Prescription drug abuse: CMS releases draft recommendations

Sunday, September 01, 2013 12:19 PM

Susan Koontz, JD, CMS General Counsel

The momentum is building in Colorado to set and implement policies to curb the abuse and diversion of prescription drugs. The Colorado Medical Society has been actively engaged on this issue over the past year and recently released a draft platform titled, “The Public Health and Safety Challenges of Treating Chronic Pain: The Medical Perspective.”

This platform developed by the CMS Workers’ Compensation and Personal Injury Committee (WCPIC) and special advisors to WCPIC, recommends setting guidelines for state agencies and regulatory boards and supports the development of a CMS educational platform.

The recommendations set forth in the platform are based on the medical society’s long-term goal and strategies approved by the CMS Board of Directors in May: to assure access to compassionate, evidence-based care for patients who suffer from acute and chronic pain while implementing a multi-pronged, coordinated strategy to significantly reduce the potential for medically inappropriate use and diversion of prescribed medications.

CMS will meet this goal by reviewing current evidence, developing and promoting new tools and existing resources and education, developing an educational campaign for physicians, promoting screening and access to treatment programs, working collaboratively with all stakeholders and elected officials, and urging the establishment of a monitoring and tracking system for intervention strategies that allows expert evaluation and adjustments to interventions.

The platform dives into the specifics, focusing on five platform planks: the Prescription Drug Monitoring Program (PDMP), licensing boards standardization, physician education, law enforcement, and prescription drug abuse as a public health issue. The platform will be presented to the House of Delegates in September.

Prescription Drug Monitoring Program
The largest piece of the platform addresses the Prescription Drug Monitoring Program (PDMP). Colorado’s Electronic Prescription Drug Monitoring Program was originally authorized by law in 2005 and was reauthorized in 2011. The program provides a secure database of controlled substance prescriptions that have been dispensed by registered Colorado pharmacies, and allows prescribers and pharmacists to gather information about the patients they serve to ensure their prescribing and dispensing is appropriate under the circumstances.

The information collected on patients is only available online to health care practitioners licensed by the state for the patient under review, is considered to be a medical record, and is highly protected. Licensees cannot share their login information or allow office staff to access or utilize the PDMP on their behalf, at the risk of being fined.

Funding is one major barrier to the PDMP’s long-term success. The Colorado Department of Regulatory Agencies (DORA) is in the process of rate setting to determine an annual fee for prescribers of not more than $20. The proposed platform before the House of Delegates asks CMS to support appropriate funding for the Colorado PDMP and begin the process of exploring funding alternatives.

Time is another barrier to the PDMP’s effectiveness. The proposed platform supports real-time access to the information to ease the demand on the prescriber’s workflow. Currently, dispensing pharmacies report to the Colorado PDMP twice monthly and a delay can exist from about 25 days from date dispensed to when the data is available in the PDMP.

The state of Oklahoma has implemented real-time data collection for its PDMP. Additionally, CMS supports the concept of delegated access: a specific individual designated by a prescriber could be accredited to access the PDMP under specific conditions and, perhaps, a different level of access.

The proposed platform supports integration with other systems across state lines and to all patient populations, maintaining voluntary use of the PDMP, capturing outcomes data on whether use of the PDMP reduces the abuse and diversion of prescription drugs, and the exploration of the use of unsolicited reports.

Licensing boards called upon to set same standards
The platform calls on all prescribing boards to agree upon and set the same minimal standards for opioid prescribing, with all prescribers – including nurse practitioners and dentists – held to these standards. All prescribers, pharmacists and members of the continuum of care should work together to ensure appropriate access to necessary medications for patients with legitimate medical needs.

This will not only improve management of patients but will also allow appropriate conversations between pharmacists attempting to decrease inappropriate prescriptions and providers who can explain how they are following the standards.
The Colorado Board of Medicine is currently seeking feedback to update its policy on the use of controlled substances for the treatment of chronic, non-cancer pain.

Physician education
The proposed platform supports continuing, voluntary medical education to assure safe prescribing and effective relief of moderate to severe pain. All physician education should be peer-reviewed and easily available to physicians; help physicians identify at-risk prescribing practices and implement strategies to minimize the potential consequences of opioid prescribing; be tailored to meet a physician’s practice and population needs; be consistent in message; promote collaboration of members of the health care team; encourage the use of validated screening tools; and be evaluated for effectiveness and outcomes. Physicians can access opioid prescribing and patient management CME at www.cms.org or visit the AMA website at www.ama-assn.org/go/stopdrugabuse.

Law enforcement
The proposed platform recognizes that law enforcement plays a role in supporting efforts to prevent abuse and diversion. However, this crisis requires a public health focus rather than a strictly law enforcement focus to emphasize the treatment and recovery needs of addicted patients. CMS supports enforcement to stop criminal activities related to the prescribing and distribution of medically unindicated pain medications.

The proposed platform does not support unfettered access by law enforcement to PDMP data. Rather, CMS recommends making training available to district attorneys and law enforcement about the PDMP, providing options for law enforcement access that protects the confidentiality of patient-sensitive information, and placing strict prohibitions for releasing information from the PDMP while allowing for study of the standards for a probable cause-search warrant.

Prescription drug abuse as a public health issue
If we aim to maintain awareness and address prescription drug abuse as a public health issue we must implement public health programs that provide access to training in the use of opioid antagonists that can save lives, increase education and funding for take-back events and disposal programs, and develop more resources for prevention and addiction treatment and support for non-medical measures to treat pain.

Collaboration among all public health stakeholders is necessary to raise public awareness and address the role of opioids, safety, and education on the issues of safe storage and the diversion of medications.

CMS would like to thank Daniel Blaney-Koen, JD, AMA Senior Legislative Attorney, for his help with the development of this proposed platform.