Massachusetts Medical Society: Comments of the Massachusetts Medical Society to the Massachusetts Opioid Task force

Comments of the Massachusetts Medical Society to the Massachusetts Opioid Task force

The Massachusetts Medical Society wishes to thank the members of the Opioid Task Force for their service on this important issue and for their attention to our comments both in writing and in person on April 1.

The Massachusetts Medical Society supports the highest clinical standards in the provision of medical care in the compassionate and effective diagnosis and treatment of our patients. Opioids provide an essential treatment option for our patients suffering from pain. Their use is essential in the compassionate care of many patients, particularly those suffering from cancer and terminal illness. We must not forget that prescribing, dispensing and administering of opioids is an appropriate part of high quality care for many patients. Therefore, we must strive to preserve the role of opioids in appropriate standards of care while directly addressing the impact prescription drugs have on opiate addiction and overdose. 

The fact that opioids are a clinically indicated part of a good treatment plan for many patients does not preclude those same prescription pills from being diverted to non-patients.  Studies and the experience of many physicians indicate that patients prescribed opioids for pain without a prior history of addiction do not misuse, abuse or become addicted to them [i] and that a very high percentage of those who misused or abused prescription drugs were not prescribed those drugs. Many surveys and studies of young people involved with prescription drugs find that the majority got opioids for free from a medicine cabinet or bought them from a friend or relative who got them from a similar source.  The MMS strongly supports public education on proper storage and disposal of opioids. Ways must be found to insure that necessary prescription medications for advanced cancer patients and others incapable of managing their own treatment are responsibly dispensed and stored by designated caregivers or family members. We commend the working group for its Facebook page which provides information on this important issue. We stand ready to help inform patients about their role in preventing diversion.

Massachusetts needs local data to specify exactly what sources are contributing to opiate addiction and overdose. The prescription monitoring program is a key potential component of such data review.

The MMS supported the establishment of the PMP in 1992 and supported creation of a recurring $150 registration fee to fund the PMP, its database, its clinical advisory group and support staff.  We were among the voices pushing for physician access to the database as a clinical tool. However, the PMP has never had the resources to fulfill its mandates. The PMP operated on $500,000 per year for decades while the general fund kept the rest of the registration fees. Recently the PMP budget has gone up to a little over $1,100,000 per year. However, well over half of that funding reverts back to the state for use of its virtual gateway system. The PMP desperately needs funding from the legislature if it is to meet the expectations of its value as a clinical and public health tool.

Specific PMP Suggestions

  • The PMP database is still using the 1992 software which is an adapted infectious disease reporting format. This needs to be replaced with a PMP specific system.

  • New software must facilitate integration into all widely used EHR’s

  • Support staff must be available to answer phones, automatically enroll prescribers, facilitate new passwords and ID’s and solve technical glitches for participants.

  • Improved software, staffing and funding to support research grants on the data is essential to show Massachusetts specific data on trends, the role of prescriptions in overdoses and addiction, and to search for outliers.

  • Robust and funded clinical review teams are necessary in the development of valid screening metrics of prescribers and patients to assure real time data collection and immediate e-mail or online notices to prescribers and pharmacists of conflicting prescriptions. 

  • New software must support pharmacy reports in real time rather than waiting more than a week for data to be available.

  • The technology of other state PMP’s such as Rhode Island, New York and Oklahoma should be adopted in areas such as two click access to the database, real time reporting and integrated systems. Reasonable plans for interstate sharing of data must be developed, beginning with New York and New England.

Going by nationally reported data, Massachusetts ranked in the top 10 states in prescribing long-lasting painkillers, but ranked low, 41st nationally, in overall prescribing of opioids by volume [ii] . We are in the below average category by the number of prescriptions written for opioids. [iii] What is the distribution of these prescriptions among physicians, nurse practitioners, physician assistants, podiatrists, veterinarians, dentists? What is the breakdown by specialty and type of patient? Only with such information can we determine whether or not any specific prescription is clinically appropriate?  Do individuals who overdose have prescription histories? Only when we have a fully functional and state of the art PMP system can we answer these questions and determine what is really happening in the Commonwealth concerning overdoses and addiction.

