President's Blog

The nurse-anesthetist is starting a patient on anesthesia for an imminent surgical procedure. As the patient starts to fade, he sees a figure walking in the room in surgical scrubs. He thinks this person is the surgeon but then realizes that it's the bachelor’s level therapist who screened him for psychiatric issues prior to surgery. "Wait," he cries out, "you're a therapist, not a surgeon. There's no research to demonstrate that you can perform surgery!" The therapist lowers his mask and smiles. "That's true, but there's no research to say that I can't either."

This scenario is the basis of a nightmare with many specialties of medicine, but for some reason, addiction is treated by many who have no significant healthcare qualifications. And there has been no research demonstrating that these non-physicians have the necessary skills to treat a chronic medical illness. Even our research often utilizes a comparison group in which patients receive "treatment" from non-physicians. If Drug A is superior to Treatment as provided by midlevel clinicians, then Drug A is approved. No one bothers to demonstrate that Drug A is better than Treatment as provided by physicians. Is it because they cannot? Or is it because the perception is that there is no difference?

But of course as our nightmare therapist points out, there is no research to say that physician-provided treatment is any more effective than midlevel clinician treatment. Or that there isn't a wide range of quality among physicians themselves. Much depends on what question is asked, and how the question is worded. Let's say I ask, "Do anesthesiologists and nurse-anesthetists have equivalent rates of negative outcomes?" The answer is that, in fact, they do. So at first glance one might say there's no difference. But then let's ask a different question: "Given an emergent situation during a surgery, do anesthesiologists and nurse-anesthetists have the same rate of negative outcomes?" That comparison provides a very different outcome.

As we say in the airplane, nearly all pilots can get you from Point A to Point B safely. But throw in bad weather, an in-flight mechanical failure, and a bird strike and only the best pilot will successfully land the plane. The problem in life is that we never know if any one patient has these problems. From a population standpoint, we know most do not, but from an individual standpoint - as seen by any one patient - you want to be in the best hands at all times. I want the best pilot, the best physician, in any circumstance because I don't know if on this particular day, my patient will come up with a losing hand.

So who is the best? Lou Baxter, Penny Mills, and I met with NIAAA today. We'll share more about that meeting in future blogs, but I was particularly interested to hear of research funding being made available for comparative efficacy trials. We can finally begin to address the question as to which set of initials should be carrying out which role within addiction treatment. If in fact we're all the same, then we need to markedly reduce the educational burden on physicians entering this field - we would be shown to be overeducated for the given job. And if we're not the same, then we could speak out for our patients to ensure that they receive appropriate care for their illness just as we would expect given any other chronic medical condition.

My patients in Massachusetts who are on Medicaid are unable to fill prescriptions for Suboxone Film. It simply isn't covered by MassHealth. And if I should write them a prescription for Suboxone that exceeds 16 mg per day, the patient is required to obtain a prior authorization. The prior authorization takes three business days to go through the system. So imagine the scenario:

Mr. Smith has been on 16 mg of Suboxone and his last prescription runs out today. He shows up in my office, and we agree that his dose should go up to 20 mg. He goes to the pharmacy, they tell him he needs a prior authorization, and he suddenly is out of Suboxone because the PA will take three days to go through. And this will happen each time the prior authorization needs to be renewed should his dose remain above 16 mg.

The problems I face in Massachusetts are, however, nothing compared to the problems patients may have soon in Maine. The Maine budget task force recently recommended that MaineCare have a two year limit on Suboxone treatment. Strangely, the budgetary task force did not recommend a two year limit on pharmacotherapy for diabetes or hypertension. It appears that they picked specifically on those with opioid dependence in this round.

Given the increasing volume of complaints about issues of this nature that we're receiving, and the fact that problems are being described in far more than two states, we have established an Access to Pharmacotherapies Task Force. The new group will help coordinate ASAM's response to the roadblocks preventing our patients from receiving necessary treatment. We will be performing a state-by-state survey of policies. The group will undoubtedly also reflect upon the parity and Affordable Care Act related implications. And eventually, we will develop a document demonstrating that the economic impact of NOT providing appropriate care exceeds the cost of providing the medication, although we will certainly recognize that the budgetary silo into which the expense falls differs from the silo which eventually reaps the gains from the expense.

Are you interested in participating in the Task Force? Send us a note to let us know.