Thursday, December 7, 2017

How much pain will proposed opioid regs create for doctors?

The Mississippi State Board of Medical Licensure wants to make it tougher for doctors to prescribe opioids.  The Board proposed the new regulations in response to recommendations made by Governor Phil Bryant's task force on opioid abuse that were released in August.* Earlier post. The rules will limit surgery patients to opioid prescriptions for only two weeks.  Weight loss and pain management clinics face new rules.  More paperwork is recommended for the doctors.  

Section 2640 of the Board's administrative code governs the prescription, dispensing, and administration of medication.  The Board proposed submitted amendments to the Secretary of State that would overhaul Section 2640  on September 21 in response to the opioid "crisis." The proposed amendments received a great deal of attention from doctors as it will make some major changes in how they practice medicine if adopted.  

 A hearing was held on November 15 at the Board's  offices.  Over 150 people attended the 5 hour-long hearing.  However, before JJ delves into what took place at the hearing, it is probably a good idea to explain the proposed changes to Reg 2640 before the readers get lost in the weeds.  Here are some of the major changes to Reg 2640.  The actual amendments are posted below as well.

Opiods prescribed for acute non-cancer pain or post-surgery recovery

Rule 1.7(H) When opioids are prescribed for acute pain, the licensee  must prescribe the lowest effective dose of immediate release opioids, as the use of long-acting opioids for acute non-cancer pain is prohibited. 

Licensees are discouraged from prescribing or dispensing more than a three day supply of opioids for acute non-cancer pain and must not provide greater than a seven day supply for acute non-cancer pain. Licensees may issue an additional seven day supply if clinically necessary... (p.36)

The current language states: Three days or less should be sufficient and more than 7 days should be avoided in absence of significant justification (example: Post-surgical pain stemming from a significant procedure.).  

The doctor's ability to prescribe pain medication to those suffering from pain lasting more than two weeks after a major operation would be removed.  Suffering from severe pain several weeks after surgery?  The Board says that is just too bad.  Suffer away.   This proposed change in the regulations generated a firestorm of protests from Mississippi physicians, as they sent quite a few letters to the Board of Medical Licensure.  Some of those letters will be posted over the next few days. 

Mississippi Prescription Monitoring Program (MPMP)

Rule 1.3 orders every person who holds a medical license and has prescriptive authority to register with the Mississippi Prescription Monitoring Program (It will be referred to as PMP, p.24).  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.   The patient's PMP report should cover the time period since the last PMP report was run.  The doctor must generate an annual PMP report for his entire practice and keep it available for inspection. 
Rule 1.7 (J) reinforces this new rule:

When a licensee treats chronic non-cancerous pain and/or psychiatric conditions outside the definition of a pain management practice, the licensee shall actively utilize the MPMP upon initial contact with a new patient and every 3 months thereafter on any and all patients who are prescribed, administered, or dispensed controlled substances (p. 37).. Reports generated on patients must span the length from the previous review of the MPMP so that adequate information is obtained to determine the patient's compliance for treatment.
Mandatory Drug Testing

Rule 1.7 (K)  Point of service drug testing must be done each time a Schedule II medication is written for the treatment of non-cancer pain.....

Drug testing must be done every 90 days for patients prescribed benzodiazepines for chronic medical and/or psychiatric conditions as well.   Schedule II drugs include adderall, ritalin, percocets, codeine, oxycontin, hydrocodone, dialaudid, demerol, and morphine.  "Benzos" include Xanex, Valium, Klonopin, Ativan, and other drugs found on this list. 

 Benzo Prescriptions

Rule 1.10 H: 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. (.19)

Pain Management Practice

Rule 1.14 governs pain management practices. The rule changes the definition of what constitutes a pain management practice.  The current rule states it is a medical practice "that provides pain management services to patients..."  A majority of the patients are issued prescriptions for opiods, barbiturates, tramadol, and similar drugs for the treatment of "chronic noncancerous pain."  The amendment drops the threshold from 50% to 30%.  A medical practice where more than 50% of the patients are treated for terminal illness are exempt from this classification.

The new rule appears to attempt to place somewhat of a fence around Mississippi.  The current rule states that a majority of the practice must be owned by physicians.  However, it changes the ownership requirement.  The majority ownership must be Mississippi-licenses physicians AND practice at least 20 hours per week within the state of Mississippi.  This amendment will affect doctors who are practicing in Memphis or New Orleans but might have satellite practices on the coast or in the Memphis suburbs as it forces them to practice medicine in Mississippi several days per week.

