Archive for the ‘prescription monotoring programs’ Category

My Occupational Pet Peeves

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I feel like venting. It’s my blog, so I can if I want to. These things annoyed the stuffing out of me this week:

 Opioid treatment programs who list themselves as capable of dosing patients with both methadone and buprenorphine, but when the counselor calls to set up guest dosing for her bupe patient, they don’t really use buprenorphine.

That’s false advertising. Why do you waste everyone’s time by advertising something you don’t provide?

 Pharmacies who list prescriptions for patients in the North Carolina Controlled Substance Reporting System (my state’s prescription monitoring program) BEFORE the patient picks up the prescription.
I called the patient in to see me, and she denied filling the prescription listed on the NC CSRS. I called the pharmacy, and the patient is right. This pharmacy chain enters data as being filled before it’s picked up by the patient because they can’t do it any other way with their computer system.

If this database is worth doing, isn’t it worth getting it right?

 Patients being prescribed controlled substances by the VA (Veterans Administration) in my state don’t have their medication listed on our prescription monitoring site.
This is a patient safety issue. Why won’t the VA protect their patients?

 I call the doctor for one of my opioid treatment programs to discuss how best to coordinate his care. After spending five minutes on hold on the phone, a nurse comes on the line and says “Doctor is in with a patient right now. He can call you when he’s done.”
What the flip does Doctor think I’ll be doing when he calls me back? Sitting with my feet on the desk, playing free cell on my computer, waiting breathlessly for his phone call? No, I’ll be talking with my next patient.

This is doctor one-upmanship. When Doctor does call me, I’ll interrupt the patient I’m with, come to the phone, and it will be Doctor’s receptionist who says, “Hold for Doctor, please,” and I’ll have to wait a few more minutes if I’m lucky.

 New patients who don’t keep their appointments with me.
I don’t have many office- based Suboxone openings, what with the 100 patient limit. I can’t take every new patient who calls, so if you call at the right time and do get an appointment, please keep it, or at least call to let me know you won’t be there. There are other people I could see during the hour I set aside for you. And if you don’t keep that first appointment or call to cancel it, don’t call for another. I can’t afford to have you in my practice. Sounds harsh? Yes, maybe so, but I have financial realities to meet.

 Insurance denials of coverage for buprenorphine products (Suboxone, Subutex, Zubsolv, etc.)
Coventry (that’s right, I’m calling you out, you lame excuse for an insurance program) recently denied coverage for Suboxone films because my patient was found to have received a prescription for tramadol from a dentist.

First of all, my patient told the dentist not to prescribe any opioids because he was in recovery from addiction and had to be careful. My patient took the prescription his dentist gave him, on which was written both tramadol and an anti-inflammatory medication. He called my office and asked if he could take the anti-inflammatory. He didn’t ask about the tramadol because he didn’t intend to take it.

When we found his insurance company refused to pay for his monthly Suboxone prescription because he had filled a tramadol prescription, he told me he still had the tramadol at home, if it made a difference. I said yes, and asked him to bring it in, which he did. I did a pill count. All the pills were there, and I watched him discard those pills, and wrote a letter to his insurance company, appealing their decision to stop paying for his Suboxone.

That was last week. I haven’t heard back. For now, my patient is paying out of pocket for his medication, which as readers know, is not cheap.

Ah, I feel much better now….

Each State Gets a Report Card

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You have got the check this out…an organization called Trust For America’s Health, or TFAH, supported by the Robert Wood Johnson foundation, has released a report called, “Prescription Drug Abuse 2013: Strategies to Stop the Epidemic.” You can find the report at their website at: http://www.healthyamericans.org

This report grades each state on its policies for managing the prescription pain pill epidemic.

The report begins with a description of the scope of the problem: current estimates say around 6.1 million U.S. citizens are either addicted to or misusing prescription medications. Sales of prescription opioids quadrupled in the U.S. since 1999, and so have drug overdose deaths. In many states, more people die from drug overdoses than from motor vehicle accidents. The costs of addiction and drug misuse are enormous; in 2011, a study estimated that the nonmedical use of prescription opioids costs the U.S. around 53.4 billion dollars each year, in lost productivity, increased criminal justice expenditures, drug abuse treatment, and medical complications.

The report identifies specific groups at high risk for addiction. Men aged 24 to 54 are at highest risk for drug overdose deaths, at about twice the rate of women, although the rate of increase in overdose deaths in women is worrisome. Teens and young adults are at higher risk, as are soldiers and veterans. (Please see my blog of October 19th for more information about veterans.) Rural residents are twice as likely to die of an overdose as urban residents.

TFAH’s report declares there are ten indicators of how well a state is doing to fix the opioid addiction epidemic. This report grades each of the fifty states by how many of these indicators each state is using. TFAH says these ten indicators were selected based on “consultation with leading public health, medical, and law enforcement experts about the most promising approaches.”

Here are their ten indicator criteria:
 Does the state have a prescription drug monitoring program?
 Is use of the prescription drug monitoring program mandatory?
 Does the state have a law against doctor shopping?
 Has the state expanded Medicaid under the ACA, so that there will be expanded coverage of substance abuse treatment?
 Does the state require/recommend prescriber education about pain medication?
 Does the state have a Good Samaritan law? These laws provide some degree of immunity from criminal charges for people seeking help for themselves or others suffering from an overdose.
 Is there support for naloxone use?
 Does the state require a physical examination of a patient before a prescriber can issue an opioid prescription, to assure that patient has no signs of addiction or drug abuse?
 Does the state have a law requiring identification to pick up a controlled substance prescription?

 Does the state’s Medicaid program have a way to lock-in patients with suspected drug abuse or addiction so that they can get prescriptions from only one prescriber and pharmacy?

I thought several of these were bizarre. Several are great ideas, but others…not so much. For example, I think a law against doctor shopping leads to criminalization of drug addiction rather than treatment of the underlying problem. The addicts I treat knew that doctor shopping was illegal, but still took risks because that’s what their addiction demanded of them. Such laws may be a way of leveraging people into treatment through the court system, however.

