"Because so many patient problems have fallen at the feet of primary care, we need to look at ways primary care can be part of the solution and not part of the problem," said Michael M. Miller, MD, president of the American Society of Addiction Medicine.
Dear Friends and Colleagues:
Attached a very informative article from a recent AMA NEWS edition.
Some great quotes including Mark Gold and Michael Miller,MDs.
Bernd
AMA NEWS 03/17/08
HEALTH & SCIENCE
Dangerous diversions: Specter of prescription drug abuse creates tough balancing act for doctors
Questioning patients about past addictive disorders can alert physicians to the need for care when prescribing medication with the potential for misuse.
By Susan J. Landers, AMNews staff. March 17, 2008.
Walking the line between appropriately prescribing controlled substances and unwittingly contributing to the increase in prescription drug abuse becomes less precarious when certain precautions are taken, say those familiar with the balancing act.
Prescription drug abuse is widespread and on the rise. Nearly 7 million Americans abused prescription drugs in 2005, compared with 3.8 million in 2000 -- an 80% jump, says the Justice Dept.
While research has shown that most medications are prescribed responsibly and that the Internet and street sales feed the illegal drug trade, physicians could play a larger role in fighting this problem, several experts said.
Prescribing of controlled substances has increased dramatically, said Robert DuPont, MD, president of the Institute for Behavior and Health, a nonprofit drug abuse policy organization in Rockville, Md., a block from the National Institute on Drug Abuse, where he served as the first director.
"Before the last decade, doctors were very reluctant to prescribe these medications to outpatients. But because of concern about the undertreatment of pain, their prescription has become ubiquitous," Dr. DuPont said.
If physicians think their practices are immune from prescription abuse, they should think again, said Mark Gold, MD, distinguished professor and chief of addiction medicine at the University of Florida's McKnight Brain Institute in Gainesville.
10% of adults will have some kind of addictive disorder in their lifetimes.
Properly prescribed medications can be diverted by teens pilfering drugs from their parents' medicine cabinet before heading out to a party. Or patients may sell their medications to supplement their incomes. And then there are the "doctor shoppers" who hit a different physician's office every day, seeking controlled substances.
Regardless of how it happens, the outcome of this abuse can be deadly. Actor Heath Ledger, who died Jan. 22 after taking a variety of prescribed medications, can be counted among its victims, as can musicians Elvis Presley, Judy Garland, Dinah Washington and Jimi Hendrix.
For as long as there have been medicines, the danger of overuse, experimentation and abuse has existed. The rise of patent medicines -- based largely on morphine and cocaine -- in the middle and late 1800s resulted in one in 200 Americans becoming addicted. These widely used substances were embraced by doctors and patients alike before harm was detected and the first drug control laws were passed.
That was then. The drugs of choice now, according to the National Institute on Drug Abuse, are opioids commonly prescribed to treat pain; central nervous system depressants used to treat anxiety and sleep disorders; and stimulants used to treat narcolepsy and attention-deficit hyperactivity disorder.
Pain reliever or drug of abuse?
But there is a flip side. The same medications subject to abuse provide much-needed relief to patients. A larger problem comes when pain is not treated adequately or when patients are afraid to ask for pain relief because they fear they might become addicted, said A. Thomas McLellan, PhD, CEO and founder of the Treatment Research Institute, a nonprofit group in Philadelphia that studies addiction.
American Medical Association policy also cautions that undertreating pain is a concern that must be balanced against the risk of abuse.
70 million Americans experience pain every day.
Undertreatment of chronic pain is an important public health concern, said B. Todd Sitzman, MD, MPH, president of the American Academy of Pain Medicine. An aging population means that arthritis, cancer, degenerative disc disease and other disorders will become more common, leading to an increase rather than a decrease in pain scripts, he said.
The need for both pain treatment and addiction treatment is clear. "We know there are 70 million Americans who experience pain every day. Along with that, we know 10% of the adult population will have some kind of addictive disorder in their lifetime, although most will be addicted to some legal substance, like alcohol."
Primary care physicians can address these problems before even picking up a pen and prescription pad, several physicians said. "Because so many patient problems have fallen at the feet of primary care, we need to look at ways primary care can be part of the solution and not part of the problem," said Michael M. Miller, MD, president of the American Society of Addiction Medicine.
