Sunday, January 7, 2018

Pediatricians oppose opioid amendments.

Add the pediatricians to the ER docs, Ob/Gyn's, orthopedic surgeons, and a multitude of other Mississippi doctors who oppose the Mississippi Board of Medical Licensure's opioid amendments*.  Here are some excerpts from some of their letters.

Blair Batson Hospital Surgical Division Chiefs 

We respect the work that you are doing; however, it  has come to our attention that there will be some spillover of the new requirements for the use of narcotics in the acute management of postoperative pain.  It would make sense that our pediatric patients present a low risk for opioid addiction, and certainly not when treating within the narrow window of acute pain suffered in the initial postoperative period.  The necessity to run reports on our children is not only unnecessary from an abuse standpoint, but produces a real and undue burden on busy surgical practices.... (p.1)

Mississippi Chapter of American Academy of Pediatricts

As pediatricians, we do not prescribe a large number of Opioids or Benzodiazepines; however, we do write a great number of ADHD medications. As an example, my partner and I see  approximately 40-50 ADHD rechecks per week, and we see this large number of patients with ADHD because we do not  have enough mental health providers to take care of them.  We are required to recheck these patients every 6 months. For patients that are well controlled on their medications, we refill their medications on a monthly basis. We have an electronic medical recore and can make sure that patients are not refilling their medications more often than they should. But with the new rules, we will have to  check the  MPMP every 3 months.  As a primary care physician, I often have only 10 minutes allotted for each patient visit. A valid concern is that, although checking the MPMP may only takes 5 minutes per patient, cumulatively that is still a significant amount of time. In our clinic, like many other pediatric clinics, nurses do most of the refilling of medicines, and they are exceptionally  busy between answering phone calls, making referrals, administering shots, ordering vaccines and supplies, and other responsibilities. Adding more work to their overscheduled day would have a negative impact.  In Mississippi, rural pediatricians have the burden for providing most mental health services for  our children in Mississippi due to  a lack of mental health resources -this actually increases the  number of children with ADHD seen in their clinics. The above requirements for documentation pose an administrative burden that may keep children in our rural areas from getting the care they need. ... (p.3)

Dr. Tanya Fitts (Lafayette Pediatric Clinic, Oxford)

However, these rule changes greatly impact my practice as a pediatrician.  To date this year, this clinic has had 345 visits for ADHD, which comes to about 15% of our charges.  Most pediatric practices routinely treat ADHD patients as the incidence of this condition is about 5-10% of school aged children....

Rural pediatricians have the burden for providing most mental health services for our children in Mississippi.  Our nearest child psychiatrist in private practice is in Tupelo.  Communicare provides services, but has limited resources and couldn’t take on all of the ADHD care provided by the 7 excellent pediatricians in Oxford.  The above requirements for documentation will present a hassle factor that may keep children in our rural areas from getting the care they need.... (p.7-8)

Dr. Mike Artigues (McComb Children's Clinic)

General pediatricians rarely have to deal with chronic pain and long-term opioid use. What we DO often prescribe is behavior-modifying medications. These controlled substances already have a number of safety standards built in: meds cannot be prescribed over the phone, there can be no refills and only 30 day supplies can be given (in addition to up to two post-dated prescriptions). There are many limitations such as those found on the various preferred drug lists we deal with and, not infrequently, medications require prior approval.

What we do not want to see with these new changes is anything that makes care of our patients more difficult or cumbersome. These patients with ADHD and related conditions need long term, daily medications and have to follow-up with their physicians frequently..... (p.10)

Dr. Karen Stringer (UMMC Assistant Professor of Pediatricts)

However, there is also a big pediatric mental health problem in our state as well where we are struggling to maintain office staff, fighting with insurance companies in getting prior authorizations for various stimulant medications, and patients not being able to  have adequate and accessible behavioral therapy.  My office uses an electronic medical record that keeps track of medications.  My nurse spends 70-80% of her day on the phone getting prior authorizations for Medicaid, CHIPS, and private insur ers.  Therefore adding and keeping a list for the Prescription Monitoring System in the patient's record and checking it every time I prescribe a stimulant medication for each patient is absurd.  The Prescription Monitoring System needs to be linked to our EMR or the pharmacy's EMR and the alert can be systematic that way.  The board has not explained if anything is found on the list and how this is suppose to help prevent missuse, abuse, and diversion. Who do I call and what happens to the child when the police and DHS get involve?  Will the parent get the substance abuse treatment they need or just be another prisoner?

Also I have looked at the Prescription Monitoring System and have questioned if pharmacies are recording in it accurately.  2 months ago, I have a patient that received several prescriptions  of stimulant medications due to the patient having side effects and finding the right dose of his stimulant medication.  Their local Fred's pharmacy called  me concerned about missuse and abuse.  I have records of when the  parent called my office, my nurse sending prior authorizations, and of my changes to the patient's medication in the EMR.  When the pharmacy questioned the prescription, I looked at the Prescription Monitoring System and found no record of the prescriptions being filled at any pharmacy including Fred's in past 2 months.  About 90% of my patients take a stimulant
medication.  This state already has a low person to physician ratio.  Adding more regulation is going to make my job harder and therefore leave this state. I am asking for a public hearing and finding a solution that is more reasonable..... (p.11-12)
As usual, these letters will not be seen anywhere else in the media.