And where are the indicators about addiction treatment? Toward the very end of this report, its authors present data regarding the number of buprenorphine prescribers per capita per state, but make no mention of opioid treatment program capacity per capita for methadone maintenance. Buprenorphine is great, and I use it to treat opioid addiction, but it doesn’t work for everyone. And there’s no data about treatment slots for prolonged inpatient, abstinence-based treatment of opioid addiction.

Expanded Medicaid access for addiction treatment is a nice idea… but not if doctors opt out of Medicaid because it doesn’t pay enough to cover overhead. If expanded access is not accompanied by adequate – and timely! – payment to treatment providers for services rendered, having Medicaid won’t help patients. Doctors won’t participate in the Medicaid system. I don’t. I have a few Medicaid patients whom I treat for free. It’s cheaper for me to treat for free than pay for an employee’s time to file for payment and cut through red tape.

In one of the more interesting sections in this report, each state is ranked in overdose deaths per capita, and the amount of opioids prescribed per capita.

The ten states with the higher opioid overdose death rates are: West Virginia, with 28.9 deaths per 100,000 people; New Mexico, with 23.8 deaths per 100,000; Kentucky with 23.6, then Nevada, Oklahoma, Arizona, Missouri; then in eighth place is Tennessee, with 16.9 deaths per 100,000. In ninth and tenth places are Utah and Delaware. Florida came in at number 11, with 16.4 deaths per 100,000.

North Carolina placed 30th in overdose death rates. We’ve had a big problem with prescription drug overdose deaths. From 1999 until 2005, the death rate rose from4.6 per 100,000 to 11.4 per 100,000. But at least our rate has not increased since 2005. The rate in 2010 was still 11.4. It’s still way too high, but many agencies have been working together over the past six years to turn things around. In a future blog, I intend to list the factors I think helped our state.

Use of the ten indicators does appear to correlate with reduced rate of increase of overdose deaths. In other words, states with more laws and regulations have had a slower rise in overdose deaths than states with fewer laws and regulations, though there are some exceptions.

This report also compares states by the amount of opioids prescribed per year, in kilograms of morphine equivalents per state per 10,000 people. Florida, not surprisingly, came in at number one, with 12.6 kilograms per 10,000 people. Tennessee and Nevada tied for second and third place, with 11.8 kilos per 10,000 people. The next seven, in order, are: Oregon, Delaware, Maine, Alabama, West Virginia, Oklahoma, and Washington. Kentucky was 11th, with 9.0 kilos per 10,000. North Carolina doctors prescribe 6.9 kilos of opioids per 10,000 people per year, in 27th place and less than the national average of 7.1 kilos.

It appears to me that amount of opioid prescribed per capita does correlate, somewhat, with overdose death rates.

Let’s look closer at Tennessee, the state who, just a few months ago, rejected a certificate of need application for an opioid treatment program to be established in Eastern Tennessee. In 1999, Tennessee had an overdose death rate that was relatively low, at 6.1 per 100,000 people. By 2005, it zoomed to 10.4 per 100,000 people, and by 2010, rocketed to 16.9 per 100,000 people, to be in the top ten states with highest overdose death rates. Furthermore, Tennessee is now second out of fifty states for the highest amount of opioids prescribed per 10,000 people. Only Florida beat out Tennessee. And lately Florida has made the news for its aggressive actions taken against pill mills, which may leave the top spot for Tennessee.

West Virginia is no better. It was the worst state, out of all fifty, for overdose deaths, at 28.9 per 100,000 people in 2010. Wow. If you think lawmakers are asking for help from addiction medicine experts…think again.

West Virginia legislators recently passed onerous state regulations on opioid treatment programs. That’s right, lawmakers with no medical experience at all decided what passed for adequate treatment of a medical disease. For example, they passed a law that said an opioid addict had to be discharged from methadone treatment after the fourth positive urine drug screen. In other words, if you have the disease of addiction and demonstrate a symptom of that disease, you will be turned out of one of the most evidence-based and life-saving treatments know to the world of medicine. West Virginia passed several other inane laws regulating the medical treatment of addiction.

Getting back to the TFAH study, the report calculates that there are 21.6 million people in the U.S. who need substance treatment, while only 2.3 million are receiving it. This report identifies lack of trained personnel qualified to treat addiction as a major obstacle to effective treatment.

This report makes the usual recommendations for improving the treatment of addiction in the U.S… They recommend:

 Improve prescription monitoring programs. Nearly all states have them, except for Missouri and Washington D.C.

States should be able to share information, so that I can see what medication my North Carolina patients are filling in Tennessee. Right now, I have to log on to a separate website to check patients in Tennessee, so it takes twice as much time. Tennessee is already sharing data with several other states, but not with North Carolina, or at least not yet.

TFAH also recommends linking prescription monitoring information with electronic health records.

 Easy access to addiction treatment.

Duh. The report accurate describes how underfunded addiction treatment has been, and says that only one percent of total healthcare expenditures were spent on addiction treatment. We know how crazy that is, given the expense of treating the side effects of addiction: endocarditis, alcoholic cirrhosis, hepatitis C, gastritis, cellulitis, alcoholic encephalopathy, emphysema, heart attack, stroke, pancreatitis, HIV infection, gastrointestinal cancers, lung cancer…I could go on for a page but I’ll stop there.

Access to treatment is limited by lack of trained addiction professionals. Doctors abandoned the field back in 1914, when it became illegal to treat opioid addiction with another opioid. Even with the dramatic success seen with methadone and buprenorphine treatment of opioid addiction, there are relatively few doctors with expertise in this treatment.

This reports shows that two-thirds of the states have fewer than six physicians licensed to treat opioid addiction with buprenorphine (Suboxone) per 100,000 people. Iowa has the fewest, at .9 buprenorphine physicians per 100,000 people, and Washington D.C. had the most, at 8.5 physicians per 100,000 people.