A report about prescription drug abuse will be presented at the AMA Annual Meeting in June. Current AMA policy supports physician education, research activities and the development of state-based programs.
As a first step, physicians need to ask questions about a patient's history of addiction or previous difficulties in controlling their prescription drug use, Dr. Miller said. While addiction to opioids and psychostimulants is relatively rare when the medications are properly prescribed, these screening questions can alert physicians to the need to exercise particular caution, he said.
Doctors can incorporate such queries into a busy practice, Dr. Gold said. Questions about tobacco use, once a rarity, are commonplace today.
Doctors may think that national statistics don't apply to their practices, he said, but that's not the case. "Tobacco, alcohol and drug problems are so important in our society and health system, it is imperative for physicians to acquire the skill to ask and intervene."
Physicians also should consider what might happen to the medication that isn't used right away, said Kyle Kampman, MD, medical director of the Charles O'Brien Center for Addiction Treatment at the University of Pennsylvania. Physicians often provide too many pills, he said. "We hate to see somebody in pain run out of medicine, so sometimes we may be a little too generous."
Pharmaceutical leftovers are kept in case patients need them again. And where are they stored? In medicine cabinets and kitchens, where they can be found by children and others, Dr. Kampman said.
Physicians need to warn patients to lock up unused medications, he added. "Patients tell me they worked as a maid at the height of their addiction and they would go through people's medicine cabinets. I had a patient who was a roofer tell me, 'If you ever let a roofer in your house and in the bathroom, chances are they are looking through your medicine cabinet.' "
Physicians also need to look for signs of abuse, such as patients who return early for a refill. "It's a joke among addiction providers that sinks and toilets seem to be magnets for people's medications. That's an excuse you often hear: 'I dumped my medicine down the sink or down the toilet.' So that should ring alarm bells," Dr. Kampman said.
If this occurs, it's best to confront a patient directly, he said. Sometimes patients will acknowledge a problem, and the physician needs to stop prescribing and insist the patient be evaluated for substance abuse, Dr. Kampman said.
Other times, patients' pain is undertreated, leading them to take increasing amounts of a medicine. In these cases, referral to a pain specialist is necessary, he added.
Every physician prescribing controlled substances has clear responsibilities set forth by the Federation of State Medical Boards, Dr. Sitzman said. These duties -- which include obtaining a physical exam before prescribing, having a written treatment plan and stressing the responsibilities of both patient and physician -- aren't always followed closely, he said.
Physicians should tell patients that it is illegal to share medications with other people, and that unused or expired drugs should be destroyed, Dr. DuPont said. Destroying them means rendering them unusable by mixing them with cat litter or coffee grounds. Flushing them down the toilet is permissible only if the label says so, according to the Office of National Drug Control Policy.
Detecting doctor shoppers
Turning to a prescription drug monitoring program, a searchable database for tracking users of controlled substances, is another option for physicians on the trail of doctor shoppers. For instance, the Indiana Scheduled Prescription Electronic Collection & Tracking program is gaining popularity in that state.
"It takes about 30 seconds to check to see if patients are filling other prescriptions," said family physician Terry Haffner, MD, of Kokomo. Previously available only to law enforcement agencies, the INSPECT program opened to doctors last July.
Congress enacted the National All Schedules Prescription Electronic Reporting Act in 2005 with strong doctor support. But the law, which authorizes a system of federally supported, state-based drug monitoring programs, has yet to be funded.
NASPER investment is critical, said Andrea Trescot, MD, president of the American Society of Interventional Pain Physicians. If it were funded, the law would provide an important preventive tool, she said.
Talk-show host Rush Limbaugh might not have gotten into trouble with prescription abuse if NASPER had been operational, she noted. He was charged in 2006 with doctor shopping to get extra pain killers. "When he saw a second doctor, [that] doctor would have said, wait a second, maybe there is a problem here. Let's see if we can intervene before you crash, burn and die."
Discuss on SermoBack to top.
ADDITIONAL INFORMATION:
Getting pain pills
Friends and relatives were the primary source of prescription pain relievers abused by those 12 and older, a new survey finds. But physicians were also sources.
