Monday, July 30, 2012

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.


26 comments:

  1. So if the drug screen comes back positive for anything not prescribed what happens to that patient? Is it one fail and your out or should the doctor work with the patient to find out why they are self medicating?

    ReplyDelete
  2. If it comes back with anything not prescribed the physician must stop prescribing for the patient and send the patient to a drug treatment program.

    ReplyDelete
  3. After completion of the drug treatment program will the physician then be able to resume any prescriptions previously discontinued?

    ReplyDelete
  4. I've been so busy with the other administrative aspects of the bill, I've not studied this reg, but my memory suggests yes, although most physicians would be reluctant and unlikely to do so.

    ReplyDelete
  5. Do you see patients crossing over to Indiana?

    ReplyDelete
    Replies
    1. No, but one of our best pain clinics (NOT A PILL MILL) did move to Indiana. Makes it harder for our patients to get care since they don't want to go to Indiana to be seen.

      Delete
    2. 93% of the current patients that are prescibed a certain drug but are LAW ABIDING CITIZENS!!! is what the author is conveying....

      Delete
  6. 93% of KY patients need a controlled substance? That seems awfully high.

    ReplyDelete
    Replies
    1. It is high! Thanks for pointing that out, it wasn't at all what I intended to say.

      Delete
  7. Great post. I was checking constantly this blog and I'm impressed! Extremely useful information particularly the last part :) I care for such information a lot. I was looking for this particular information for a long time. Thank you and good luck.
    Take a look at my website : Stress and Cancer

    ReplyDelete
  8. Can potential employers run a KASPER report on you as part of a "back ground check?" I'm curious. I've had severe anxiety for years, and ADHD since childhood, and my prescribed meds help TREMENDOUSLY. My doctor has seen me since I was in my 20s, but I have been on these for years, and do not doc shop/pharmacy shop, and only fill mine monthly, as prescribed.

    I'm really worried, since I'm looking for work, that someone (potential employer) I apply for a job with, can find out what I'm on. This scares me. Should I be concerned? Thanks for any responses.

    ReplyDelete
    Replies
    1. Employers do not have access to KASPER reports. Only healthcare providers who can prescribe pain medications, pharmacists and law enforcement have access to the KASPER data base.

      Delete
  9. PS--I find it quite odd that my 24 year old son, that has had 2 snow-boarding accidents (slamming his ACL) in one snow season, and lives in constant pain can not get our regular doctor to prescribe even the lowest level of pain meds, to use when pain is more unmanageable, and aleve/tylenol doesn't work. Must my son go to a pain clinic to be evaluated, and take the CD imaging from his MRI (on his knee) that shows fluid and scar tissue build up (in his joint of knee) to prove his pain is real? Our medical internist just looks at his knee, every 3 months we go for our check ups, and then NEVER will prescribe anything. It is getting SO bad, he can't take the pain anymore. I don't know what to do. Any suggestions of a good pain clinic he can go to? We don't care if it's in Indiana, we live close to downtown Louisville, so going over the bridge is close. He needs some help, now I'm worried he won't be able to get any help. Thank you for your response, Doctor.

    ReplyDelete
    Replies
    1. I cannot give medical advice on this forum but would encourage you to have your son speak with his Internist regarding further treatment, including a pain doctor if warranted.

      Delete
    2. Dr. guerro on broadway is very compassionate to his patients in pain. It is a pain clinic and u needs a referral. Good luck.

      Delete
  10. Just found this out on Christmas Eve when I was having a hard time getting my refill on Tramadol. No warning any month prior! My Doc & the pharmacy should have told me about this new law! I take Tramadol & have for 3 yrs. because I don't want narcotics w/more potential for addiction. I used to be a nurse at public hospital & clinic & saw drug abuse & addiction ravage lives. I agree we need intervention for our state's appalling illegal prescription drug problems, but this makes no sense. KASPER is great, but we probably should have gone with federal drug reporting & prescribing guidelines. Seems KY went with some laws that are uninformed & cause the typical patient to suffer.

    ReplyDelete
    Replies
    1. The regulations are in the process of change, both by the Board of Medical Licensure and, purportedly, by the legislators when they return to Frankfort. Hopefully this will results in less harm to the 93% of non-abusers of prescription drugs in our state while still reducing access to those who would.

      Delete
  11. Funny... I've been trying to figure out why the nurse practitioner I saw today told me she couldn't prescribe me any cough medicine. I was diagnosed with sinusitis and bronchitis.

    I have been sick for 5-6 days now with runny nose, sore throat, cough, aches, etc. and finally went to the dr. this morning as the final straw when I woke up 6:00 a.m. coughing so violently that I was gagging and on the verge of throwing up. The sensation has been the same all day. I can handle the runny nose and even the congestion in my chest, but the cough, I cannot do. Especially when I can't lay down to get any sleep.

    The NP told me that there's a new law in the state of KY outlawing any cough syrup with narcotics in it. I don't care if it has narcotics or not or how it works, all I know is that everything OTC for cough suppressant in the stores is all the same ingredient that doesn't work. If I have to pay the first $1600 (annual deductible) out of pocket on my insurance to be seen, I would like a real drug that actually works.

    I'm not seeker, and any KASPER records would show that. But after today, as a consumer and law-abiding citizen, I'm quite upset that the laws are such that I can't get what I need. Or so it seems...

