By Alix C. Michel and David J. Ward
Alix C. Michel and David J. Ward, with Michel & Ward, Chattanooga, Tenn., have a combined 50 years of legal experience, primarily in medical and professional malpractice and prescription drug abuse matters. Their expertise in prescription drug abuse prevention is sought nationwide. Michel and Ward presented on “The Legal Issues of Prescription Drug Diversion, Signs and Strategies” at the first National Rx Drug Abuse Summit and can be reached at firstname.lastname@example.org and email@example.com.
The misuse and abuse of prescription drugs have taken a devastating toll on our communities. To address the problem, a number of promising strategies have been developed at both the national and state level in consultation with hospitals, medical professionals, law enforcement and public health/drug prevention experts. In October 2013, the Trust for America's Health (TFAH) issued a report identifying the 10 most promising strategies being employed at the state level. This article will examine four of those strategies and suggest modifications/adaptations that can be made by health care institutions looking to address prescription drug misuse and abuse.
The TFAH noted it is important to educate providers about the risks of prescription drug misuse to prevent providers from prescribing incorrectly and/or to ensure they consider possible drug interactions when prescribing a new medication to a patient. The report further noted that most medical, dental, pharmacy, and other health professional schools currently do not provide in-depth training on substance abuse and students may only receive limited training on treating pain.
In July of 2012, the Food and Drug Administration approved a risk evaluation and mitigation strategy (REMS)for extended release opioids that requires manufacturers to fund voluntary painkiller training programs, at little to no cost, to all U.S. licensed prescribers. The FDA then issued a letter to prescribers, which was distributed by the American Medical Association (AMA), American Academy of Family Physicians (AAFP), the American Academy of Physician Assistants (AAPA), the American Academy of Pain Management (AAPM) and American Society of Addiction Medicine (ASAM), which recommended that prescribers take advantage of those educational programs.
How critical is the need for re-education regarding prescribing of opioids? In May 2013, Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, stated: “When I went to medical school, the one thing I was told was completely wrong. The one thing I was told was if you give opioids to a patient who is in pain, they will not get addicted. Completely wrong. Completely wrong. But a generation of doctors, a generation of us grew up being trained that these drugs aren't risky.”
If Dr. Frieden is correct, then shouldn't health care institutions emphasize the re-education of prescribers who hold privileges in their facilities? Should re-education be considered as a mandatory part of the credentialing process and peer review? Those adaptations at the institutional level may help speed up the re-education process Dr. Frieden is calling for.
The TFAH noted that 49 states have an active prescription drug monitoring program (PDMP). These programs hold the promise of being able to quickly identify problem prescribers and individuals misusing drugs. The Prescription Drug Monitoring Program Center of Excellence at Brandeis University, the National Alliance for Model State Drug Laws, the Alliance of States with Prescription Monitoring Programs and other organizations have stressed the importance of PDMPs in fighting prescription drug abuse and misuse and improving patient safety. These organizations also have issued a variety of recommendations and best practices for PDMPs including interstate operability, mandatory utilization, expanded access, real-time reporting, use of proactive alerts, and the integration with electronic medical records.
While some providers have bemoaned mandatory use of the PDMP as something that will take time away from their “one on one” patient interactions while adding to their administrative burden, the TFAH also reported that 16 states require use of the PDMP by providers (in certain situations). However, of those states, only eight require use of the PDMP before the initial dispensing of a controlled substance. This finding is appalling in light of the recommendation from the Brandeis University center that utilization of PDMPs should be mandated for all prescribers.
How many departments at our local hospitals are currently using the PDMP? Emergency departments long have been the target of drug seekers who frequent ERs with complaints specifically designed to help them obtain pain meds. Several states currently limit the duration/amount of such meds that can be prescribed in the ER and many ER physicians check the PDMP before prescribing pain killers. Are such practices uniform throughout your community? And what about the other departments in the hospital that may benefit from using PDMPs? For example, if a trauma patient arrives and pain meds are part of his/her treatment, does the hospital's prescribing physician check the PDMP for red flags?
The majority of health-care providers rank patient health and safety as a priority, and given the undeniable prevalence of the misuse and abuse of prescription drugs, this goal only can be furthered by health care institutions' aggressive use of the PDMP. A review of institutional polices with regard to using PDMPs may go a long way in helping to reduce the misuse and abuse of prescription drugs.
The TFAH noted that in 2011, 21.6 million Americans, age 12 and older, needed treatment for a substance abuse problem, but only 2.3 million received treatment at a substance abuse facility. This is clear evidence of a “treatment gap” where treatment is not readily available for millions of individuals who are in need.
The authors have experienced firsthand the need for additional substance abuse treatment during radio shows we have hosted on prescription drug abuse issues. Invariably, several callers express frustration over not being able to receive substance abuse treatment either for themselves or a loved one and want to know where they can go to find needed care. Sadly, some resort to committing a crime so that they may receive the treatment they need while incarcerated.
The TFAH found that 24 states and the District of Columbia have expanded Medicaid under the Affordable Care Act (ACA), thereby expanding coverage of substance abuse treatment. Should health care institutions consider expanding their coverage/provision of substance abuse treatment? If they are part of an ACO, should the hospital/institution consider taking steps to ensure that substance abuse treatment comprises some portion of the ACO?
According to the TFAH, 17 states and the District of Columbia have a law in place to either provide a degree of immunity from criminal charges or mitigation of sentencing for an individual seeking help for themselves or others experiencing an overdose. These laws are designed to encourage people to actually help those in danger of an overdose, as opposed to walking away or not even making the call to 911.
The TFAH noted that a study conducted after passage of Washington's 911 Good Samaritan Law found that 88 percent of prescription painkiller users indicated that once they were aware of the law, they would be more likely to call 911 during future overdoses. Would some form of Good Samaritan policy at health care institutions make a difference in decreasing drug diversion by medical professionals? For example, if a hospital were to adopt an amnesty policy not to fire medical employees if they step forward and seek treatment for a drug addiction, would a David Kwiatkowski/Exeter Hospital type “Hep C” outbreak be avoided in the future? This suggestion may be a difficult one to implement as there may be no ability to keep a position open for an addicted health care employee. However, further discussion should at least be debated at the risk management level.
While there is no “silver bullet” for stopping the misuse and abuse of prescription drugs, reports and studies such as the one authored by the TFAH provide fruitful strategies for health care institutions to examine and discuss when deciding how and where to allocate resources to this battle. We applaud the TFAH for its report and encourage all to review it.
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