North Carolina has 3.2 buprenorphine physicians per 100,000 people, while Tennessee has 5.3 physicians per 100,000. This makes Tennessee look pretty good, until you discover than many of Tennessee’s physicians only prescribe buprenorphine as a taper, refusing to prescribe it as maintenance medication. If these doctors reviewed the evidence, they would see even three month maintenance with a month-long taper gives relapse rates of around 91% (1)

I’m really bothered by the lack of attention to the number of methadone treatment slots per capita. That’s information I’d really like to have. But the authors of this report did not deign to even mention methadone. Even with forty-five years’ worth of data.

**Sigh**

 Increased regulation of pill mills.

 Expand programs to dispose of medications properly. In other words, make sure citizens have a way to get rid of unused medication before it’s filched by youngsters trying to experiment with drugs.

I know many tons of medications have been turned in on “drug take-back” days. But I’ve never seen any data about how much medication is addictive and subject to abuse, versus something like outdated cholesterol lowering pills.

 Track prescriber patterns. Another benefit of prescription monitoring programs is that officials can identify physicians who prescribe more than their peers. Sometimes there’s a very good reason for this. For example, a doctor who works in palliative care and end-of-life care may appropriately prescribe more than a pediatrician.

I get uneasy about non-physicians evaluating physicians’ prescribing habits, though. I think this is best left up to other doctors, enlisted by the state’s medical board to evaluate practices. Other doctors are better able to recognize nuances of medical care that non-physicians may not understand.

 Make rescue medication more widely available. In this section, the report’s authors make mention of Project Lazarus of Wilkes County, NC, a public health non-profit organization dedicated to reducing opioid overdose deaths, not only in that county, but state-wide. Project Lazarus is well-known to me, since I work at an opioid treatment program in Wilkes County.

 Ensure access to safe and effective medication, and make sure patients receive the pain medication they need. Obviously, we want opioids available to treat pain, especially for acute pain. Hey, you don’t have to convince me – read my blog from this summer about how grateful I was for opioids after I broke my leg. Opioids were a godsend to me in the short-term, and knowing what I do about opioids, I didn’t use them after the pain subsided.

It was an interesting report, though I saw some unfortunate gaps in their information, particularly regarding opioid addiction treatment availability.

But at least this is another agency looking at solutions and making some helpful recommendations.

1. Weiss et al, “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” Archives of General Psychiatry, 2011;68 (12):1238-1246.

The Drug Czar Praises Project Lazarus

On Wednesday, August 22, the Drug Czar came to town.

Mr. Gil Kerlikowske, the director of the ONDCP (Office of National Drug Control Policy) gave the keynote speech at the Project Lazarus Symposium held in Wilkesboro, NC.

Being a drug czar isn’t as much fun as it sounds like it might be. It means Mr. Kerlikowske works hard helping to create the drug control strategy for the nation. His agency advises the president regarding drug-control issues, and sets the tone for the nation’s approach to drug addiction and treatment. For more information see my blog of April 20th, 2011. At the Project Lazarus Symposium in Wilkesboro, Mr. Kerlikowske gave the keynote speech and elaborated on these topics.

The Drug Czar came to Wilkesboro because of the impressive program Project Lazarus. Project Lazarus is a grass-root, non-profit organization established in 2008 in response to the very high rates of opioid overdose deaths in Wilkes County. That county had one of the highest drug overdose death rates in the entire nation, but over the last four years, those rates have dropped dramatically. For more data about these rates and about Project Lazarus, go to their website at:  http://projectlazarus.org

The ONDCP has placed more emphasis on prevention and treatment, acknowledging that law enforcement efforts alone won’t fix our nations’ problems. During his keynote address, Mr. Kerlikowske praised Project Lazarus and said it should be used as a model for communities in other states facing the same problem of overdose deaths.

Project Lazarus’ founder and CEO, Fred Brason, gave an overview of the components of the program and most recent data. Then Mr. Kerlikowske spoke for about twenty minutes, explaining the ONDCP’s vision for drug control policy. Then came a roundtable discussion where parties from various agencies and organizations explained their role with the project.

I was invited to the roundtable because I am the medical director at Mountain Health Solutions, an opioid treatment program in North Wilkesboro that prescribes both buprenorphine and methadone to treat patients with opioid addiction. This OTP is now owned by CRC Health, but was started by Dr. Elizabeth Stanton nearly three years ago, in response to the need for medication- assisted treatment in Wilkes County. At first, her program prescribed only buprenorphine, but later she saw the need for methadone for those patients for whom buprenorphine didn’t work.

I started working there relatively recently. I’ve been amazed at the number of patients presenting for treatment for pain pill addiction, nearly all of whom live in this relatively small community. At present we have more than three hundred and fifty patients enrolled in treatment.

As part of Project Lazarus, all of our patients receive a prescription for (free) naloxone kit to prevent opioid overdose deaths. I was invited to the Project Lazarus Symposium because in my blog on March 28th, 2012, I described how a patient of our OTP clinic saved a relative’s life by using one of the kits.

At the roundtable, I said a few words about the effectiveness of medication-assisted treatment using buprenorphine and methadone, and then made a few comments about the overdose death that was prevented with the naloxone kit.

Next, during the roundtable discussion, representatives from many different organizations and locations across North Carolina described the role Project Lazarus plays in their missions. Representatives from such disparate populations as the Cherokee Nation and the military at Ft. Bragg described how they used Project Lazarus’ programs to keep patients safer. Several epidemiologists gave information about the lowered overdose death rates in Wilkes County. A local doctor explained how doctors have revised their prescribing of opioids in the Emergency Department. We also heard from several people connected with the Harm Reduction Coalition, and from the county’s sheriff.

Representatives from state organizations such as the Governor’s Institute on Substance Abuse, the North Carolina Medical Board, the NC Department of Health and Human Services, and the NC Division of Public Health, Injury and Prevention all explained how they worked with Project Lazarus. For example, a portion of Project Lazarus’ activity has been to encourage physicians to sign up for – and use – our states’ prescription monitoring program.

We heard about the Chronic Pain Initiative, a program developed with the help of Project Lazarus, which helps educate physicians about the best practices of opioid prescribing. Initially meant for Medicaid patients, the Chronic Pain Initiative is now available to help all patients.

