Your Practice Made Perfect
This podcast series provides support, protection, and advice for today’s medical professionals. Brought to you by SVMIC, a mutual insurance company that is 100% owned and governed by our policyholders.
May. 11, 2018
Episode 015: Taking Great Pains
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Speaker 1: You are listening to Your Practice Made Perfect. Support protection and advice for practicing medical professionals. Brought to you by SVMIC.
Brian: Hello and thanks for joining us, we're going to be talking about updates on prescribing laws today and joining me is Miss Julie Loomis. I am Brian Fortenberry. Julie, welcome.
Julie: Thank you Brian, I'm happy to be here.
Brian: As we start today, why don't you tell us a little bit about yourself. I know you work at SVMIC, but kind of fill in some of the blanks for us.
Julie: Well great, I started in SVMIC about 12 years ago, after a nursing career. I returned and went to law school, and decided I wanted to get into something different out of the hospital and so I picked up on risk management. So I joined the Risk Management Department, which has now become the Risk Education Department and I'm currently the Assistant Vice President for SVMIC of risk education.
Brian: Well fantastic. One of the hot topics that has been in the news for some time is the opioid epidemic and it is just that, it is an epidemic. It has caught the attention of just about everybody out there in the nation and seems to be spurring on some legislatures to create a number of new prescribing laws and making changes out there. Can you tell us a little bit more about what's out there with that right now?
Julie: Absolutely, as you said, I don't think it's a surprise to anyone that the United States is facing an unprecedented opioid crisis. As you mentioned it's in the news almost every day, but even worse, it's really creeping into our communities, our schools...
Julie: … and even our homes. So, what I'd like to talk about today is no so much the crisis itself, but what the states and legislature, and nationally, that we're trying to do in response to this crisis.
Brian: Absolutely. And there is a push out there is there not? From these legislatures to put law into place, to try to quale some of that back. What does that look like? Is it different on a state by state basis? Or is there more of a national blanket over this? Maybe you can fill in some of those blanks for us.
Julie: Yes, there has always been a national push toward this, but what really elevated this, was when this past October 26, when President Trump directed the Department of Health and Human Services to declare the opioid crisis a national public health emergency. What that does, is it provides appropriations and more funding for some of the state and local efforts that have already been in place for quite some time. Following that declaration, the President's commission on combating drug addiction and the opioid crisis released a report with over 50 recommendations, which kind of gives us a peek behind the curtain so to speak on what's on the forefront. But as you mentioned, states have been enacting laws for a number of years. Particularly in Tennessee, which is the homebase state for SVMIC. So, we've been exploring this and responding to this as a company and as a state for quite a while.
Brian: Explain to me, one of the terms that I hear very often is this phrase or this term, “doctor shopping,” you hear about that in the opioid epidemic and explain to us exactly what that is, and what that means for the opioid crisis.
Julie: Well “doctor shopping” generally refers to a patient whose attempting to obtain controlled substances from multiple healthcare practitioner's without that practitioner's knowledge of those other prescriptions. So all 50 states and the District of Columbia have a general fraud statute adopted from provisions from the Uniform Narcotic Drug Act of 1932, so this goes back ages.
Julie: Twenty states have also enacted specific doctor shopping laws, essentially prohibiting a patient from obtaining a prescription for a controlled substance by knowingly misrepresenting or withholding information from a practitioner. State “doctor shopping” laws such as we have in Tennessee, may actually even specify other elements such as a disclosure time frame, maybe the patient only have to report within the past 30 days. Types or classification of drugs, maybe they don't have to report that their taking a stimulant, but they have to report if they're taking an opioid. If that makes sense...
Julie: Or disclosure of receipt of the same or similar controlled substance for the same therapeutic use. So many medical offices and pharmacies have posted notices to warn patients that “doctor shopping” is illegal.
Brian: How do they keep up with this doctor shopping going on. How is it monitored? How do you know that someone, I'm assuming that it takes the part of many in the medical community from physicians, to nurses, to pharmacists, to whoever, to kind of get all of this information together and put the pieces together. But, how do they keep up with it? And how to they know?
Julie: That's right. Essentially, there's a prescription drug monitoring database in every state, except Missouri. Missouri has some local counties that are doing it, but all states have a prescription drug monitoring database. There isn't a national database that's currently in use.
