Friday, December 13, 2013

A Critique of the American College of Physicians Position Paper on Prescription Drug Abuse

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. 

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  1. Regarding the stand-off position on urine testing, perhaps they are reacting to the Federal Court precedent showing that urine testing cannot be used to monitor compliance to a prescribed regimen.

    Here is a link to one of the relevant court documents:

    1. Jim -
      Thanks for the comment. I'm not suggesting (nor would our parent company, Ameritox, suggest) that UDM is sufficient in and of itself to determine compliance with a prescription drug regimen. UDM can, however, give the physician information that can inform interactions with the patient, influence the introduction of other compliance testing approaches, and ultimately achieve a higher level of patient and community safety. I'm still not clear why the ACP wouldn't so much as mention patient safety in a discussion around opioids, pain management, and urine drug monitoring.