Such practices can not employ doctors or other employees such as physician assistants who have been denied or received a limited certificate to prescribe controlled substances are denied.  Disciplinary action by any licensing body because of misuse of controlled substance prescriptions disqualifies them from such employment as well.
All doctors and P.A.'s must register with the PMP.  A PMP report must be obtained for each patient at "every visit." Read that again: every visit.  (p.48)

Any practice that advertises pain management services will be considered to be a pain management practice as well.

Chronic Pain

Such pain is considered to be non-terminal.   The current rule defines chronic pain treatment as the use of controlled substances for more than six months.  The amendment lowers that threshold to three months.  The doctor must review the course of treatment every three months instead of the current requirement of six months (p.35).  Doctors must provide the lowest effective dose and are discouraged from prescribing more than 50 mg at a time (p.36).  Doses greater than 90 mg must be justified in the record.  The doctor must refer the patient to a pain management specialist if more than 100 mg doses are required.

Bariatric Medicine and Weight Management Practices

The amendments define such practices as those where at least 30% of the patients receive any controlled substances prescribed for weight loss.  A practice that advertises "weight loss by any means" is included in this definition as well unless non-drug treatment for weight loss management is advertised.  Surgeons who use bariatric surgery to treat obesity are excluded from this definition.  See Rule 1.2 (K)(p.24).

Clinics covered by these amendments must have an affiliation or collaboration agreement with a Mississippi-licensed doctor. 

Stay tuned to this website.  JJ is going to stay on this subject for awhile.

*Dr. Randy Easterling and Dr. Claude Brunson (UMMC) served on the task force. 


Anonymous said...

More regulations and more paperwork. Why do we allow this in the medical profession but decry it everywhere else???

Anonymous said...

Regulatory disaster for parents with ADHD children. Drug testing every 90 days? You're an idiot Phil Bryant.

Anonymous said...

My suboxone addicted sister will keep getting her Medicare-paid-for suboxone. It will just cost taxpayers more and she will also have to pay more (co pay) but she'll just steal it from her relatives.

Anonymous said...

This is devastating news for many Rankin County residents.

Anonymous said...

I thought Philbilly and his republican stooges were supposed to be the party of limited government and deregulation?

Anonymous said...

Opioids are a problem across America and we must adjust strategies and fight this epidemic. So here is my proposal: lets stop wasting time, effort and resources fighting Marijuana. Legalize weed and take all of the counter-drug resources and focus them on fighting drugs that are ACTUALLY KILLING PEOPLE and destroying families. And to all of you geriatric farts born before 1970 that want to holler, "but marijuana is a gateway drug, blah blah blah" just get your head out of your rear end and try to think past the brainwashing you've been through growing up. Marijuana is not a healthy substance to abuse and neither is alcohol but they are no where near as destructive as opioids and experiments in other states have proven that weed can be regulated just like alcohol.

Anonymous said...

Been there, done that, escaped with my life. Marijuana IS a gateway drug.

Anonymous said...

If it wasn't for Cannabis many more people would be addicted to Opioids. The stuff out now is medical grade.

Here's The Deal With Feel... said...

All Feel wants is a federal appointment. Listen to me! It's a fact. He fancies himself as some sort of Federal drug enforcement Czar, flying about the country, holding break-out sessions on drug abuse with some black guy in each hotel lobby polishing his boots.

Kingfish said...

So what do you do when you have surgery and still hurt like hell three weeks later?

Anonymous said...

Marijuana is an off ramp, not a gateway. States with medical marijuana have lower rates of opioid usage. That’s a fact.

Anonymous said...

You get the hell over it just like new mothers do who’ve had a c-section and have newborn to nurse.

Anonymous said...

Opioid deaths have increased over the years, but they pale in comparison to alcohol-related deaths, motor vehicle crashes, and a long list of other preventable causes, yet there's no public outcry to create new task forces who propose more regulations or restrictions for those causes.

Anonymous said...

States with medical marijuana have lower rates of opioid usage. That’s a fact.

Link? PUT UP.

Anonymous said...

less than 10 percent of people who take prescription pain meds will have an issue with it. So it makes sense to punish the other 90 percent. Alcohol is the primary gateway drug. Most people start with alcohol regardless if they become addicted.

Anonymous said...

7:36, while I have no doubt that your c section was very painful, you have no idea about how other people suffer from more painful surgeries that aren’t as quick and routine as your birthing procedure. I respect women and motherhood and am very grateful for what y’all contribute to society but don’t act like you are so morally superior and dont cast judgement on others who need medication to recover and manage pain. I had my appendix removed in high school so I know how painful an abdominal surgery can be and I understand the need to control pain.

Anonymous said...

Pain management is now how doctors are taught in medical schools.

Pain is not a symptom anymore but rather it’s seen like cancer.

So the focus is on how to treat/end pain....which has lead nicely to profitable Rx companies and wealthier doctors.