Julie: And that has its own problems, because you obviously want to have some interstate data being transferred back and forth. But in Tennessee, it's called the Controlled Substance Monitoring Database. So, the state run electronic database promotes safe prescribing and dispensing practices for controlled substances. And what it typically does, it requires retail pharmacies, instate, mail-order, or even internet, to report all controlled substances dispensations into this database. Depending on state law, these dispensers report this controlled substances in either real time, every 24 hours, three days, up to eight days, depending on the state. So there's a market difference in the variation of access. The database calculates the patient's MMEs per day. Which is really the amount of milligrams of morphine an opioid dosage is equal to when prescribed. That's really what the database is for, is to alert physicians and other practitioners, with prescribing privileges to identify patients at risk of opioid misuse, abuse, overdose, and as you mention “doctor shopping” diversion… things like that. The database is probably the single most effect and important tool that clinicians can actually use for those purposes. Not for prescribing purposes, but for this identification.
Julie: Licensure boards also use them to support these investigations. And when you talk about “doctor shopping,” Tennessee has a mandatory reporting rule. So, if there's an opportunity for a practitioner to solicit information from a patient about recent use of drugs of the same class or for similar purpose, and if they don't take that opportunity to disclose that information, then in Tennessee at least the physician has a duty to report that within five business days to law enforcement. And these “doctor shopping” communications are not privileged in a number of states so they lose that doctor-patient privilege because of the fraud aspect of that. But, yes the database is how that is primarily discovered.
Brian: So that is mandatory for physician's to use in each state then, correct? As it sounds like each state put their own database together. So is it mandated from legislatures or whatever that they use that?
Julie: Exactly, only 16 states currently require checking the database before prescribing certain controlled substances. 36 states has specific circumstances where the prescribers require to access it. So there's a little bit of a difference there.
Brian: This is obviously not a way to monitor all medications that anyone has owned. You said that MME was one, which stands for Morphine...
Julie: … Mili-Equivalence. Right.
Brian: Okay, so you're really just looking at this for narcotics or addictive type of medications or things of that nature. In this database, can you tell the number of pills or the number of doses that have been given out? Because I know one of the pushes has been the number of pills that are prescribed at any one time. Can you tell us a little more about that?
Julie: Yes. That's exactly what the databases will do also. They show, hopefully at some point, real time prescribing history, and it'll give you the pharmacy and whether they paid cash, or commercial insurance, how that was accepted, and it will tell you the drug dosage and the amount, the number of pills dispensed. Sometimes there's only a partial fill, because the pharmacy may not have the number of doses required. So then that should be displayed appropriately, so that it doesn't adversely inflate a patient's MME. But it will also, which is a huge benefit, it automatically calculates that MME. Because certain drugs have a different Morphine Equivalency, if that makes sense.
Julie: So doctors don't have to hold their calculator out. The database does it for them. In Tennessee for instance, the range for acceptable, if you will, Morphine Mili-Equivalence per day, per patient is 90 to 120. However, the CDC had a guideline, March 2016, and theirs is 50 to 90. So you can see there's a discrepancy, which somehow causes confusion for some prescribers, absolutely. But, the CDC also noted a three day supply for acute pain, should be enough to treat most conditions. And that's what really started, I believe, this landslide of other legislation and states, and health plans, looking at putting hard stops on the number of pills. Supply reduction is certainly a national and state health goal to get that supply reduction.
Brian: So is there a number of pills that a physician can prescribe at any one time? Or are they just looking to stay in the state's level of what is the MME? How do they know what's acceptable and what's not acceptable? As far as the number of pills in a prescription.
Julie: Well the physicians as this point for the most part are allowed to use standard of care, their clinical judgment, and decision making, in determining hopefully, to treat the underlying medical condition. What would be the most appropriate pills, but at the state level, 17 states have enacted rules to limit the number of opioids prescribed generally in an acute pain situation.
Arizona, Connecticut, Delaware, Massachusetts, New Jersey, and Ohio have all passed laws limiting the duration of initial opioid prescriptions to five or seven days. Other states are passing dosage limits on the dosage and, in Kentucky, a law went into effect recently capping opioid prescriptions for acute pain to only three days.