    ReplyDelete
    Replies
    1. Rachel,
      I understand your frustration. The fact is: there is no law that outlaws cough syrup with narcotics in it. However, the law makes it tedious and time consuming to prescribe them. There are non-narcotic alternatives such as tessalon perles, and there are studies that suggest that narcotics do not actually suppress cough so many physicians do not prescribe them anyway.
      http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2710.1992.tb01289.x/abstract
      http://onlinelibrary.wiley.com/doi/10.1111/j.2042-7158.1997.tb06039.x/abstract

      Delete
  12. There is not a drug problem in ky. There is however a problem with patients not being able to get necessary medical treatment in ky. This has been going on for years because ky has been cracking down on legitamate drs and patients for years now. Yes its easy to say there's a prescription drug problem in ky when medication is not accessible. What are Kentuckians supposed to do suffer in pain and anxiety while the law doesn't allow these meds in ky. I don't know why they started cracking down here first or who it was that's allowing the undertreatment of patients in ky but ky thinks that this stuff is a bad thing for some reason leaving ky citizens to suffer. I know other states actually care about their citizens. Yes there is a prescription drug problem in ky. Its called not allowing care that's the real truth instead we get a reputation of being pill heads when in all reality we are not getting necessary medical care!

    ReplyDelete
  13. I hope all know kasper reports are not always accurate. They are to be use as a tool not to accuse. I know of two instances that patients with the same first name ,last name and birthdate who live in different parts of the state had each others medication profiles combined on both patients's records. Example Jane L Doe #2 birth date 3-22-66 gets xanax and lives in Pikeville ky. The xanax prescription was also place on Jane L Doe #2 birth date 3-22-66 ( who lives at the land between the lakes area )kasper report. Totally two different people with the same name and birthday. BIG PROBLEM. People at kasper know but They say inorder to be sure to get every prescription possible on someone on a report and make the report complete as possiblethat sometimes errors like this occur because they say first prioty is first and last name then birthday . Social sercurity number way down on list because people will provide wrong ssn. Easy fix would be to require a picture state id along with some other form of id before controlled prescriptions are allow to be pickup at pharmacy.

    ReplyDelete
  14. I recently called my MD's office to request a short-term script for Xanax to help deal with a temporary but very stressful situation. I had taken Xanax for 5 years back in the 80s and never had any problem with them. I have no history of substance abuse. I was already doing all the typical things to reduce stress such as good diet and regular exercise, but this wasn't enough to keep me from blowing up at my children over things that I typically handle with more grace. So, instead of taking a small pill as needed, I've increased my intake of wine. As we Ll know, Kentucky doesn't care a wit if you end up an alcoholic.

    ReplyDelete
  15. Just curiuos, what happens if you have thc + test once ( though I can't belive it!! ) is this info available to all doctors through Kasper' s system?
    Also, how long will doctors not prescribe controlled drugs?? How long does this info stay with the individual? Would other doctor consider frequent testing/re-testing & prescribing?
    Thanks!!

    ReplyDelete
  16. This new law sucks for people who need pain medication. It doesn't hurt the seekers as they will just pay more from some street corner. I had gone to "Pain Clinics" from 1991 thru 2006, taking every non-narcotic medicine available, especially drugs that were initially developed for some other health problem and proved to work for pain management for some people. I had all the injections that were around. I went to many doctors besides pain clinics and not once in those years did I ever ask for a narcotic type pain reliever. In 2006 my new (seems like pain clinics go out of business as soon as they pop up) pain clinic doctor performed a physical including films and told me the only med that would help me was a Fentanyl type drug but he said that he was too busy to write scripts for me every month and instead wrote a letter to my primary care doctor saying I indeed needed this drug if I was to get any relief.
    In October 2006 I finally caved and went on Fentanyl but it made me so nauseous that I could not tolerate the drug. My doctor started me on Oxycontin and it, along with Advil, helped a great deal, it was like a new life had been handed to me. Then I learned that I was going to need more and more, stronger dosages as my body became used to the current dosage, bummer. I have been on it since 2006, never taking anymore than what was prescribed, never having to call the doctor for more than the regimen I was on. My wife could stop on her way to work and pick up the monthly prescription for me and while not liking the mood that this drug can put a person in at times I was able to cope since it did help a lot.

    Now move to the new laws. Now I have to drive to my doctor's office every month which could cost me a DUI if found out and forget about life if I have a wreck or hit someone while driving to and fro to the doctor. Last week I had to go to the doctor for a urine test to make sure I am not doing something illegal. So that means I have to drive some more. My wife cannot call work every month and say she will be late for work because of this new law. My doctor would only prescribe a dosage for seven days till the results came back from the test. Everything is fine except I went down to get my regular monthly dose and find out it is only for ten days. On top of that my pharmacy next month is requiring me to show an ID and at least an hour wait (their words) while a check is done on me. So, to anyone who says things will change for the better as things get ironed out I say they are full of it. All these new laws do is hurt the people who are legal. I think the governor and the senate must be watching Justified on the FX channel and actually believe that everyone is as portrayed on that series. Oh yeah, whoever drops my script off at the pharmacy has to be the same person who picks it up. This starts next month. Don't even think about things getting better.

    ReplyDelete
  17. I am having these same issues as others on here. I have taken klonipin for 3 years for an extreme panic disorder PTSD and agoraphobia. I had two drug tests done that were fine. Then I had a third done where I didn't have enough in my system. Just was havin a better month than usual and didn't have to use all 3 pills every day. Because of this my doc dropped me from the medicine and won't even talk to me about. Just sent me a letter stating he will no longer be treating me for anxiety. Now if that's not the government tying the doctors hands then I don't know what is.
    Very frustrated and saddened My panic disorder is completely out of control. Insomnia is every night. And it seems as though other docs are afraid of me now as well because of this one drug test. I don't know what to do but my quality of life is non existent :(

    ReplyDelete
  18. everyone needs to write their State Senator and Representative to have this law repealed or revised further. http://www.lrc.ky.gov

    ReplyDelete