This initiative helps reduce overdose deaths by providing physicians with, among other things, a toolkit for healthcare providers. It gives them everything from evidence-based information about safe opioid prescribing to a form that can be filled out to gain access to the NC CSRS. It contains worksheets, flow sheets, and addiction screening tools. It contains everything a doctor could want to keep patients on opioids as safe as is possible, while still making opioids available for patients who need them.

I’ve blogged about this program in the past. I knew there was more to Project Lazarus than distribution of naloxone rescue kits, but I didn’t know the full extent of the Projects activities in the state. At Wednesday’s program, I was impressed as professionals from organizations across the state explained how Project Lazarus helps them prevent, intervene, and treat opioid addiction, and reduce overdose deaths.

I was inspired with the depth of knowledge and commitment of all of these people, and by their collaborative spirit. People in all strata of the community cared enough about overdose deaths that they were trying to fix the problem before more lives are lost. These groups were cooperating, which is essential. Both Gil Kerlikowske and Fred Brason took pains to emphasize the importance of working together and not against each other.

In other words, naloxone kits aren’t enough to fix the epidemic of opioid overdose drug deaths. Law enforcement can’t arrest our way out of this problem. Prescription monitoring programs aren’t enough to stop all drug diversion. It takes the sustained efforts of people different segments of the community, working together, to get results. No one intervention is enough. That was the bottom line message I got from the Project Lazarus Symposium and the Drug Czar.

Information from the ASAM Conference: the CDC

At the recent ASAM conference, Dr. Ileana Arias, Deputy Director for the Centers for Disease Control and Prevention, spoke at a plenary session, explaining the public health impact of our epidemic of prescription drug abuse and addiction. She did a great job explaining how bad the problem of opioid addiction has become in the U.S. She also had some great slides. The above slide shows how by 2008, poisonings overtook motor vehicle accidents as the number one cause of death in the U.S. Overwhelmingly, the poisonings were drugs, and the vast majority of these drug overdose deaths involved opioids. Dr. Arias explained the ice berg phenomenon, where for each person who dies from opioid overdose death, an estimated 118 are estimated to meet the diagnosis for opioid abuse and dependency. She presented information showing that the amount of prescription opioids sold quadrupled between 1999 and 2010.

Dr. Arias spoke at our conference to encourage us and to let us know the CDC was committed to help solve our nation’s prescription opioid addiction problem.

She outlined some of the measures the CDC is taking to help prevent opioid addiction and overdose deaths.  She explained the new lock-in programs now being used by some insurance companies, where the patient can have only one doctor and one pharmacy to prescribe and fill medications. The CDC is advocating for all states to have prescription monitoring programs, and for those state programs to be linked, so that a doctor can access medications filled in other states.

Dr. Arias mentioned the progress being made in Florida, where pill mills are being shut down. Unfortunately, some pill mills have moved to other states like Georgia, Texas, Louisiana, Ohio, and – my favorote state to criticize – Tennessee.

She also spoke of the success of medication take-back days, where people drop off old medication for appropriate disposal so that it doesn’t fall into the wrong hands, and she described many other actions the CDC has started.

This was all great information, familiar to those of us treating opioid addiction over the past five to ten years. I’m grateful the CDC has joined the effort to quelch this problem. Their resources and experience can help a great deal. I just wish all doctors in the country could hear her message.

The addiction medicine doctors had a chance to make comments and further suggestions to the CDC through Dr. Arias, and I was pleased to see how carefully she listened.

One of the suggestions I liked the best addressed the expense of maintaining state prescriptoin monitoring programs. Apparently these can cost around a million dollars a year to administer. One doctor said why not have the pharmaceutical companies that make and sell controlled substances pay or help pay for the monitoring programs? These companies are the main entities that have benefitted from the sales and diversion of their products; why not ask them to bear at least some of the cost for detecting the problems they cause? Genius, though it would be hard to mandate the pharmaceutical companies to do this.

One doctor suggested that law enforcement personnel be educated about the types of treatment available to opioid addicts, so they can stop being barriers toward effective treatments, namely medication-assisted treatments using buprenorphine and methadone.

Another doctor suggested the CDC promote the naloxone programs that provide kits to reverse fatal opioid overdoses. Why not help fund these projects and/or help create more? The Harm Reduction Coalition estimates there are around 155 naloxone programs in the U.S. Some are government-funded and some are privately funded, but around 10,000 fatal opioid overdoses have been reversed. Like Project Lazarus in North Carolina, many of these programs started at a grass roots level because citizens got involved.

Another doctor made the extremely common sense suggestion that the best way to allow more patients into suboxone treatment would be to allow doctors to treat more than one hundred patients at a time. At present, suboxone doctors are allowed to have no more than thirty patients on buprenorphine in their first year prescribing, and no more than one hundred after the first year. This would cost next to nothing for the government to implement, and expand treament dramatically.

One of our past ASAM presidents endorsed mandatory physician education as a requirement for maintaining medical license.

One person compared the prescription opioid addiction to HIV infection in past years, and commended the CDC on its past efforts to reduce the stigma associated with having HIV. This person asked the CDC to make public service announcements to help reduce the stigma of addiction, and encourge people to get treatment.

Another doctor asked the CDC to produce public service announcements telling people to lock up their medications, to prevent medication diversion to a teen or other person for whom it was not prescribed. This doctor also said that patients need to know that not all pain conditions require prescription opioids. He recommended telling the general public the true risks of opioid addiction, which have been downplayed. In the past, pain medicine experts underestimated the incidence of addiction in patients prescribe opioids for chronic pain for more than three months.

The CDC representative, Dr. Arias, confirmed that the CDC already has plans to make PSAs about pain pills and pain pill addiction, much like their present (and very successful) anti-smoking television PSAs.

All great information, and now let’s get the word out to all physicians, and the public too.

New Controls on Opioid Prescribing

As discussed in my last blog entry, prescription monitoring programs will help diminish our present-day epidemic of prescription opioid addiction, but these PMPs are just a start. State and federal governments are passing other laws, with the intent to reduce pain pill addiction.