To be useful as a clinical tool, the PMP must allow medical support staff to perform searches of the database but not the evaluation of the data. The law mandates that the PMP establish systems for the use of delegates. However, the initial rules are not efficient in how delegates can work. Delegate selection by registered users needs to be simplified by elimination of the requirement for notarized paper applications for each delegate. Delegate teams should efficiently serve hospitals, clinics and groups through batch look ups on one log in so that all appointments may be run and data distributed prior to visits beginning. Any clinical office staffs are governed by HIPPA requirements and penalties, the DPH does not need additional assurances of confidentiality.

Given the inclusion of benzodiazepines and behavioral health prescriptions in recent years, patient privacy concerns have increased significantly.  The PMP has clear value for clinical use, population based research, and prescriber education. Its value in law enforcement efforts is not well established in Massachusetts. Protocols on access to patient specific information by law enforcement agency staff should be reviewed and firmed up. In many states a warrant is necessary to obtain specific patient information. Massachusetts should consider such confidentiality protections for patients.

Training needs to be available online for delegates and participants. The MMS has offered to work with the DPH to make educational programs available on demand. Currently DPH programs in PMP use are limited to a few one hour midday live webinars with a capacity of 250 participants. There are 40,000 licensed physicians in Massachusetts. More needs to be done.

Controlled substance registrations have no real modern function and are a relic of the days when physicians carried narcotics and dispensed drugs from their offices. No one has ever been denied a controlled substance registration if they have a medical license. The DEA license is necessary and maintains standards for who may prescribe federally controlled substances. State registrations only apply to non-federally controlled substances such as antibiotics. If the registration is retained it should be issued at the time of licensing by the Boards of Registration. Funds may continue to go to the general fund but all such funds should be appropriated for substance abuse services and the PMP.

Clinical standards are always evolving. The MMS is working with an internal task force on developing advisories for physicians and other providers. One clear area that needs improvement is communication on prescribing issues among prescribers and other clinicians. We are researching to develop assistance for prescribers on:

  • When and how to communicate with your peers who also prescribe to your patients.

  • How to recognize and discuss with patients issues of addiction

  • How to refer patients for pain management and substance abuse treatment

While there are educational programs to help physicians with many of these issues and they are increasingly part of medical education and residencies, no clear standards and best practices yet exist. For example, there are no well-established clinical advisories on how to use the PMP in spite of its use in 49 states. We urge the task force to support the development of good clinical tools while resisting the urge to mandate educational programs for prescribers where no clear source of such programs exists. Massachusetts requires continuing medical education in several different areas as a condition of licensure. Pain management courses are required for all physicians every time they renew their license. If new programs are developed relating to the PMP, addiction and pain management, the existing mandate will insure they are fully utilized.

Substance abuse and addiction treatment is desperately needed to help those individuals who are ready to seek help whether through their own initiative or through the intervention of friends, family, health care providers or the courts. The MMS is proud of its work last legislative session with the Mass Bar Association, the MA Dental Society, the MA Association of Behavioral Health Systems, MA Pain Initiative, The MA Society of Clinical Oncologists, the MA Society of Anesthesiologists and the MA Psychiatric Society to advocate for the passage of legislation that resulted in Chapter 258 of 2014, ""An Act to Increase Opportunities for Long-Term Substance Abuse Recovery." This landmark legislation is a forward step towards parity in the treatment of addiction and holds out hope of treatment on demand for individuals suffering from substance abuse issues at the time they are ready for clinically appropriate care. The landmark provision requires insurers to “provide coverage to any …. insured …for medically necessary acute treatment services and medically necessary clinical stabilization services for up to a total of 21 days before initiating utilization review procedures and shall not require preauthorization prior to obtaining such acute treatment services or clinical stabilization services. Medical necessity shall be determined by the substance use disorder treatment facility or the treating clinician in consultation with the patient.”[iv]