Brian: Wow. So this is a slippery slope or a difficult situation to find doctors in because they're having to use their own judgment based on standard of care, it sounds like, but then also meshing that with what the laws are in their particular state. So, this has gotta be difficult for a physician practicing today to know exactly what to do. Correct?
Julie: Yes. It definitely is, because although there are the CDC guidelines, those guidelines were intended for primary care physicians. Sure, there are specialty guidelines out there. There are guidelines for the veterans administration. Other states, such as Tennessee, Washington, and many others, Kentucky, have guidelines that are intended to be utilized by all practitioners for the most part in prescribing for chronic pain. But again as you mention, they're not condition specific or discipline specific. They're typically this range. It's a great starting point, but I think that's where we're going in the future, will be to have more discipline specific, treat the underlying medical cause, but that's gonna be up to the specialty of societies and associations to determine what the standard of care, so to speak, might be for those particular conditions. At least as a starting point.
Brian: That does make sense. And even a step further than that, physicians that are practicing in cities that really border two states are going to have to really be up to par on those laws, because they could be looking at a different set of laws in one state, and then as they cross the line, maybe a different set of laws in the other state. So that could be pretty tricky, as well... and then on top of that, my understanding is, now we have some health insurance programs and even some large chain pharmacies that are enacting some of their own stipulations, and their own laws around this. Can you tell us maybe a little more about their policies and rules, and how they interact and how that really affects this process?
Julie: Yes. There are a lot of chain pharmacies who are looking at putting their own hard stops on the supply, so to speak, of these drugs. By saying, if it's for a certain condition, they're gonna put a seven day limit, or they're not going to dispense a prescription for a benzodiazepine and an opioid if they're written by different providers. Because one of the goals of safe practicing and prescribing of opioids for chronic pain management is to have the patient sign a treatment agreement that states they will use one provider and one pharmacy. That's just another way to help with this. But pharmacies long have been requiring pre-authorizations for certain drugs. They require step therapy, for instance you might have to try a certain drug before you can go up to the next drug.
Brian: I understand that there are more screening processes out there that are being emphasized by prescribers and monitoring techniques to identify certain patients who are potentially at more of a risk for some of these opioids and some medications than others. Is there a rhyme to reason of that? And, could you give us an overview of these types of screening tests? What are they? How do they use them to help with this problem?
Julie: The toll that I'm hearing the most about in conferences and opioid discussions is the SBIRT, which is S-B-I-R-T. It's the Screening Brief Intervention and Referral to Treatment evaluation tool. It's an evidenced-based systematic method to screen for problematic use of all substances and, depending on accumulative score, you follow up with a brief intervention or referral to specialty treatment. The good thing about SBIRT, and even other screening monitoring tools, is that health care systems are incentivizing these by issuing billing codes to them. In some instances, the physicians can be reimbursed for providing this tool. Another one is call SOAPP, it's Screener and Opioid Assessment for Patients with Pain, this is a 24 item patient completed written risk assessment questionnaire. Some studies have shown that it has a good sensitivity of any patient completed questionnaire. It's best at identifying those patients who may later engage in medication aberrant behavior.
Brian: Are these screenings and monitoring techniques, are they required by law? Is that part of that system of monitoring? Or is this something that certain practitioners and physicians can use on their own, in addition to these other laws and regulations to help prescribing problems?
Julie: That's a great question because they're not prescribed by law per se. However, they do appear in the guidelines, they're not required screening assessment tools are strongly encouraged, they're part of a checklist, if you will. In that clinical decision making process to determine what opioids and what the risk factors are, for this patient sitting in front of you. Honestly, I think in large part the opioid is going to start becoming less the drug of choice because the idea is to keep opiate naïve patients, opiate naïve. If that makes sense?
Julie: So if there's anything else out there, they would like to try to use that instead.
Brian: So Julie, what are some other future laws and policies that are out there in the works right now for deterring this abuse and misuse of opioids that we have in our population?
