President's Blog

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.

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!

There are some things that computers handle particularly well. Back in the 1970s, I used to help my father prepare his books for the accountant each tax season. We would sit up late into the evening adding columns of numbers and going through piles of canceled checks and receipts. After what seemed like a few weeks of this, everything was ready for the CPA. Now I simply set up Quicken to generate a report of the previous year. Weeks of potential work are boiled down into a punch of the OK button. There are those who would have us believe that online education and conferencing is an equivalent improvement over live conferences. The live conference involves a worsened carbon footprint, we're told, not to mention days away from the office and home.

And yet when I'm in the exam room with a patient, my treatment approach depends as much upon what I learn in the halls of medicine as in the classroom of medicine. I have no doubt that our Program Committee has put together their usual brilliant collection of presentations at our annual Med-Sci Conference later this month. It is for this reason that ASAM will capture every session from the conference to post on its e-Live Learning Center to provide all with the opportunity to learn from the leading addiction specialists and fulfill education requirements from the comfort of their home or office.

What I look forward to, however, are not only the sessions listed in the program but the unscheduled moments spent with friends, colleagues, and mentors as we discuss treatment, policy, and research approaches. These moments are impossible to recreate with a computer, no matter how inventive and imaginative we construct a website. The live meeting represents our chance to share, in person, with our fellow addiction specialists.

One of my pet peeves of some organizations is leadership-by-good-ol'-boy-network. I've worked hard with our Officers and Staff to ensure that we have new and diverse blood in our committee structure and our leadership moving forward. I hope those of you who have been coming to our annual meeting for years will enjoy the new faces of our organizational committees. And if you're interested in being involved, whether it’s your first Med-Sci or your twentieth, please introduce yourself and let me know what your interests are. For if it weren't for the efforts of our members over the years, and if it weren't for those same members speaking out before anyone recognized them, we wouldn't be able to do a fraction of the activities in which we're now involved.

So...come to Atlanta, enjoy the sessions, and don't forget to say hello. I'm looking forward to seeing you there.