22 Days into Implementing KY's "Emergency" Narcotic Regulations

(This is the second of my blog series on KY's "Pill Mill Bill". Please access the first blog post here)
At some point in the discussion of the perfect storm created by Kentucky's new narcotic-prescribing bill someone asked "How can regulations that aren't going to be enforced until October be considered emergent?" I have no clue what the answer to that is but I can give an update into my office's attempt at implementing the regs. Let me start by describing it as chaotic, confusing, time-consuming, and utterly frustrating.

We have patients calling from other doctors' offices who want to switch their care because those physicians have thrown their hands up in frustration and are simply refusing to prescribe any controlled substances. We are not accepting any new patients on controlled substances until the dust settles. I spoke with an ER doctor a couple of days ago who told me it is taking 15 more minutes per patient who needs a controlled substance prescription. I was unable to find any statistics on how many patients leave an ER needing a narcotic or other scheduled medication, but given that it is an acute care environment, one could assume at least 25%. Emergency Departments are already over-crowded, so imagine the issue with increasing the waiting time due to these ill-conceived, burdensome regulations added to a law already over-reaching in its original form, now with many more medications than originally intended.

I try to explain the regulations to patients, including the need to have urine drug testing because of their Ambien (a sleep aid of mild abuse potential) or testosterone prescriptions. Their expressions and questions are of disbelief and frustration.

• Question: Will my insurance pay for the drug tests?  Answer: I have no clue. 
• Question: Why am I being treated like a drug abuser? Answer: Call your governor. 
• Question: Am I going to have to be seen every three months? Answer: As long as I have to run a KASPER report on you every three months--yes.
• Question: Will my insurance pay for those visits? Answer: I have no clue.
• Question: Who thought this up? Answer: I'm not sure but I'd recommend asking Governor Beshear that one too.
• Question: I've heard some doctors are just not prescribing controlled substances. Are you going to do that too? Answer: No, uh, let me qualify that. I don't think so.

Despite Governor Beshear's reassuring words "For doctors who worry their ability to prescribe will be compromised, you have nothing to fear", it is taking my associates and me an average of twenty minutes per patient to explain the regulations, have patients sign informed consent papers, obtain drug tests, and run KASPERS. We only have fifteen minutes slots for patients so this is, of course, making us run behind all day long. And we are about average in the number of patients we have who take a controlled substance. The bill in its original form, covering only Schedule II meds (drugs like Oxycontin, morphine, amphetamines) and Schedule IIIs with hydrocodone would only have been an inconvenience during flu season with cough meds. But with the medications added in the emergency regulations, it's a nightmare).

So far I have run maybe fifty KASPER reports. How many have had any surprises on them? ZERO. Let me repeat that number--ZERO. Not one of my patients have had any controlled substances that they have obtained in this state over the last year that I didn't know about. Let me repeat that number--not one. When I asked the ER doctor what he thought of the law, he said, "This is a waste of time. None of the KASPERs we are running have anything of significance on them. The people that come in here who are drug-seekers we know about and we don't get KASPER reports on them because we don't give them controlled substances. Everyone else have clean reports. And the people from out-of-town we can't get a report on anyway." Then he said, "Oh here's your patient's KASPER. It has one entry." I guessed, "The 20 Valiums I gave her last February?" His response? "Yep. That's it. A real abuser, this one." She's 75 years old and her family begged me to prescribe something to help when she is completely overwrought with caring for her demented, terminally-ill husband. So far she's taken two of them. Yep, a real abuser there! 

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.