The MMS strongly urges the task force not to undermine this important option for recovery for individuals suffering from addiction. Amendments to the law that would allow insurers to limit access to care by imposing their own standards for care or approval processes by plan medical directors would take us back to the prior authorization systems that created the lack of access in the first place. The MMS strongly supports high quality, proven clinical care as a key determinant of coverage of medically necessary services. However, given the crisis in opioid addiction, the reports of patients overdosing repeatedly until they finally succumb to a fatal overdose without ever entering treatment, and the desperation of families and addicts who are forced to wait for approval when a bed is available, we urge the task force to support the existing provisions of Chapter 258 regarding treatment on demand without modification. Let’s see what we can do with simpler access to care.

Recent research is raising questions about the value of opioids in the treatment of chronic pain. When physicians are confronted with the realization that ongoing opioid treatment has provided no improvement in a patient’s long term prospects of recovery, difficult decisions have to be made. Insurers will often cover referrals to pain management specialists. This is appropriate. Insurers should also cover clinically supported alternative options for pain management such as cognitive behavioral therapy, physical therapy, yoga, meditation and other options to improve a patient’s quality of life. If we are to move from opioid prescribing for many patients, we need insurance coverage to provide alternatives. The underlying clinical diagnosis that leads to opioid prescribing has a basis in the patient’s symptoms. This basis must be addressed.

One trend that is disturbing both locally and nationally is the response of national pharmacy chains to actions taken against them for inappropriate or questionable dispensing in other states. The MMS is opposed to pharmacy policies, legislation or regulation mandating routine inquiries from pharmacies to verify the medical rationale behind prescriptions, diagnoses and treatment plans as an interference with the practice of medicine and an unwarranted invasion of patient privacy. The MMS supports a standard whereby a pharmacist presumes the routine validity of a prescription. We fully support the discretion of pharmacists to use appropriate professional judgment on when to seek validation of questionable prescriptions and how to work with physicians in order to reduce the incidence of drug diversion and inappropriate dispensing. Routine calls to physicians on every prescription for an opioid doesn’t reflect good clinical judgment by pharmacists and should not be encouraged. An improved PMP should provide better data for pharmacists to judge a prescription’s validity. 

We do have concerns about the popularity of requiring insurers to limit opioids to no more than specific amounts or morphine equivalents. The MMS met with Blue Cross Blue Shield while they were developing their system for review of prescribing practices. Their initiative was clinically driven with significant exceptions based on legitimate treatment considerations. The program appears to have had very positive results. We must recognize the complexity of the program, study its clinical lessons and avoid simplifying its approach by adopting strict limits on prescribing for all patients. More needs to be done to develop and enforce clinical standards but patient needs vary immensely.  Simplistic solutions may move us away from compassionate care without solving the addiction crisis.

It is worth mentioning in closing that a well-run PMP has four uses:

(1) Real time identification of patients who get prescriptions at the same time from multiple prescribers and electronic notice to these prescribers;

(2) Identification of prescribers who write a large number of prescriptions or write prescriptions for high dosages;

(3) Clinical review of identified patients and prescribers to determine whether identified outliers are providing or receiving appropriate care and what interventions might be taken if they are not

4) Facilitation of the work of public health researchers in determining trends, practices and problems in opioid use with MA specific data.

We hope to work together to help establish such a system.

The MMS appreciates the opportunity to present our views. We look forward to working with the task force, the Governor and the Attorney General on solutions to the opioid crisis.  

[i] (Cochrane Database of Systematic Reviews, 2010) In 2012, according to the National Survey of Drug Use and Health (Substance Abuse and Mental Health Services Administration, 2012)



[iv] Chapter 258 of the Acts of 2014 section 9.

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