further, prescribers are not notified of doctor shoppers among their patients with any frequency, another action that could reasonably be taken with an electronic system and an accurate read of the database.

An electronic database is a strong tool in the fight against prescription drug abuse, but the data must be accurate and timely. Real-time information, instead of that from the current lag of 10 days in pharmacies reporting to the DPH, is better.

Let’s also recognize that a major source of the prescription drugs being abused come from outside the state – a fact reported by the Cape Cod Times – and confirmed by law enforcement – in an eye-opening three-part series, “Pills that kill,” published in September of 2010.

We’re  keenly aware that “doctor shopping” is part of the problem, and that means that doctors can be part of the solution.  As prescribers, we are willing and eager to help. But it is not, as The Boston Globe suggests, “inconvenience”and “technophobia” that prevent us from enthusiastically backing the proposed legislation.

Before the state adds more administrative and costly steps, and before we take those steps that may risk delaying and denying appropriate care to patients who require it, let’s recognize that we have an adequate system in place. We should use it to its fullest capacity.

New: Read Dr. Young’s  Commentary on CommonWealthMagazine.org

This post was updated on February 15, 2012.

MMS President Shares Concerns With Senators On Prescription Drug Abuse Bill

Posted in Drug Abuse, Health Policy, Mass. Legislature, Public Health, Uncategorized on February 2nd, 2012 by MMS Communications – 2 Comments

In a letter delivered today to state senators, MMS President Lynda Young,  M.D. shared physician concerns on Senate 2122, An Act Relative to Prescription Drug Diversion, Abuse and Addiction, proposed legislation intended to address the growing problem of prescription drug abuse in the Commonwealth. Here is the text of her letter:

The Massachusetts Medical Society shares your concern over high rates of opioid abuse in Massachusetts.  The Society works closely with the legislature and the Patrick administration to address the problem and frequently hosts events targeted at educating physicians regarding responsible prescribing habits, pain management, drug diversion and patient education.  Most recently, the MMS collaborated with the Board of Registration in Medicine to implement CME’s for physicians on pain management.  We are proud of our efforts to reduce prescription drug addiction and diversion, but realize more could, and should be done.

S.2122, “An Act Relative to Prescription Drug Diversion, Abuse and Addiction” is a good multi-pronged approach to the problem of prescription drug abuse.  The MMS supports language in the bill designed to increase the usefulness of the prescription monitoring program as a valuable clinical tool in prescription decisions.  We support the production and distribution of educational materials to inform and enlist consumers in actions that will protect their families from access to narcotics and help patients decide their treatment options.  We strongly support the provision of limited immunity from drug possession charges and prosecution when a drug related overdose victim or a witness to an overdose seeks medical attention.  The Society also looks forward to working with the Executive Office of Health and Human Services on a joint policy group to investigate best practices for reducing diversion, abuse and addiction.

However, the Society must register its concern regarding S.2122’s mandate that all prescribers enroll in the Prescription Drug Monitoring Program, some by next January, and utilize the program before prescribing any schedule II or schedule III drug.  While a very useful tool, the PDMP is still evolving and the MMS questions its ability to accommodate the needs of twenty thousand or so new practitioners in a timely and useful manner.  For some physicians, including those who may fall into the “high prescriber” category like emergency physicians, time is of the essence.  Primary care providers have a jam-packed schedule and checking with the program several times a day during a patient visit may extend waiting times for patients, extend clinical hours for overworked clinicians and distract providers from patient care issues unrelated to abuse.  What if the system is down, or unavailable?  Would the physician be prohibited from writing the necessary prescription?

First it is essential that the DPH has the capacity to develop good quality data on prescriptions and that the data is accurate and meaningful.  A phased-in registration process that begins with high volume prescribers of schedule II opioids is a reasonable approach which we support.  Mandating review of patient records in the PMP prior to an initial prescription for oxycontin is a reasonable approach to gain value from the PM P.

The legislation should require the DPH to make outreach efforts to all prescribers detailing the program’s benefits and making free and quick on-line registration for physicians available before mandates are initiated.  By working with Board of Registration, the DPH could issue secure passwords and registrations to all actively licensed providers with prescribing privileges in the Commonwealth.

Coming on the heels of last year’s mandate for pain management CME’s for all physicians who write prescriptions for any medication, the MMS would further suggest that the working group created in Section 18 of S.2122 should begin its investigation and study into best practices for reducing drug abuse, and that those recommendations be considered prior to any further legislative mandates or requirements.  One point for consideration is to remove mandates for pain management training for physicians who do not write prescriptions for opiates and other pain medications.

In conclusion, the MMS appreciates the efforts of Senator John Keenan and the Mental Health and Substance Abuse Committee and looks forward to continuing to work on revisions to S.2122 and other initiatives to reduce prescription drug abuse.

Sincerely,

Lynda M. Young, M.D., F.A.A.P.