For example, over the summer, Ohio enacted legislation aimed at physicians who primarily see patients prescribed opioids for chronic pain. Doctors prescribing opioids for more than 50% of their patients are now required to take periodic continuing medical education classes about the safe prescribing of opioids. These physicians are required to take a minimum of twenty hours of training every two years. Ohio also now says that physicians who own pain practices need to register with their medical board and undergo site inspections, as well as comply with patient-tracking requirements. Six other states now mandate doctors get yearly continuing education on pain management and the safe prescribing of opioids to maintain licensure from their medical boards.

Some doctors protest these measures, but this training is intensely needed. More than ten years ago, CASA (Center on Addiction and Substance Abuse at Columbia University) did a study that showed physicians are poorly trained to recognize and treat addictive disorders. Of doctors who were surveyed about the training they received in their residency programs, thirty-nine percent received training on how to identify drug diversion, and sixty-one percent received training on identifying prescription drug addiction. Seventy percent of the doctors surveyed said they received instruction on how to prescribe controlled substances. (1)

These findings are appalling. Thirty percent of doctors received no training on how to prescribe controlled substances in their residency programs.  Nearly a third of the doctors leaving residency – last stop for most doctors before being loosed upon the populace to practice medicine with little to no oversight – had no training on how to prescribe these potentially dangerous drugs. Sixty-two percent leaving residency had training on pain management. This means the remaining thirty-eight percent had no training on the treatment of pain.

 These doctors weren’t in specialty care. They were in family practice, internal medicine, OB/GYN, psychiatry, and orthopedic surgery. The study included physicians of all ages (fifty-three percent were under age fifty), all races (though a majority at seventy-five percent were white, three other races were represented), and all types of locations (thirty-seven percent urban, thirty percent suburban, with the remainder small towns or rural areas). This study shows that medical training in the U.S. does not, at present, do a good job of teaching doctors about two diseases that causes much disability and suffering: pain and addiction.

 Despite having relatively little training in indentifying and treating prescription pill addiction, physicians tend to be overly confident in their abilities to detect such addictions. CASA found that eighty percent of the surveyed physicians felt they were qualified to identify both drug abuse and addiction. However, in a 1998 CASA study, Under the Rug: Substance Abuse and the Mature Woman, physicians were given a case history of a 68 year old woman, with symptoms of prescription drug addiction. Only one percent of the surveyed physicians presented substance abuse as a possible diagnosis.  In a similar study, when presented with a case history suggestive of an addictive disorder, only six percent of primary care physicians listed substance abuse as a possible diagnosis. (2)

Besides being poorly educated about treatments for patients with addiction, most doctors aren’t comfortable having frank discussions about a patient’s drug misuse or addiction. Most physicians fear they will provoke anger or shame in their patients. Physicians may feel disgust with addicted patients and find them unpleasant, demanding, or even frightening. Conversely, doctors can feel too embarrassed to ask seemingly “nice” people about addiction. In a CASA study titled, Missed Opportunity, forty-seven percent of physicians in primary care said it was difficult to discuss prescription drug addiction and abuse with their patients for whom they had prescribed such drugs.

From this data, it’s clear physicians are poorly educated about the disease of addiction, as well as the safe treatment of pain. Medical schools and residencies need to critically re-evaluate their teaching priorities to include training in pain management and addiction. Until that can be done, states need to mandate yearly training for physicians on these topics, because most practicing physicians never got adequate training on these topics.

Most doctors are not happy about these government mandates. It’s human nature to resent being told you need more training, especially if it’s at your own expense. It’s difficult to get time off work for trainings and it’s inconvenient. Yet the alternative – no increase in training for practicing physicians – isn’t acceptable. The addiction rate is too high in this country to ignore, or to avoid taking actions.

Not all of the new state mandates are good ideas.

The state of Washington passed a law in 2010 that took effect in July of this year. It says only pain management specialists can prescribe more than the equivalent of 120mg of morphine per day for a patient. Non-pain management doctors cannot prescribe more than this, by law.

I think it’s alarming when lawmakers set dose limits for any medication. I don’t know of any other medication in any other state that has a dose limit set by non-physicians.

I assume Washington’s lawmakers had good intentions. They’re concerned about the rising numbers of opioid overdose deaths in their state. They based the cut-off of 120mg of morphine on a study (Annals of Internal Medicine, Jan 19, 2010) that showed patients taking more than 100mg of morphine, or its equivalent, were nine times more likely to have a drug overdose than those prescribe 20mg or less. But these lawmakers aren’t equipped to understand the real life complications that may occur due to this law. Government officials have already admitted they don’t know how patients will be able afford to see pain specialists, or even be able to find a specialist, since there aren’t enough pain specialists in that state. The government’s website explaining the new rules (3) also admits there are no lists of physicians pain specialists. I couldn’t find the state’s definition of a “pain specialist” on this website, so there will be confusion as to what this even means. If it means only doctors who are board-certified in pain management, that will surely be a very small number. Some doctors have said they will avoid prescribing opioids at all, given the additional regulatory burdens.

Other critics of this new law say it gives false gives reassurances to patients and doctors that doses under the 120mg cutoff are safe. We know that’s not true. Many times the danger lies in other medications, like benzodiazepines, that are prescribed with opioids.

This same law goes into great detail about how pain patients are to be screened before opioids for chronic pain are started, and how patients who are prescribed opioids are to be managed. Patients must be screened for past addiction, and for depression and anxiety disorders. The law outlines how patients are to be followed by their doctors. Washington’s lawmakers also mandate random urine drug screening of patients being prescribed opioids, and written patient agreements. The law gets in to specific details about what needs to be in the patient monitoring agreement.

Some doctors feel the government has overstepped its bounds and will interfere with physicians’ clinical judgments. Patients are already complaining that they have great difficulty finding doctors who will prescribe opioids to adequately treat their pain.

I support most legislation that helps physicians identify and treat opioid addiction, but I think Washington’s law has gone too far. Balanced, rational decisions are urgently needed. If we over-react out of fear, the pendulum will swing too far to the other side. Over-regulation could have unintended consequences including having patient in acute or pain or with cancer pain unable to get an adequate prescription for opioids.

