Page 9 - Volume 70 Number 2
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There were only physicians on the panel: Steve Bell, D.O., Health Services Director for the Pokagon Band
of Potawatomi representing the Michigan Osteopathic Association, and R. Corey Waller, M.D., Senior Medical Director for Education and Policy at the National Center for Complex Health and Social Needs/Camden Coalition of Healthcare Providers (CCHP), formerly
an emergency physician and specialist in addiction medicine at Spectrum Health. With the exception of two pharmacists and one mental health administrator, the rest were politicians, government officials,
and law enforcement personnel.
Their report begins by recapitulating national statistics
from the CDC and the National Institute on Drug Abuse, but also includes some data from the Michigan Automated Prescriptions System (MAPS), which recorded a 24% increase in prescriptions for controlled substances between 2007 and 2014 associated with a quadrupling of pill counts. The increase in deaths due to overdose is emphasized. After 3 months, the task force produced its recommendations, shown in the adjoining Table. If you read through all the recommendations, you will recognize a few of them (a cynic might say, the ones that had no budgetary requirements) found their way into the new law, which was signed by Lt. Gov. Calley in December 2017.
It is apparent from the tenor of the task force report and the legislative history (see separate article) that legislators felt the pressure to “do something” but did not have the interest, background or wherewithal to actually try to deal with all the various underlying social and economic causes. What legislators do have the power to do is to regulate the practice of medicine. Their political response to the crisis, as a result, has been to place a majority of the blame on physicians and restrict their ability to prescribe.
I am not arguing that physicians have not played a significant role in creating the problem; they have, in particular a small number of those who have operated pill mills and participated in pharmacy kickback schemes. The pertinent question is whether the new restrictions and barriers placed on prescribing will have any noticeable impact on curtailing the problem of deaths due to drug overdose. It could well place a large population of patients with current opioid dependence in a worse position than they are at present, because physicians are going to be heavily discouraged from prescribing Schedule II-V drugs and when these prescriptions are stopped, patients will develop withdrawal symptoms. Who will take care of them? See the related article in this issue, “Poor Prescribing or Poor Pain Management?”
Right now, one cannot avoid the feeling that as physicians, we are going to be judged going forward on the basis of our Schedule II – V prescribing practices, and the people doing the oversight are not necessarily going to be our peers. The Michigan Board of Medicine, which was never part of the process, will now have to work under heavily prescriptive rules that reflect law enforcement’s perceived concerns but ignore patient care realities.
Where Do We Go From Here?
The causes of the opioid crisis are many and complex. The new legislation does not make it easier for physicians to manage their patients with pain management needs, it makes it harder. It does not expand the access to specialized pain management or set up systems to assist physicians to practice better pain management, it makes them feel they will be penalized for doing the wrong thing. There is already some blowback on the unintended consequences of one of the new rules, namely the requirement for a “bona-fide doctor patient relationship.” Legislation has been introduced to defer implementation of that aspect of the law for at least a year to allow time to modify it to make align better with reality.
Table 1. Michigan Prescription & Opioid Abuse Task Force Recommendations. The three recommendations that found their way into law have been highlighted
in boldface.
  Require additional training for all professional who will be prescribing controlled substances.
  Encourage the development and maintenance of relationships among state and local agencies to provide necessary information regarding prescription drug abuse, prevention and treatment.
  Collaborate with local coalitions, pharmacies, health profession boards, state agencies and the DEA to increase availability of prescription drug drop-off bins.
  Review successful state and local collection programs for possible replication and expansion.
  Review programs and parameters established within the Medicaid system as well as actions taken by other states to determine the best route forward to eliminate doctor and pharmacy shopping.
  Review programs already in use in Tennessee and Washington to determine how their systems operate and if any of those systems would work in Michigan.
  Develop a multifaceted public awareness campaign to information the public of the dangers of abuse, how to safeguard and properly dispose of medicines, publicize improper prescribing practices, and reduce the stigma of addiction. The state should try to partner with pharmaceutical companies on this campaign.
  Allow pharmacists to dispense Naloxone to the public in a similar fashion to how pseudoephedrine is dispensed.
  Create a public awareness campaign about the laws that limit civil and criminal liabilities for administering Naloxone.
  Explore the possibility of limited statutory immunity for low-level offenses involved in reporting an overdose and seeking medical assistance.
  Explore ways for the state to increase access to care, including wraparound services and Medication >>
Volume 70 • Number 2 Washtenaw County Medical Society BULLETIN 9

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