President's Blog

We had a very successful meeting of the American Medical Association (AMA) last week with respect to addiction medicine. New AMA policies are now in place as follows:

• The AMA supports permanent authorization of and adequate funding for all states to have an operational Prescription Drug Monitoring Program (PDMP).
• The AMA considers all PDMP data to be protected health information.
• The AMA recommends that PDMP's be designed so as to make data immediately available upon clinical inquiry.
• The AMA recommends that PDMP's have connectivity across state lines.
• The AMA will promote medical school and postgraduate training focusing on pain medicine, addiction medicine and related issues.
• The AMA opposes federal legislation that would require physicians to check a PDMP prior to prescribing controlled substances.
• The AMA believes correctional facilities should provide addiction care meeting prevailing community standards, including appropriate referrals upon release.
• The AMA urges development of community-based programs offering naloxone and other opioid overdose prevention services.

The AMA House of Delegates explored issues pertaining to stigmatization of mental health disorders in medical professionals. We advocated for the removal of language on application forms for licensure, credentials, and other certification which asks whether the applicant has a diagnosis or history of a substance use disorder. This entire matter was referred to the Board of Trustees for decision, and we will undoubtedly have additional opportunities for input.

We attempted but failed to garner support for mandatory education tied to DEA certification. There was initially compromise language that would have offered physician’s benefits such as a decreased DEA certification fee in return for obtaining CME on the appropriate subject matter, but even this ultimately failed to be approved by the AMA.  However, we will surely revisit this at the next meeting in November, and I'm optimistic that we will obtain an acceptable compromise eventually.

The AMA's House of Delegates meets twice each year. I had the pleasure of working in this year's AMA meeting in Chicago beside Ilse Levin, Todd Kammerzelt, Norm Wetterau, Brian Hurley, Mike Miller, and Penny Mills, all of whom presented on so many occasions that we fielded numerous comments about the size of ASAM's delegation. Please let me know if you would like additional information about any of the new AMA policies. We would welcome additional members joining us at future AMA meetings. To participate, you need to be an AMA member in addition to being an ASAM member.

Several states, Connecticut being the latest, have moved in the direction of not providing coverage for prescriptions written for Medicaid-covered patients by physicians who do not accept Medicaid payments. There are several results of such behavior on the state's part, some of which impact physicians and some which impact patients. The primary difficulty for patients is that they will be unable to choose a physician based upon variables that are important to them. Back in the day, patients chose physicians based upon word of mouth. It was quickly understood in a community that Dr Smith was a relaxed and personable sort while Dr Jones was more matter-of-fact; Dr Smith made choices by virtue of experience while Dr Jones did so by virtue of his extensive scientific knowledge. Patients could also choose physicians based upon location. Dr Smith is a 5 minute walk from work, while Dr Jones is across town.

In recent years, patients have looked at whether a given doctor accepts payments from their insurance plan. But given how many of us do not accept any insurance payments, this is not the only factor. Patients continue to utilize other variables as important factors in their decision as to which physician to see. And indeed, if the actual cost of the prescribed medication is low, patients may continue to see the physician of their choice, simply paying out of pocket for both physician visit and medication. But for patients who are prescribed expensive medication that choice may now be off the table.

For these patients, Connecticut's decision has decreased access to care, and in some cases, eliminated access entirely. My understanding is that over 600 patients receiving buprenorphine/naloxone from physicians within the state will suddenly discover that their prescription is valid only if they pay cash for their medication. Very few of these 600 will have alternative access available once this policy is enforced. There will be hundreds of entirely predictable and avoidable episodes of relapse, decompensation, withdrawal and overdose. These episodes will potentially impact thousands more through the victims' friends and family.

For those physicians who have built their practices around the ability of patients to choose their physician, there may be a sudden decline in patient visits. This may result in physicians leaving their practices and thereby a further reduction of access. Ultimately, what is the goal of such regulation? It can't possibly save money for the state, which will ultimately be forced to cover emergency after emergency. It decreases the patients' access to care. It eliminates professional opportunities for physicians. We have added this to our list of priority items to be dealt with on a state-by-state basis.

Two DEA representatives met with us today to audit one of our physicians in my private group practice as a result of our being authorized under DATA-2000 to prescribe drugs for the maintenance treatment of opioid dependence. The meeting went smoothly and took well under one hour. This was the first time the DEA met with any of us. 

Under DATA 2000, physicians are authorized to prescribe to either 30 or 100 patients depending upon their qualifications. Using the 100 patient mark as a standard, it is important to recognize that the limitation applies to the physician, not to the facility. So if you prescribe to 50 patients at Facility A, you can prescribe to only 50 more at Facility B. Each physician as a result must maintain his or her own list of patients to be certain that the limitation is not exceeded. The DEA will call upon you at the address where you are registered (the address on your DEA certificate), so that is the location where you should have all your records pertaining to buprenorphine prescribing.

How does one count a patient? We use a spreadsheet that we update each time we issue a prescription. The spreadsheet calculates the end-date of the prescription, thus any patient with an active prescription counts toward the limit. If the prescription has run out, even if the patient is still counted as a patient in the office, the patient does not count toward the limit. At the end of each month, we print two hard copies of the spreadsheet identifying the total count per physician. One hard copy, for our records, includes the name of the patient. The other, for the DEA, includes only an identifying number.

So when the DEA agents asked to see our records for the last three months, we showed them the last three printouts with the names stripped off. Each line of the spreadsheet displayed the patient ID, the prescribed medication, the dose prescribed, and the expiration date of the prescription. The agents shared that this was precisely what they needed to see. They looked over the records for a few minutes, did not take them, and did not ask to look at any medical records. They noted that sometimes they request information covering the last two years of prescribing, so it would be best to maintain this type of information for at least that long.

We have a special Informed Consent form specifically for patients to be prescribed buprenorphine. The agents asked how we provide informed consent, and this document was shared with them.

The agents asked about the dosage of buprenorphine that we prescribe. We use 16mg as our maximum dose other than in extreme circumstances, and this is demonstrated on our spreadsheet; this appeared to be an acceptable response.

We had some difficulty responding to their questions as to what we do when patients have positive urine screens for opioids or for illicit substances. While we routinely screen all our patients on a random basis, patients often have a tendency to drop out of treatment if they are told to come in more frequently. We have observed that these patients often relapse entirely thereafter, returning to us after many months in far worse shape. We therefore utilize other therapeutic techniques designed to improve overall efficacy of treatment. The agents shared that this was typical, and that other facilities had shared with them their concern for this issue as well.

The agents were formal but friendly; the entire process was relaxed and comfortable though the physician being audited was understandably nervous. There are so many stories online concerning these DEA audits that are scary and concerning; I felt it would be sensible to report on a good experience with the process.