When anethesisists quit because $600k isn’t enough money to go make $1,000,000 per year managing pain.....shit has gone sideways.

Anonymous said...

Here’s your link, 9:03. Kingfish also posted about this a few days ago.

Anonymous said...

This is going to be disastrous. Beyond shortsighted. Treating anyone prescribed a controlled substance as a drug abuser and/or criminal is brilliant. What a phenomenal brain trust that came up with this plan of action. We can't get state records access, but our personal medical histories will be documented for the world to see. By medical assistants that don't know their rearend from a whole in the ground.

I take klonopin as needed for anxiety. As needed. Maybe a few times a month. Have for years. Gainfully employed, pay more than my fair share of taxes, and married for a very long time with children, etc. Don't drink. Don't smoke. Not overweight. Functional member of society in every way. Now I'll be drug tested and looked down upon as if there is something "wrong" with me or denied effective treatment. More stigmatizm for those who seek help. Moving things backwards one dumb regulation at a time, Mississippi. The rebulicans are certainly a refreshing change from those backwards democrats.

Who is paying for all of this paperwork and drug testing? Time to open up another neighborhood liquor store. Sales are about to go up!

Anonymous said...

I just am not sure about all of this. Pain thresholds vary so greatly. I have lost a young person to opiod overdose and it hurts like hell. Hers was not an RX drug although she probably thought she was illegally buying the real drug. I don't believe regulations or lack of regulations can control all situations. Have to ask: Are ADHD children on opiods? Do any of you bloggers truly believe Opiods are harmless? Some people are addicted in less than seven days from what I've read. They are a wonderful drug for so many and help the dying out of life with less pain, but they also help others out of life who don't need to be taking them. Where's the balance?

Anonymous said...

Let's just make sure that any member of the Medical Licensure Board who has surgery, gets the "tough shit, we'll decide how much pain medicine your getting" talk right before he goes under the knife.

No procedure's for me without a crystal clear agreement concerning pain meds.

Anonymous said...

What's all this about 'drug testing'? If I've had surgery or a continuing ailment and my doctor is about to give me another prescription for pain management, what are the chances that I might test positive? Probably somewhere above 98% since he is renewing a scrip.

Anonymous said...

Speaking as a physician: Along with the burden and inaccuracy of electronic medical records, the added hassle of these not-well-thought-out regulations is going to be the last straw for many doctors who are just about ready to retire.

Anonymous said...

Thank God that Randy Eastering got his ass whipped in Warren County. Maybe he will stay away from the Capitol and crawl back under the rock from where he came from!

Anonymous said...

the biggest reason to keep long term pain pills in place is to treat cancer, there is not one oncologist on this team?

Pittpanther said...

Shouldn't we be building more jails and hiring more cops, and asking for two strike and even one strike laws (since three strikes isn't working)? That's what we did for the crack epidemic.

Arrest all these drug abusers! Why are you guys being soft on crime?

Anonymous said...

when does this go into effect?

Anonymous said...

I had abdominal surgery before. The doctor told me the quicker I got on my feet and started walking the quicker I would heal. I got out of bed the same day as the operation. He gave me a prescription but I threw it in the trash. Sure it hurt. That is what happens when someone cuts you open and sews you back up. It isn't a spa treatment.
Nature has a way of removing the weak from the breeding pool. Let nature take it's course. We have too many weaklings messing up the breeding pool. Time to clean it out.

Anonymous said...

They are not just focused on micromanaging pain meds with these new regulations. It's way beyond that. These regulations will limit access to care. Period.

Anonymous said...

Ask the Republicans how the top down control of these regulations is any different than the heavy-handedness of Obamacare.

Anonymous said...

This will solve the problem for sure. They made cocaine illegal and there aren't any more problems with it.

Anonymous said...

Interesting read:

Anonymous said...

I really worry about some of the patients that I see that are functioning, but in pain. The suicide rate will probably increase as those w/ chronic pain already feel that they have no hope. Add the difficulty getting their meds to the nightmare that is our healthcare system these days & many people won't be able to take it.

Anonymous said...

all the fat asses in this country are a far greater problem than drug users. Whats the difference (besides the time it takes) to kill yourself on fast food and hoho's? We should outlaw all sorts of foods as they cause a far greater strain on our healthcare system and take forever to kill the users. I saw legalize all drugs and thin the heard a little. outlaw all sorts of foods and make the remaining heard far thinner and healthier.

Idiots all.....who gives a shit what anybody else does to their own body.....wait, hypocrites do. Alcohol is legal. Donuts are legal. both kill and cause a massive strain on our health system. why is tobacco legal and weed not? what is a bigger crisis....obesity or drugs? damn i hate hypocrites and MS politicians are the worst of the bunch. get drunk at the camp on friday night and eat enough to kill (and then depend on the taxpayers to pay for their health care) but want to get between me and my doctor and determine how much pain a patient has to feel. maybe it is the Baptist that i should be mad at. last time i attended a baptist church, i bet the average weight of the men was 220 and the women were 175....fat ass hypocrites.

