Massachusetts Medical Society: Opioid Addiction Crisis Brings New Risks, Questions

Opioid Addiction Crisis Brings New Risks, Questions

Physicians Must Maintain a “Fine Balance”


Treating a patient for pain has become in many ways like a high-wire balancing act.

With opioid addiction and overdose at crisis levels in Massachusetts and many other states, physicians must consider many factors — and comply with new state regulations — almost every time they prescribe opioids.

The most significant provisions of the PMP regulations, effective as of Dec. 5, 2014, are as follows:

  • Physicians enrolled in the PMP are required to access the database and research a patient’s history the first time they prescribe a Schedule II or III medication or a benzodiazepine to a patient for the first time.
  • Exemptions to this requirement include care provided in emergency and inpatient hospital departments, treatment of hospice patients and children under eight, and situations in which a prescriber is unable to access the PMP.
  • Prescribers are allowed to designate delegates to access on the database on their behalf.
  • Physicians who obtained or renewed their state drug registration number after Jan. 1, 2013, have been automatically enrolled in the PMP.

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In December, the state Department of Public Health officially promulgated long-awaited new regulations for the Massachusetts Prescription Monitoring Program, or PMP, requiring physicians enrolled in the program to access the database and research a patient’s history whenever they prescribe a Schedule II or III medication or a benzodiazepine to a patient for the first time.

There are exemptions to this requirement, but the nature of prescribing for pain appears to have changed permanently for Massachusetts doctors, according to local physicians.

Heightened Concern

“There’s such a heightened concern about opioid abuse that often times we’re forced to think more about the fact that a patient may be abusing an opioid medication rather than [whether this is] a patient who actually needs their medication for legitimate pain control purposes,” said family physician and MMS President-Elect Dennis M. Dimitri, M.D.

“We don’t want to see physicians become so frightened about the aspects of legitimate use in prescribing opioids that they’re no longer taking care of patients who need to be taken care of for chronic problems,” he said. “There’s a fine balance all physicians have to walk to be sure that they’re not contributing to the problems with abuse that we know are occurring, but are legitimately attending to their patients’ pain control needs.”

There are also concerns that physicians are not aware that they have now been automatically enrolled into the PMP, or that its use has become mandatory.

“It’s not at all clear to me that physicians who are enrolled in the PMP know they are enrolled and still have the IDs or passwords that were issued to them at the time,” said William J. Ryder, Esq., regulatory and legislative counsel for the MMS.

But overall, Massachusetts prescribers agree that the PMP is a valuable tool in addressing the state’s opiate crisis. “It will give us better information to identify doctor-shopping in real time,” said Christopher Gilligan, M.D., M.B.A., a pain management specialist at Massachusetts General Hospital. “This is important clinically as part of keeping that patient safe and part of keeping society safe,” he said.

New York Mandate

Gilligan also noted that other states, such as New York, that have mandated PMP use have seen a dramatic reduction in patients looking for duplicate pain prescriptions.

“It’s a burden to practices, no doubt, but it has some significant benefits.”

Hopes PMP Will Evolve, Improve Interoperability

Physicians versed in the new requirements say they are pleased the PMP allows prescribers to use delegates to assist with database research. This ability to delegate will be critical to physician practice workflow, said Dr. Gilligan.

“It’s important to be able to say to your administrative staff that for all new patients who are coming in with a pain complaint, ‘I’d like you to print out [PMP data] and have it with the patient’s paperwork when I see the patient,’” he said. As a result, using the PMP will prevent a lot of physicians from doing all the lookups themselves, Dr. Gilligan added.

When it comes to potential improvements, the MMS would like to see nursing-home care added to the list of exemptions because the risk for abuse in that setting is low, said MMS President Richard Pieters, M.D.

“We also don’t think the DPH should have included benzodiazepine at this time, certainly without formal hearings and review of the clinical evidence of the value of a PMP in benzodiazepine prescribing,” Dr. Pieters said. “We’re hoping the DPH will revisit this decision under a new commissioner. I would urge the revival of the clinical review board. This was created by the original DPH regulations the MMS helped craft, and it has not been an active and visible factor for many years. Its responsibility is to review data and advise public officials when there is problematic behavior among prescribers.”

In addition, the state’s PMP does not integrate with most electronic medical record systems, an issue Dr. Dimitri said he hopes will also be addressed soon.

“In order to use it, if you’re seeing a patient and you’re working in your EMR, you have to leave your EMR, go to the virtual gateway, log in, and open up a search for the patient. It’s not an easy transition out of your EMR and through this process,” he said.

The approximately two-week lag time from the time a patient fills a prescription to its appearance in the PMP database is another long-time problem cited by users. While this lag does leave room for “doctor- shopping” to take place within its time frame, having the information when it’s available is better than not at all, noted Dr. Gilligan.

Dr. Pieters said doctors will need to continue to work in concert with state officials for the foreseeable future on how opioids are monitored statewide.

“We’re going to work with the DPH to make the PMP a good, data-driven system to identify state problem areas and prescribers and not adversely impact good physicians who are treating patients appropriately,” Dr. Pieters said.

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