The American College of Physicians (ACP) just published a
“position paper” on prescription drug abuse.
While one might find fault in the details of such exercises (and I do…
please read on), one should also commend such organizations for attempting
to tackle this very difficult issue. As
the paper states, “the challenge for physicians and public policymakers is how
to deter prescription drug abuse while maintaining patient access to
appropriate treatment.” A challenge,
indeed. In fact, it’s one of the most
significant public health challenges in a generation.
The paper includes several very helpful statements,
including recommendations for:
-
A national prescription drug monitoring program
(PDMP)
-
Consideration by physicians of “the full array
of treatments available for the effective treatment and management of pain.”
-
A comprehensive national policy on prescription
drug abuse
-
The adoption of evidence-based medical treatment
guidelines
On the other hand, several of the other recommendations come
with caveats that are hard to explain given the breadth and depth of the
prescription drug abuse epidemic. For
instance:
The ACP “supports efforts to education physicians… on the
appropriate medical uses of controlled drugs and the dangers of both medical and
nonmedical use of prescription drugs.”
However, the ACP goes on to say that “it does not support additional
legislative mandates or DEA registration prerequisites specifying education
requirements regarding prescribing controlled substances.” Why not?
“The prevention, identification, and treatment of prescription drug
abuse take time, and the significant extra time required to adequately perform
this task is not reimbursed.” I find
that a relatively weak rationale for the avoidance of mandatory education in
light of the largest man-made epidemic in history.
Education isn’t the only area where the economics of
physician practice run afoul of potential best practices. “ACP favors a fair and balanced approach to
permit safe and effective medical treatment utilizing controlled substances and
efforts to reduce prescription drug abuse.
However, educational, documentation, and treatment requirements toward
this goal should not impose excessive burdens on prescribers or
dispensers.” I’m not suggesting that
it’s ok for the provider community to bear excessive administrative burdens,
but the position paper goes on to state that the real issues are potential loss
of DEA licensure, state disciplinary actions, loss of medical license, and
potential criminal sanctions based on failure to comply with documentation and
treatment requirements. We have reviewed
thousands of pages of medical records here at PRIUM and I can vouch for the
fact that most of them are awful. The
documentation related to chronic opioid therapy is critical to the physician
education the ACP says it supports.
Lives are stake. Our view: At a
minimum, make sure documentation is thorough, accurate, and in compliance with
legislative and regulatory standards. Do
it right or face penalties.
The ACP appears to reluctantly support random drug testing when
Medicare, Medicaid, private insurance, or law enforcement authorities identify
patients as being at significant risk of drug abuse. They emphasize that the 3rd party requiring
such testing should pay for that testing (to which I have no objection), but go
on to point out that when a third party mandates drug testing, the patient
should be informed that the testing will occur on a random basis, patient
consent should be obtained, and the procedure should be implemented in a manner
that helps maintain the patient’s dignity.
Finally, the ACP points out that this recommendation only applies to
third party mandated testing rather than a situation in which a physician
includes monitoring as part of an overall treatment plan developed to meet the
evaluated needs of a given patient. Not
one mention of the necessity of random drug monitoring to ensure both patient
and community safety.
The ACP position paper is a start, but rather than balancing
deterrence of prescription drug abuse with access to appropriate treatment, the
ACP appears more focused on balancing deterrence of prescription drug abuse with
physician practice processes and economics.