Anonymous said...

4:43 - You could not be MORE wrong. The average weight of Baptist men in church settings is 243. And when they leave church, they're headed to get fried chicken for lunch.

Anonymous said...

This would discourage me from having surgery. I have had several, major ones as an adult. When I had my tonsils out in my late 40s, I needed pain meds for a month, nearly. I ha eve had spinal surgery, childbirth, hysterectomy. I needed pain meds. This is punishing everyone with blanket prohibition, regardless of circumstances.

Anonymous said...

10:36 is correct. This going to cause tremendous inconvenience, costs, and privacy issues for patients and doctors. It will also cause a lot of unnecessary pain (literally). I’m a doctor and will continue to give narcotics to my patients in pain. This is a great example of why the government needs to get out of medicine. Several years ago they were on a big kick to ensure adequate pain management. Hospitals were graded on adequate pain management and mandated grading pain by having a patient pick a frown or smiley face. Guess what. More narcotics were given. Now they want to manage it the other way. The politicians want to look tough on opioid abuse. The Med licensure board doesn’t have the balls to rein in a few bad docs. What a mess. At least half of a doctor’s time is spend on documenting stuff. This will be another beaurocratic wedge in the doctor-patient relationship.

Anonymous said...

I imagine this will result in st least a percentage of suffering patients trying heroin. Heroin was unheard of in MS, in my day. I haven’t ever done any and don’t intend to, A ridiculous, draconian policy that treats innocent patients as criminals, creates as many problems as it aspires to solve.

Anonymous said... it being suggested that if I have surgery, my doctor will NOT be able to write me a pain med scrip post-surgery?

Anonymous said... understanding is that it will be for a bare minimum amount and you will be drug tested in order to receive it.

i have a surgery coming up. when would this go into affect? i may cancel and head to another state to have it done.

Anonymous said...

Heroin overdoses will skyrocket.

Count on it.

Anonymous said...

" understanding is that it will be for a bare minimum amount and you will be drug tested in order to receive it."

That makes no sense. If New South Neuro Spine, for example, has been treating me for 12 months using their pain-management protocol (including injections and hydrocodone) and finally they decide the only remaining option is a bilateral discectomy, they perform it and before releasing me from the hospital, prescribe pain medication....what's the chances I'll test positive for the meds they've had me on for months? 100%!

Of course all tests that report-out with a positive require the involvement of an MRO to interpret and consider the results and confer with the person who was tested. And that will naturally result in a dismissal of the positive.....which means everybody has wasted time and money on this wacky mandate.

Anonymous said...

so law enforcement will now be into our medical records. hippa issues? lawyers, figure something out. i know some of you smoke and have some sort of prescription to something on the list. you probably use both as they were meant to be and are a fine upstanding contributor to our society. man up. stop this bullshit. sue these bastards now.

Anonymous said...

Remember back when Bill Clinton wanted the feds to have access to all your medical records, and HIPAA resulted? And of course he fought like hell to make his own records of herpes secret.

Anonymous said...

All of you who are commenting about the drug testing - it is done to see what ELSE is there other than what is legally prescribed for you as these other substances can interact with your prescribed drug AND use of other meds could be indicative of an addiction.

Secondly, the drug tests are
done to see if you are indeed taking your prescribed med properly. If you test negative for the prescribed med, then why aren't you taking it? What are you doing with it? They WANT you to test positive for your prescription med!

Kingfish said...

All Fisher knows is Ban & Bust. He can not contemplate any other course of action. All his little Sudafed adventure did was push addicts into pills and heroins and import the Mexican cartels.

Anonymous said...

Exactly. Less drugs will be prescribed, more drugs will be illegally imported. He cartels will love this.

Anonymous said...

9:09am, i tried to post a retort to your perfect little self but apparently the fish found it to be somewhat lacking in tact.

it is nobody's business what else is in my body. it is my damn body, not the states and not yours.

what if i am dealing with an injury that flares up with overuse and i only take medicine when needed, not on a routine (as my doctor and i determined over several years to be the best way to treat my ailment and avoid any addiction issues). i sometimes have medicine in my system and sometimes i don't. if i havent had to take any and get tested, will i now face charges?

i bet you are one of those perfect little baptist hypocrites someone described above. your world is perfect and your shit don't stink. you are the exact type of moron that comes up with this shit. i hope one day you get to deal with pain that makes you want to blow your head off. your self righteousness is going to hit you square in the face one day.

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