Even Non-Kentucky Doctors need to examine Kentucky’s Narcotic Bill

Kentucky has had a well-documented problem with narcotic diversion and over-prescribing for some time. In recent years, particularly in the eastern part of the state, prescription drug abuse has flourished and killed an estimated 1000 Kentuckians yearly. In the legislative session this year a “Pill Mill Bill” was passed, aiming to crack down on over-prescribing of schedule II controlled substances and hydrocodone. “Pill Mills” are loosely defined as any clinic or doctor’s office where controlled substances are recklessly prescribed. In Kentucky the issue often centered around pain clinics that were not owned by physicians and were operated for the purpose of generating cash, not treating patients[1]. Physician groups lobbied to keep the bill from becoming over-burdening in its effect and not punish legitimate use of prescription pain-killers. HB1 passed and was signed into law on April 24. Most physicians felt a satisfactory compromise had been made that would protect patients without being over-reaching in its effect.

On July 20, 2012, the day the bill was scheduled to take effect, “emergency” regulations were signed into law by Governor Beshear. These ten pdf’s worth of regulations went FAR beyond the intent of the legislation. As of this writing physicians must get KASPER reports every time they initially prescribe any schedule II or schedule III drug and some schedule IVs (see below for an explanation of how controlled drugs are classified). KASPER is defined as

The Kentucky All Schedule Prescription Electronic Reporting System (KASPER) tracks controlled substance prescriptions dispensed within the state. A KASPER report shows all scheduled prescriptions for an individual over a specified time period, the prescriber and the dispenser.” 

This includes ADHD stimulants in adults, testosterone, and Ambien, tramadol, alprazolam, lorazepam, clonazepam, diazepam, soma, Librium, and phentermine. Patients must see their physician MONTHLY until the physician determines that this is a medication that they should remain on. This must be repeated EVERY THREE MONTHS for as long as the patient is on the drug. In addition we must discuss and have the patient sign an “informed consent”. This covers their understanding that the drugs are addictive, reminds them to stop the drug when they no longer have the problem they are taking it for, and how to destroy the medications they do not use. After the initial three months the physician must do random drug urine screens on ALL patients using these medications, discuss if there has been any history of drug abuse in any first degree relative or themselves, ask if the patient has had any legal problems with drug abuse and revisit the issue every three months ad infinitum.

How appropriate is it that I ask my 88 year old patient to submit to a urine screen for the hydrocodone she takes some nights for her severe spinal stenosis? Oh, and if you follow the letter of the law, if that drug screen is NEGATIVE I am supposed to stop prescribing the hydrocodone and send her to a drug treatment program!  Then again there is the patient who calls in for a couple of Xanax to take for an eight-hour plane ride, usually someone who’s been a patient of mine for years. They have to come in first for a COMPLETE physical exam (which their insurance will not pay for unless it been more than a year from the last and it is a two month wait to get a physical in my office) and be counseled regarding use and abuse of narcotics including signing the informed consent. Same for cough medications–so how many doctors will be prescribing cough medications with controlled substances do you think? How much time does the governor think we primary care doctors have?

Despite Governor Beshear’s comforting remark “Let me be very clear, if you need a prescription, you will get your medicine”, he will not be opening up the governor’s mansion to prescribe medication. Last time I checked he didn’t have an MD behind his name. In a time when primary care doctors are already over-extended, to enact over-reaching regulations of this magnitude reveals an ignorance of monumental proportions. It is not that it is far easier to say “no” than to spend the time necessary to prescribe the “offending” medications, it is that there are not enough hours in the day to support the implementation of this bill. It’s important to understand that these regulations go far beyond the intent of the legislature to stop Pill Mills and over-prescribing of narcotics by physicians. These regulations will reduce the access of necessary controlled substances to ordinary citizens of the state of Kentucky because of the administrative burden placed upon offices already reeling from insurance and other governmental regulations. In addition, they will make the ordinary individual feel like they are requesting “street” drugs, when all they want is relief from their insomnia, their cough, the symptoms of low testosterone, their pain or their anxiety.

Let ME be clear. The 93% of patients in Kentucky that don’t have a controlled substance problem will suffer, and suffer unjustly because of the regulations enacted by our governor and attached to this bill.

Defining “Scheduled” Drugs or Controlled Substances:
In 1970 the Controlled Substances Act (CSA) was enacted which placed drugs into categories based on their abuse potential. There are five “schedules”
Schedule I
-high potential for abuse and no accepted medical use for treatment in the US. Instances include heroin, marijuana, or LSD
Schedule II
-high potential for abuse. Patient must have a written paper script to fill. Cannot be refilled by phone. Instances include morphine, methadone, Adderal, or cocaine
Schedule III
-potential for abuse is less. Instances include combination products with hydrocodone such as Vicodan, codeine, or testosterone. 
Schedule IV
-potential for abuse is lower than Schedule III drugs. Instances include valium, ambien and xanax. Tramadol is NOT a scheduled drug under the CSA Act and is only considered controlled in a minority of states, including KY.
Schedule V
-This schedule primarily contains combination products containing very limited amounts of narcotics used for cough suppression or diarrheal control.