  1. 1. Missed Opportunity: A National Survey of Primary Care Physicians and Patients on Substance Abuse, Center on Addiction and Substance Abuse at Columbia University, April 2000. Also available online at http://www.casacolumbia.org  
  2.  Under the Rug: Substance Abuse and the Mature Woman, Center on Addiction and Substance Abuse at Columbia University, 1998. Available online at http://www.casacolumbia.org
  3.  http://www.doh.wa.gov/hsqa/Professions/PainManagement/

More about Prescription Monitoring Programs

In October, Florida’s prescription monitoring program finally became functional. This means doctors in Florida (finally) can go to this database to see if their patients are being prescribed controlled substances by other doctors. The program isn’t mandatory. Physicians don’t have to use the system if they don’t want to do so. But in my opinion, if a doctor is prescribing controlled substances to a patient, particularly in Florida, it would be sloppy medical practice NOT to use this program. Doctors who are truly interested in indentifying doctor-shopping drug seekers will use this database.

Florida’s prescription monitoring program has been a long time coming. If you read this blog frequently, you’ll remember I was highly critical of Florida’s Governor Scott’s initial reluctance to allow a prescription drug monitoring program. His reluctance mystified me, given the tremendous numbers of pain pills being prescribed and dispensed in Florida. The pain pills prescribed and dispensed by Florida’s pill mills didn’t stay in Florida. They were exported north to states like Kentucky, Tennessee, North Carolina, and Georgia. This occurred so commonly that it became known as the “Flamingo Express.”

At present, only a few states are still dragging their feet about getting an operational program. As of now, only Missouri and the District of Columbia don’t have prescription monitoring programs, and have no plans to start one. (It seems odd that D.C., where lawmakers started the push for prescription monitoring programs, doesn’t already have a functioning program.)

In recent news reports, Florida’s Governor Scott said he felt the new laws that prevent physicians from both prescribing and dispensing pain pills are an important part of reducing Florida’s pain pill problem. Prior to these new laws, physicians were able to both prescribe and dispense opioid pain pills. This created a financial incentive for unprincipled doctors to prescribe opioids, since they then sold these opioids to their patient for more than the average pharmacy price. This practice was common in Florida’s pill mills. In 2010, Florida physicians bought 89% of all the oxycodone sold to U.S. medical practitioners.

In these recent news reports, around 80 doctors have had their licenses suspended due to their prescribing habits. These doctors often prescribed large amounts of opioids without demonstrating a clear need and without taking precautions to assure the “patients” they saw weren’t abusing the drugs.

 I believe this has already led to a relative scarcity of pain pills available on the black market in our state of North Carolina, and a subsequent increase in price. For the last month, the opioid treatment program where I work has seen a sharp increase in the numbers of addicts entering treatment. These patients say the same thing when I ask why they decided to seek help now: they’re spending too much money on pills, to the point of financial ruin, and pills are more difficult to find. One addict said, “I can’t find pills like I could. And when I do, I can’t afford them anyway.” Recently, addicts report spending more per milligram for illicit prescription opioids like oxycodone, morphine, and hydrocodone.

I don’t care whether it’s Florida’s new prescription monitoring program or their crackdown on unscrupulous doctors that’s causing fewer pills for sale on the black market in our area. I’m just thankful that it’s happening.

Readers of this blog, do any of you have opinions as to the availablility of black market prescription opioid drugs now, compared to several months ago?

National Prescription Drug Action Plan

Yesterday, government officials proclaimed the formation of collaborative plan to address this nation’s problem with prescription opioid abuse and addiction. Speakers included Mr. Gil Kerlikowske, the director of the ONDCP (Office of National Drug Control Policy), Dr. Howard Koh, from the department of Health and Human Services (DHHS), Dr. Margaret Hamburg from the Food and Drug Administration ( FDA), and Ms. Michele Leonhart, administrator of the Drug Enforcement Administration (DEA).

 Speakers recited pertinent statistics regarding the state of opioid addiction and abuse in the U.S.  It’s now the faster growing public health problem in our country. Around 28,000 citizens died from unintentional drug overdose in 2007, the latest year for which data is available.  More people in the U.S. now die of unintentional drug overdose than gunshot wounds. In seventeen states and Washington D.C., unintentional overdose deaths outnumber deaths from motor vehicle accidents.

 The plan has four main points. First, both patients and prescribers of controlled substances will be provided with better education about these potentially dangerous medications. The drug manufacturers will be asked to develop educational products for both patients and providers for education, which will be reviewed by the FDA before approved for release. The medications included will likely include sustained-release oxycodone, oxymorphone, hydromorphone, and methadone. Fentanyl patches will also be included. The ONDCP is seeking to introduce legislation that will change the Controlled Substances Act in order to make training mandatory for doctors who prescribe long-acting opioids.

 Second, the national government will push the few remaining states that don’t have function prescription monitoring programs to put them in place, and to be able to share data with adjacent states.

 Third, the government will support more medication “take back” days in communities across the U.S. Citizens will be encouraged to bring old medication to community sites in order for proper disposal. Previous take back days have been very successful, with tons of pills collected and disposed. This will reduce the number of prescription opioid pills available for diversion. Surveys reveal that round 70% of the pills obtained by people misusing prescription medication for the first time are obtained from friends and family members, often without permission, from old prescription bottles.

 Fourth, state and federal agencies plan to crack down further on rogue doctors and clinics that are “pill mills.” This will require participation from state medical boards, law enforcement, and the DEA.

 At the end of this presentation, Karen Perry, founder of NOPE, told the story of her son, a bright young college student who died of an unintentional drug overdose. She described how his death affected her and his siblings. Her face was etched with the grief that can only come from such a profound loss

 The goal of this plan is to achieve a 15% reduction in prescription opioid misuse in this country by at within the next five years.

 I’m so pleased to see this announcement. Back in 2001, when I first started treating prescription opioid addiction, I was amazed at the numbers of people seeking treatment for this disorder. Studies since then have shown the situation has gotten much worse.

