President's Blog

We've heard statistics again and again - a small percentage of physicians are responsible for a large percentage of prescribing specific drugs. Earlier this month, the Wall Street Journal reported that 15% of NYC prescribers wrote 80% of opioid prescriptions in 2010, and that 1% of prescribers wrote 31% of opioid prescriptions. Among these prescribers, the Journal noted, oxycodone prescriptions rose by 86%.

The popular sentiment appears to be that these prescribers are doing something wrong. But as ASAM Member Michael Miller, MD, pointed out at a lecture during our recent conference, the statistics themselves prove nothing. If we looked, for example, at chemotherapy, it is likely that a very small percentage of prescribers write prescriptions for nearly all the medication prescribed. Prescription numbers may rise because of improved identification of disease that will respond to medication, or because of improved education of physicians as to how to prescribe a given drug.

I'm not arguing that this is the case with the increase in opioid prescriptions over the past years, but I am pointing out the critical nature of our using good science upon which to base our decision-making process. How our country should respond to the over-prescribing of opioid agents should be based on a scientifically sound process; a knee-jerk response that simply bans the prescribing of opioids or limits the prescribing to a fixed number of individuals per physician would result in suffering for those patients who need opioid treatment.

And here is where we get to the interesting part; we haven't seen any significant measures being taken along these lines except for a single drug: buprenorphine/naloxone. For this drug, we've seen limitations being imposed in situation after situation, from federal limits to state limits to insurer limits. Most recently, Kentucky's Medicaid provider, Coventry Cares, informed their members taking Suboxone that it would no longer cover the drug after the current prescription ended. Legal action was threatened and discussions ensued. KYSAM, our Kentucky chapter, was in the midst of it. And fortunately, after a few days, Coventry agreed to continue providing Suboxone coverage.

But we're not out of the woods in Kentucky yet. It still seems probable that some dosing limitations may be imposed as in neighboring West Virginia. In WV, patients on Medicaid are limited to a once per lifetime 60 day 24mg qd dosing, after which their maintenance dose is capped at 16mg. Maine Medicaid also has such a limitation. And in the meantime, we all remain confined to treating only 100 patients with a medication that has demonstrated value.

To recap, we have dozens of opioids and sedative-hypnotics which can be prescribed without any apparent limitation. I can prescribe high dose Vicodin and Klonopin to dozens of patients a day without significant fear of a DEA audit, without any limit to number of patients, and without any dosage limit. So why, when we have a reasonably safe drug which is nearly impossible to overdose on, which has a lower street value than other narcotics, and which is used to deal, in part, with the increasing fallout of overprescribed opioids, does this specific drug keep getting beaten on? I can think of only one reason - discrimination against addicts.

As a result of this discrimination, we have waiting lists that are triple the number of patients that we treat, we have guaranteed unannounced DEA audits in the midst of patient hours, and we have patients who are not allowed to fill their properly prescribed treatment under their insurance program because of economically and politically driven dosing decisions made by non-physicians.

These issues will largely be addressed on a state-by-state basis. ASAM depends upon its state chapters both for early alerts regarding new regulations and procedures impacting addiction treatment, and for response and testimony. Please stay active and in close touch with your state chapter leadership.

Twice each year, your ASAM Board of Directors conducts business of the organization in person. This is in addition to several teleconferences each year. One of the live meetings takes place in the two days before our annual meeting. We opened our meeting two weeks ago with a strategic planning session focused on the potential directions our organization can take in the coming years. Two choices rose to the top:

The first deals specifically with membership and our current eligibility requirements that only physicians can join. The Board discussed at great length the pros and cons of opening membership up to those other than physicians, and there are clearly arguments that can be made for both sides. Ultimately, the Board asked that our staff prepare information that explores in greater depth the mechanisms that might be utilized to accomplish this task. The simplest approach, that of removing the eligibility criterion and changing nothing else, would leave ASAM a very different organization ultimately.

To present an analogy, let's say that 500 of us are members of a tennis club. We decide to add a golf course so that we can attract additional members. 1000 golfers join the club. They decide the tennis courts are in the way of a planned driving range and putting green. The 500 original members, finding that the club no longer meets their needs, leave to start a new tennis club. Now you could say that this is a terrible analogy, that so long as the other healthcare professionals who join ASAM have the needs of all our patients at heart, we'd all have the same goals. But I think that while we'd largely have the same goals, it's critical to ensure that our current members' needs remain met even within an organization where they could be a minority. This will likely require some creative approaches to the membership model as well as our overall business strategy.

This is in the planning stages, so now is the time for you to provide input to your Board representatives.

The second strategic issue that we asked to have addressed is the possibility of ASAM certification for practices. Facilities currently can seek generic certification from a variety of sources, such as the Joint Commission. But there is no certification specific for addiction practices. A variety of reasons were considered as background for exploring this issue further. Among them was the issue of how one can distinguish a "pill-mill" from a vibrant and busy addiction practice. In a "pill-mill," a physician might issue a large number of prescriptions for controlled substances. In a busy addiction practice, the same is true. A glance at the volume of prescriptions will not differentiate between the tapering or appropriate maintenance of the addiction practice and the inappropriate prescribing of the "pill-mill." If ASAM developed a set of criteria by which practices could be certified, the certified practices would have some degree of protection as a result of their following reasonable peer guidelines. Here too, there are pros and cons that were quickly recognized and discussed, but ultimately the Board felt that this should be investigated as a potential organizational activity.

Here too, if you have ideas and thoughts, please bring them to your Board representatives so that we can discuss them.  

    
Our Board meetings are open. Any member can attend the entire meeting but for the rare occasion in which we go into executive session. If you're interested in attending, please let us know in advance so that we can send you a copy of the agenda and provide you with the date and time of the session.

It was a pleasure visiting with so many of you at our meeting in Atlanta!