*The major features of the amendments are:

*A ten-day schedule II prescription can be written for acute non-cancer/non-terminal pain.   The prescription can be refilled for an additional ten days.

* Point of service drug testing must be done each time a Schedule II medication is written for the treatment of non-cancer pain (Rule 1.7 (K)).  Drug testing must be done every 90 days for patients prescribed benzodiazepines for chronic medical and/or psychiatric conditions as well.

*Prescriptions for Benzodiazepines  must be limited  to a one (I)  month supply with no more  than  two (2)  refills. The   MPMP  must  be  checked  each  time a  prescription  for Benzodiazepines is authorized  and evidence of such check  must be noted  within the patient file.  Rule 1.10 (H)

*Physicians must first establish a relationship with the patient before writing any prescription, not just those for controlled substances.   A physical exam is required before a relationship can be established.  Rule 1.11

 *Every doctor, regardless of specialty, must use the PMP upon "initial contact with new patients" and every 90 days afterwards for patients who receive controlled substances.  Many doctors protested  this amendment as they argued it would add an hour of paperwork to their daily practice and keep them from seeing patients.  Several told the Board it takes more than 15 minutes to run a PMP report.  The board rejected their arguments and kept the amendment without change.

The amendments also changed the regulations for pain management practices, bariatric medicine, and chronic pain. See earlier post for more information about these changes.

Earlier posts
ER Docs oppose opioid amendments. (letters) 
 Ob/gyn's oppose opioid amendments.
Medical Board releases approved opioid amendments 
 Irresponsible!  Orthopedic surgeons oppose opioid regs
 Bomgar on opioids: We have a death problem, not a prescription problem.
"Stop the nonsense. Talk to real doctors." (Letters)
 It would be nice if we could do this behind closed doors.
 Medical Board approves opioid regs with little notice. 

  Never let a good crisis go to waste.  
 Board of Medical Licensure calls meeting yesterday to discuss opioid regs tomorrow.
State Health Officer warns of unintended consequences    
 Doctors on proposed opioid regs: "dangerous", "Ill-conceived", "idiots" (Letters) 
  How much pain will proposed opioid regs create for doctors?  (Regs analyzed)
Can medical weed fight opioids?  
 Opioids prescription: Mo' taxes, mo' spending, mo' jail (Gov.'s task force report)


Anonymous said...

Why the heck do children need opioids? Don’t care what kind of surgeries they have, DONT give them opioids! Jesus, the doctor/pharmaceutical medicinal industrial complex is even pushing this crap as early as possible now on kids. Not sure you should be promoting this KF.

Anonymous said...

Well the addicts are against it as well.

Kingfish said...

Why don't you try reading the post and the actual letters? They are mainly raising hell about the drug testing and the required use of the PMP.

Anonymous said...

@8:22 It isn't just opoids but also benzodiazepines. My 21 month old son has a genetic condition that causes tumors to grow all over his vital organs including his brain. He has seizures that are difficult to control. As a result he's on several medications including a regular benzodiazepine as well as one for emergencies when the seizure lasts longer than 5 minutes. Please tell me why they need to drug test my 21 month old son and make receiving his life saving medicine more difficult? Also how do you propose they go about drug testing a toddler without being invasive?

Anonymous said...

KF, Objecting to using the PMP is not justifiable. What's the problem with having to input the info into a database and seeing what else is happening? Takes very little time, and is done by staff, and don't try to say they dont have an extra minute per patient.

As to drug testing infants, the point is to make sure the drugs are getting to the infant, not being taken or sold by the guardian. Not everybody is a concerned parent as 9:10 sounds to be; there are plenty of abused kids and foster kids in the world that drug addicted parents don't care about as much as they do their own addiction.

Anonymous said...

To 9:10...bless y’all. I can’t even imagine. And this added stress on your little one, you as parents, and the medical staff that only wants to help y’all is just one of the 100s of reasons this mess disaster of epic grandstanding needs to be shut down.

Wanting to do something to curb pill mills is one thing - going against the common sense, constantly expressed thoughts of the people who will have to deal with these asinine amendments...well, that’s just plain ol’ stoopid. I agree with the comparison of this to the equal bright idea that causes folks to need an Rx for OTC sinus meds.’s that working for slowing down meth production? Um, it has done NOTHING.

I am fortunate enough to know some amazing police officers, intelligent folks. But, would i want them having say in my health care? No. Just as wouldn’t want the wonderful health care providers i know policing my streets. I really do miss common sense. When did these older folks become more whiney than millennials?

Need Mo Govt Oversight.. said...

"As to drug testing infants, the point is to make sure the drugs are getting to the infant, not being taken or sold by the guardian. Not everybody is a concerned parent as 9:10 sounds to be; there are plenty of abused kids and foster kids in the world that drug addicted parents don't care about as much as they do their own addiction."