 There will be problems with this plan. Many doctors will not be happy they must have mandatory training in order to be able to prescribe some controlled substances (probably schedule II). Some will stand up on their hind legs and protest this new regulation, if it is passed by congress. But after seeing the prescribing habits of some of my brethren and sistren, it’s obvious we need this. We don’t get much education about appropriate prescribing of opioids, recognizing addiction, and referral for treatment. I’ve blogged before about this (see February 10th’s entry)

 I’ve been blathering on to anyone who will listen about the need for prescription monitoring plans (see prior blog entries for March 6, 8, and 31), so I’m delighted more attention is being paid to this. But I still worry about how states will communicate with each other. For example, my practice is close to South Carolina, yet that state has denied me access to their database. The only allow access to doctors licensed in South Carolina. I use the prescription monitoring program in my state both at the two Opioid Treatment Programs where I work and in my own office, where I see Suboxone patients. I’ve been using it since 2007.

I support the pill “take back” programs. While such events probably won’t do much for those with established addiction, they can help reduce the number of new users and experimental users. Remember, opioid overdose deaths don’t just happen to addicts. Youngsters experimenting with opioids can die from overdoses. In fact, new users dabbling with these pills, because they think they’re safer than “street” drugs, may be more likely to die because they don’t have any tolerance to opioids.

 We need good judgment and balance when shutting down pill mills. How can the DEA tell a pill mill from a legitimate pain treatment practice? I believe this is best done by other doctors. In this state, the medical board does investigations, which I feel is more appropriate than having investigations done by law enforcement. Law enforcement personnel just don’t have the training to tell the difference between appropriate care and careless prescribing with disregard for patients. Let other doctors do that. Granted, a few places will be so obvious that little investigation is needed.

 We don’t want the opioid pendulum to swing to the opposite side again, and become completely opioiphobic. These pain medications are addictive, but are also godsends in the right setting and used in the right way. Let’s take care not to throw out the good with the bad. The best people to set policy in this area are well-trained doctors who approach this issue with common sense and balance.

 Coming as late as it does in this epidemic, I could be negative and say the government has had an epiphany of the obvious. But I do know it takes time for all of these agencies to come together in a cooperative manner and form a plan of action. I’m just thankful that action is finally being taken.

Usefulness of Prescription Monitoring Programs

I ranted recently about Florida’s Governor Scott’s bizarre decision to give the axe torpedo their prescription monitoring program (see March 8th, also March 6th). Now I’d like to post a link to a thoughtful piece about how prescription monitoring can have positive effects.

This link was found on Brandeis University’s Center of Excellence. These folks do research for public policy surrounding prescription monitoring, among other things. The first URL below is for their home page; the second is for the specific article that I thought was interesting.

 http://www.pmpexcellence.org

http://www.pmpexcellence.org/sites/all/pdfs/methadone_treatment_nff_%203_2_11.pdf

Governor Scott’s Flamingo Express to Misery

Flamingo Express of Florida

All I could think was, “What can he be thinking???”

 I was reading an article about the governor of Florida and his bizarre decision to block the formation of a prescription monitoring program in his state. (1)

 Prescription monitoring programs are databases that contain lists of controlled substances a patient receives, the prescribing doctors, and the dispensing pharmacies. Usually, only approved physicians can get access to these databases. Prescription monitoring programs help prevent “doctor shopping,” which is the term describing the actions of a patient who goes from one doctor to another to get prescription pills, usually opioids, without telling the doctors about each other. Addicts do this to supply their ever-increasing tolerance for the drugs. Drug dealers do this to get pills to sell and make money.

 Forty-two states have approved the formation of prescription monitoring databases, and thirty-four states have operational databases. Florida was one of the last to approve the formation of such a program, in 2009, long after this recent wave of prescription pain pill addiction burned through the country. Now, the new Florida governor wants to cut this program out completely, before it even starts.

 How big of a deal is this?

In the latest survey, 5.3 million people in the U.S. used prescription pain pills nonmedically over the past month. This means they used them in ways not intended, or for reasons not intended by the prescriber… for example, to get high. In the last year, 2.2 million people misused these prescription pain pills for the first time. Our young people are particularly at risk; between 2002 and 2009, the percentage of 12 to 17 years olds misusing prescription opioids rose from 4.1% to 4.8%. Not all of these people will become addicted, thankfully. Some will only experiment, and be able to stop before addiction develops. Many won’t be able to stop taking pills, and will progress into the misery of addiction. Others will die of drug overdoses. (2)

 Why pick on Florida?

Florida is infamous for its pain clinics. As a reporter for Time Magazine pointed out, there are more pain clinics in South Florida than there are McDonald’s franchises. In 2009, 98 of the top 100 prescribers of oxycodone in the nation were all located in Florida. Altogether, these doctors prescribed 19 million dosage units of oxycodone in 2009. Estimates of the numbers of pain clinics located in South Florida vary, but most sources say between 150 and 175. (3, 4) Many of these clinics are “pill mills,” where doctors freely prescribe controlled substances with little regard to usual prescribing standards and guidelines.

 Are all these clinics pill mills?

No. Some of the pain clinics are legitimate, and their doctors follow best practice guidelines, providing quality care to patients with pain. But careful monitoring and screening for adverse events, including the development of addiction, takes time. A conscientious doctor, trying  to do a good job, isn’t going to be able to see fifty pain patients in one day.

 I’ve talked to addicts who were previously patients at these pill mills. They describe how they were shuffled through rapidly, sometimes not even seeing the doctor. Some addicts say they were asked what pills they wanted, and quickly written that prescription, with little or no conversation beyond that. That was the extent of the visit. 

But Florida’s problem doesn’t stay in Florida. Appalachian states like Kentucky, West Virginia, and North Carolina all have addicts who buy these prescription pain pills after they’re transported out of Florida. The DEA sees so many pain pills being transported from Florida to Appalachian states that they call it the “Flamingo Express.” In one of the methadone clinics where I work, I’ve noticed a peculiar upswing in the reported use of Opana, a brand name for the drug oxymorphone. It’s not a drug I’ve seen prescribed much in NC. When I ask patients where the pills come from, many say, “Florida.”