References
1. http://www.kentucky.com/2012/02/01/2051727/beshear-said-shutting-pill-mills.html
2. http://www.deadiversion.usdoj.gov/schedules/index.html

This blog post was updated on July 31, 2012 to better explain the schedule of controlled substances as well as clear up grammar mistakes in the body of the blog. The opinions and content were not appreciably affected.
It was further updated on September 10, 2012 to update the fact that 93% of patients DON’T have a controlled substance problem.


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KY Pill Bill

Today the doctors in the office had our yearly meeting with the regional medical director of my group. He explained what he understood about the newly passed KY law for prescribing controlled substances. Here are some details on the law:

Every patient prescribed controlled substances such as hydrocodone (a common synthetic codeine that is given for moderate pain and an ingredient in many cough medications) must have something called a KASPER query done on them. This involves obtaining information on the patient regarding prescribing of narcotics by other physicians from a website. This typically takes ten to fifteen minutes to do. We must discuss the risks and benefits of using a controlled substance including tolerance and drug dependence and get written consent for giving the patient that drug. 
I can only imagine what that written consent is going to look like. Some estimates suggest that it will be a seven page document. The timeline for implementation of these new rules is July 12. This may not sound like that big a deal, so let me give a couple of circumstances that are not uncommon to me. A patient presents to my office with a persistent moderate viral respiratory infection who I have known for fifteen years. She doesn’t like to take any type of narcotic or other addictive substance but hasn’t slept for three nights due to the coughing. It’s late afternoon and she is my last patient of the day, I’m already behind and need to be at a meeting on the other side of town in fifteen minutes. She’s allergic to codeine. Guess who’s probably not going to get her cough medication? Or my neighbor who is also my patient, sprains her ankle on the weekend. She doesn’t need to be seen immediately but she would like some pain medication in order to sleep tonight and I’ll see her in the morning. With this bill in place, I cannot relieve her pain. I’ve been in practice for more than 25 years. It is my job to know my patients. I know who has a tendency to overuse their pain meds. I wasn’t born yesterday and can spot a drug-seeker at ten feet. However, because Kentucky allowed “Pill Mills” to run rampant in our fair state, my patients and thousands of other Kentucky citizens will be held hostage to this new state law HB1. Here’s a link to one legal firm’s interpretation of the bill. I suppose the good news is that I can always prescribe oxycodone, since it is hydrocodone that is targeted in the bill. (What?!?!!?)

So now in addition to the insurance company, the lawyer, the employer, and the federal government in my examining room, please welcome the state of KY. It’s getting mighty crowded in there, so much so that many days it’s really hard to hear the patient. And that’s unfortunate since that’s the only way I can treat her.

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The Use and Abuse of Controlled Substances

After you’ve been in practice for a while you develop different kinds of reputations. Of course you want to be known as a good doctor, a competent doctor, a compassionate doctor. One of the labels physicians learn to avoid early in their careers is that of being a “pain pill” doc. Every new primary care doctor gets a plethora of patients who “need” pain pills and/or addictive anti-anxiety drugs, like alprazolam. If those patients are disappointed you are attributed with another kind of reputation, that of a “hard sell” and those types of patients quit calling.

As practice years accumulate you find yourself in a quandary. Who are the patients truly in pain who need medications, who are the patients who believe themselves in pain but would benefit from less medication and more mental health assistance, who are the true “drug-seekers” and how to tell the difference. It’s a lot like the Serenity Prayer, so beloved by AA. Sometimes I need to say the prayer a few times after seeing a particularly difficult patient.

In Kentucky, we use a tool called the KASPER. This way we can see if a patient is going to multiple doctors to obtain controlled substances.  For instance, a few days ago a young woman came to my office that has seen me for years. She is on an amphetamine for Attention Deficit Disorder. This visit was unusual for a couple of reasons. She wanted to increase the dose but had recently been seen in an ER and had been found to have multiple drugs, legal and illegal, in her system. She was pushy, almost demanding, that she have her medication. It made me very uncomfortable so I did a KASPER report. Unknown to me, she had been obtaining the amphetamines from another doctor for a year or more. At least an abuser, at worst she is selling them. I felt used and abused by the patient at this point–angry and disgusted but at the same time sad and disappointed. Hopefully, she will get the help she needs soon, before she ends up in prison.

The AMA publishes guidelines to help doctors make decisions about prescribing these medications. So does the KMA (although these were last published in 1996–given that Kentucky is a state know for it’s drug pipeline, it might be time to update them). These are helpful. The other skill doctors learn to listen to is their gut feelings. Unfortunately one’s intuition may be swayed by prejudices deep in the subconscious–the place where racism, sexism, ageism, and other cultural influences hide and haven’t yet been flushed out by thoughtful self-analysis.

So I turn to another William Osler quote, “Medicine is a science of uncertainty and an art of probability.” Add a little wisdom to that and I will hope to make the right decision.

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