Are you nuts? That's a reverse twist on this whole nonsense. Let's be sure we have positive drug screens so we can be sure the tested patient is the one using the prescription!

Is it the government's responsibility to concoct dark theories and scenarios about legal things that might get into the wrong hands and be misused?

Do we intend to invade liquor cabinets and their owners to ensure that teenagers are not accessing them? Do we want to devise some system of ensuring that children are not getting behind the wheel of the family car?

And condoms...If we don't put combination locks on boxes of them, surely they will be found in dresser drawers by teenagers and this will promote sexual dalliance, STDs, school dropouts and boys who disrespect girls, not to mention pre-adolescent masturbation.

Anonymous said...

Marshall fisher wants the PMP mandate so his people can check it. If he believes you are getting too much they will charge you with either doctor shopping, possession or diversion. I don't want my drug history that is between me and my doctor be reviewed by a cop with nothing better to do. No court order for these confidential records just your name bring it up.

Anonymous said...

11:05 pm You have clearly never investigated child abuse or neglect or dealt with children with serious health and behavioral issues.
You clearly haven't worked in a doctor's clinic in an area where both the doctors and their staff and other resources like mental health support are in short supply.
You clearly haven't worked with addicts and know nothing about a child's physical and mental development.
Did you decide that parents using their children's meds is a serious problem from watching Law and Order SVU or was it some story told you by law enforcement or in the doctors lounge or did you just imagine this on your own?
Do you have any idea about what is involved in drug testing children or how a child is likely to perceive that testing?
The outcome for these idiotic regulations is that more children will be abused because a parent's inability to cope with irritating or bad behavior in their child, especially when such behavior is chronic, is one of the key triggers when a child is abused.
Were you never taught that when you solve one set of problems, you are actually exchanging that set for a new set of problems that may or may not be easier to manage? That is particularly applicable when it comes to societal and human behavior problems.
Try not to be so ignorant and gullible and try to imagine what you don't know before you jump on the bandwagon of a simple solution to solve a complex problem.
By the way, have you bothered to follow the money and figure out who benefits from these regulations?

Anonymous said...

Need Mo, @11:05 has trotted out that piss weak rationale here on JJ before. Every law abiding citizen is guilty first until the 98.5% jump through all these dictatorial hoops to prove they were, and are, completely innocent.

Anonymous said...

If true @6:46, that sounds like a HIPPA lawsuit waiting to happen. Speaking of, what ever came of the one that guy filed after he was arrested at work and charged with Doctor shopping bc he got 2 scripts, one from the ER and one from his primary care physician?

Anonymous said...

HIPAA - law enforcement exclusions

Anonymous said...

Got mine in Sam's parking lot last night. No drug test, to Hippa, no hassle.

Anonymous said...

Is it true that Easterling will benefit from this if it’s passed? Rehab program or something like that?

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Trollfest '09

Trollfest '07 was such a success that Jackson Jambalaya will once again host Trollfest '09. Catch this great event which will leave NE Jackson & Fondren in flames. Othor Cain and his band, The Black Power Structure headline the night while Sonjay Poontang returns for an encore performance. Former Frank Melton bodyguard Marcus Wright makes his premier appearance at Trollfest singing "I'm a Sweet Transvestite" from "The Rocky Horror Picture Show." Kamikaze will sing his new hit, “How I sold out to da Man.” Robbie Bell again performs: “Mamas, don't let your babies grow up to be Bells” and “Any friend of Ed Peters is a friend of mine”. After the show, Ms. Bell will autograph copies of her mug shot photos. In a salute to “Dancing with the Stars”, Ms. Bell and Hinds County District Attorney Robert Smith will dance the Wango Tango.

Wrestling returns, except this time it will be a Battle Royal with Othor Cain, Ben Allen, Kim Wade, Haley Fisackerly, Alan Lange, and “Big Cat” Donna Ladd all in the ring at the same time. The Battle Royal will be in a steel cage, no time limit, no referee, and the losers must leave town. Marshand Crisler will be the honorary referee (as it gives him a title without actually having to do anything).

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Jackson Jambalaya is the home of Trollfest '07. Catch this great event which promises to leave NE Jackson & Fondren in flames. Sonjay Poontang and his band headline the night with a special steel cage, no time limit "loser must leave town" bout between Alan Lange and "Big Cat"Donna Ladd following afterwards. Kamikaze will perform his new song F*** Bush, he's still a _____. Did I mention there was no referee? Dr. Heddy Matthias and Lori Gregory will face off in the undercard dueling with dangling participles and other um, devices. Robbie Bell will perform Her two latest songs: My Best Friends are in the Media and Mama's, Don't Let Your Babies Grow up to be George Bell. Sid Salter of The Clarion-Ledger will host "Pin the Tail on the Trial Lawyer", sponsored by State Farm.

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If you get tired come relax at the Fox News Tent. To gain admittance to the VIP section, bring either your Republican Party ID card or a Rebel Flag. Bringing both will entitle you to free drinks.Get your tickets now. Since this is an event for trolls, no ID is required, just bring the hate. Bring the family, Trollfest '07 is for EVERYONE!!!

This is definitely a Beaver production.

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