 Governors of several states, including West Virginia and Kentucky, along with congressmen from New York and Rhode Island, have sent a letter to Florida’s Governor Scott, urging him to reconsider his decision to torpedo plans for a prescription monitoring program. Since the leading cause of death in West Virginians for those under the age of 45 is drug overdose, I can see why this governor is protesting Governor Scott’s poor decision. (4)

 It’s estimated that setting up a prescription monitoring program costs about one million dollars. The Florida Prescription Drug Monitoring Program Fund, Inc., a non-profit organization dedicated to raising money for the program, says on their website that they’ve already raised at least half of that from donations. Other states have received the Harold Rogers grant money, available from the federal government to set up these monitoring databases. This leads me to question the excuse of “budget cuts” as the reason for Governor Scott’s poor decision.

 I’ve also seen internet stories that mention the governor’s fear of invasion of privacy. This is a legitimate concern, but there are ways to safeguard the information in such a database, and laws that can regulate who has access. I’m no fan of the government peering into my business, but this database is essential, given the overwhelming numbers of people struggling with pain pill addiction. For a description of the ways in which the North Carolina prescription monitoring database has helped me help my patients, please see the preceding blog entry. It’s been a lifesaver.  

  1. http://articles.sun-sentinel.com/2011-03-05/news/fl-prescription-drug-forum-20110305_1_pill-mills-prescription-drug-monitoring-program-attorney-general-pam-bondi (accessed 3/6/11)
  2. Substance Abuse and Mental Health Services Administration (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings). Rockville, MD.
  3. Thomas R. Collins, Invasion of the Pill Mills in South Florida, Time, Tuesday, Apr. 13, 2010,  Ft. Lauderdale, FL
  4.  http://manchin.senate.gov/public/index.cfm/press-releases?   ContentRecord_id=f62482b4-f6dd-4adc-8b49-1563d8fa605b&ContentType_id=ec9a1142-0ea4-4086-95b2-b1fc9cc47db5&Group_id=e3f09d56-daa7-43fd-aa8b-bd2aeb8d7777&MonthDisplay=2&YearDisplay=2011 (accessed 3/8/11)

Use of Prescription Monitoring in Suboxone Patients

I enthusiastically use my state’s prescription monitoring program. This database is available only to physicians who have applied and been approved for access. It records all controlled substance prescriptions filled by a patient, the prescribing doctor, and the pharmacy where they were filled. This means it records prescriptions for opioids, benzodiazepines, anabolic steroids, most sleeping pills, and prescription stimulants. Any prescription medication with the potential to cause addiction will be listed. Medications such an antibiotics, blood pressure medication, etc, aren’t controlled substances, and aren’t list on the website. 

I use this database in several ways.

It can help me decide if a new patient is really addicted to opioids, and appropriate for treatment

If a new patient has a urine drug screen that’s negative for all the opioids, and has no record of getting prescriptions for opioids, I’ll have to see objective evidence of addiction before starting to treat him with Suboxone. But if the urine is negative, and I see monthly oxymorphone prescriptions (sometimes missed on urine drug screens) have been filled, it’s more likely this patient is appropriate for Suboxone treatment. Rarely, a misguided, misinformed person might claim to be addicted to opioids in order to be prescribed Suboxone. This happened once to me, with a patient who was addicted to Xanax, and was convinced Suboxone would cure her. I referred her to more appropriate care.

Using the database can help detect a relapse sooner

Most of the patients in my Suboxone practice (around 80%) are pill takers, not heroin users. When they relapse, it tends to be to prescription opioids, obtained from a doctor unfamiliar with their history of addiction. I check each patient on the state’s database just prior to each visit, and if there are medications on the site I didn’t know about, that will be the main topic of our visit. New medication on the database doesn’t always mean a relapse, so I need to listen to their explanation.

 When it does mean a relapse, the patient and I decide what to do next. Often, the patient decides to allow me to call the other doctor, agrees to increase her “dose” of counseling, and possibly her dose of Suboxone, if it was an opioid relapse. If there are repeated relapses, I may decide Suboxone, as an outpatient, doesn’t provide the support a patient needs. Then, I refer to another form of treatment. Usually this means to a long-term inpatient drug rehab, or to an opioid treatment center, where the patient comes to the clinic every day. Either way, I believe I’m able to address a relapse more quickly using the database.

 Frequently, Suboxone patients get prescriptions for benzodiazepines. That’s a problem for me. For a person without addiction, benzodiazepines can be helpful, mostly used short-term. But for people with addiction, they usually cause problems, sooner or later. People with a previous addiction to any drug, especially including alcohol, need to regard prescription benzodiazepines as high-risk medications.

 I try to be flexible, too. If a traumatic event has occurred in the life of a patient, I may OK benzodiazepines short-term, provided I can see the patient more often and have good communication with the doctor prescribing the benzodiazepines.

  I also have to remember the body reacts the same to a mixture of opioids and benzos, no matter why they’re taken.  Even though Suboxone is safer than methadone, it’s still not safe when mixed with benzos, when taken for any reason.

If this sounds wishy-washy, that’s because it is. So many situations arise in the lives of patients that one hard and fast rule just doesn’t exist. That’s the art of medicine.

 Is the patient filling Suboxone on time?

The database also shows me when patients are filling the Suboxone prescription. If I write a prescription today, but the patient doesn’t fill it for two weeks, what’s going on there? Has he relapsed for several weeks? Did he have a stockpile of Suboxone from a previous prescription? Was he unable to afford it until now? All these questions and their answers are important to guide treatment.

 It makes me happy.

It warms my heart to see a patient who had a long list of opioid prescriptions from multiple doctors before starting Suboxone, then after entering treatment, see only Suboxone. This occurs in the majority of my patients.

My state’s prescription monitoring program is one of the best tools to help patients that I’ve ever seen. I believe it’s saved many lives. I think it’s just as important as drug screening for my Suboxone patients. Of course, the best tool for recovery is the counseling. I prefer 12-step recovery, as that provides ongoing support even after Suboxone treatment, but any kind of counseling helps. The patients I see doing the best are the ones involved in both formal counseling, in group or individual settings, along with 12-step meetings.

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