Julie: Earlier I mentioned the President's commission on combating drug addiction and the opioid crisis released a report with other 50 recommendations. I'll just mention a couple of those here, so that we'll know what is possibly coming down the pipeline. Addressing the lack of nonopioid alternatives for pain management is high on the list. Supply reduction as we mentioned. Rapidly increasing capacity for drug treatment under Medicaid, by granting waiver approvals for the states to eliminate some barriers to treatment that had resulted from other federal laws. Increasing the use of medication assisted treatments like buprenorphine and suboxone for opioid use disorders. Those are big ones. Encouraging the development of non-opioid pain relievers, by pharmaceutical companies. Broadening good Samaritan laws, including naloxone. Naloxone, we haven't talked about yet, but naloxone is very important in saving lives after an opioid crisis, a personal crisis, an overdose potentially. There are good Samaritan laws that shield individuals from prosecution when they report a drug overdose to first responders or law enforcement officials and naloxone is very easily administered. Most states have enacted laws, and the public is very aware of these laws. That you can get naloxone in many states, your physician or even your pharmacist may be able to dispense that even to a friend or family member of someone who is being prescribed an opiate.
There's also increasing electronic prescribing of controlled substances. To prevent diversion and forgery, and “doctor shopping.” So, with some exceptions, New York practitioners are already mandated to electronically prescribe both controlled and non-controlled substances. And a long those same lines, the prescription drug monitoring data, should be becoming more integrated with electronic health records. Particularly in emergency rooms, so it's just a one click, and you know you're in the database, you're gaining access, just more fluid and seamless access is very important.
Brian: How are the different states getting the word out there, now about their own efforts to reduce the abuse of controlled substances, what are they presenting and putting out there to help assist with this?
Julie: It seems the number one method is mandatory prescribing education for their prescribers. That's where it all really starts. 23 states and the District of Columbia, have requirements for physicians and other prescribers including nurse practitioners, physician assistants, and anyone else who has a prescribing privilege to obtain a certain number of continuing education hours in certain topics, related to controlled substances: pain management, identifying substance use disorders. In Tennessee, for instance, we require education specifically addressing controlled substances, it's a two hour educational program currently and it also has to specifically educate on the chronic pain guidelines.
Nearly 120,000 physicians have completed course administered by state's specialty societies, insurers, like SVMIC, on opioid prescribing pain management, addiction and related areas in 2015 and '16. So that's really getting the word out a lot. But also, many states are creating their own public health campaigns and are collaborating with other stakeholders, such as medical societies, insurers, hospital facilities, Veteran's administration and so forth, and holding opioid summits and forming coalitions to have a goal of creating a consistent message and doing that through education. So we'll just have to stay tuned on that.
Brian: And when you're talking about collaborating with all of these different entities, certainly SVMIC wants to play a part in this collaboration effort. What resources do you have here that might be able to assist physicians with this?
Julie: Absolutely. State Volunteer has created opioid specific resources and really controlled substances prescribing resources for several years for our physician policyholders. Particularly, as it relates to this prescribing education. Every other year, we set a live seminar, specific to opioid prescribing or some prescribing topic, and we present that in an entire year, pretty much in a live format. We also collaborate with Tennessee Medical Association, we're going to collaborate with Arkansas Medical Society to create a consistent message as well. So that we're all hitting on the same topics, so that a physician or other prescriber that attends any of our programs, can come back with the same tools and message to help reduce this crisis.
Brian: Well I think maybe we can make some of those documents available in our show notes here with this podcast. Julie, thank you so much for being with us today.
Julie: Thank you.
Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host, Brian Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes at svmic.com/podcast. The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policy holders are urged to consult with their personal attorney for legal advice. Specific legal requirements may vary from state to state and change over time
The contents of this Podcast are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time. All names have been changed to protect privacy.
About our Guest
Julie Loomis is Assistant Vice President of Risk Education for SVMIC where she develops educational programs and assists policyholders and staff with risk management issues. Ms. Loomis is a member of the Tennessee Bar Association, Medical Group Management Association and American Society of Healthcare Risk Managers (ASHRM). She recently contributed to ASHRM’s Medication Safety Pearls. She serves on the Risk Management Committee of the Physician Insurers Association of America. Ms. Loomis is a speaker on risk management and professional liability topics at medical professional association meetings, medical schools and residency programs, and industry seminars.
About our Host
Brian Fortenberry is Assistant Vice President of Underwriting at SVMIC where he assists in evaluating risk for the company and assisting policyholders with underwriting issues. He has been involved with medical professional liability insurance since 2007. Prior to his work at SVMIC, Brian worked in the clinical side of medicine and in broadcast media.