56% of respondents said they had received pain relievers free from a friend or relative.
19% received them from a doctor.
9% bought them from a friend or relative.
7% identified another source.
5% took them from a friend or relative.
4% bought them from a drug dealer.
Source: "2006 National Survey on Drug Use and Health: national findings," Substance Abuse and Mental Health Services Administration, September 2007
Back to top.
Controlling controlled substances
Specialists in pain medicine and addiction medicine suggest ways to prevent drug diversion:
Ask patients about a history of addiction or any previous difficulties in controlling prescription drug use.
Don't prescribe too many pills. Those that aren't used are often kept where they can be found by teens and visitors.
Warn patients to lock up their medications.
Encourage patients to dispose of unused medicine by mixing it with coffee grounds or cat litter, wrapping it in a plastic bag, and then a paper bag, before throwing it in the trash.
Be aware of signs of misuse or of inadequate pain relief, such as "losing" prescriptions and medications or running out early.
Back to top.
Abusing Rx drugs, and more
More than 2.1 million teens reported abusing prescribed substances in 2006, according to a national survey on drug use and health released last September. People 12 and older who reported using an illicit drug for the first time in the past year (numbers are in thousands):
2,150,000 used pain relievers
2,063,000 used marijuana
1,112,000 used tranquilizers
997,000 used cocaine
860,000 used ecstasy
783,000 used inhalants
267,000 used sedatives
264,000 used LSD
258,000 used meth
91,000 used heroin
69,000 used PCP
Source: "2006 National Survey on Drug Use and Health: National Findings," Substance Abuse and Mental Health Services Administration, September 2007
Back to top.
Weblink
American Society of Addiction Medicine (www.asam.org)
American Academy of Pain Medicine (www.painmed.org)
American Society of Interventional Pain Physicians (www.asipp.org)
Monday, March 24, 2008
Monday, March 17, 2008
Impaired Healthcare Professionals in the news
Dear Friends and Colleagues:
Attached you find an article from the Sunday edition of the Miami Herald regarding the issue of impaired healthcare professionals.
Despite the apparent criticism of an opaque system that appears (for the public at least) to protect impaired practitioners Dr.Pomm points out the obvious success rate of the monitoring system.
I think that we need to proactively monitor our own profession and report those who truly need assistance and support.
We should not leave it up to the public or the lawyers to judge us but be proactive in the pursuit of protecting our patients and our profession.
I am looking forward to your comments.
Yours
Bernd
==============================================================================
Posted on Sun, Mar. 16, 2008
Healthcare practitioners with drug problems hidden by the system
BY JOHN DORSCHNER AND PATRICK DANNER
In August 2006, the former wife of a Broward psychologist sent a letter to state authorities saying she had visited his home 'and saw cocaine paraphernalia, an empty bottle of Oxycontin and a small Ziploc bag . . . with `whitish-beigy' colored small rocks,'' according to a court document.
That event started an investigation and later a lawsuit against ''John Doe, Ph.D.'' The psychologist's name has not been revealed. The Department of Health won't say if he's still practicing. ''Everything about this case is confidential,'' says spokeswoman Eulinda Jackson.
The case is another example of how far state regulators will go to protect healthcare professionals.
''Doctors like to protect other doctors,'' says Sidney M. Wolfe, a physician with the Washington-based Public Citizen consumer group which has published a series of studies on how lax regulatory groups are in disciplining healthcare professionals.
In the case of the unknown psychologist confidentiality is key in order to get professionals to seek help, says Raymond Pomm, head of the group that handles the impaired physicians' program. ``If we don't protect them, they won't come knocking on the door.''
But court records reveal John Doe, Ph.D. refused to participate. Pomm's program, Professional Resource Network, asked him to respond to his ex-wife's allegations. He didn't. In October 2006, PRN sent him a certified letter. He didn't respond. Over the next year, PRN kept repeating the request.
Finally, in November, the Department of Health sued ''John Doe Ph.D'' in Broward Circuit Court to compel him to submit to a mental and physical test. Wherever his real name appeared in court documents, it was blacked out. The psychologist has yet to respond.
''It's always been troubling to me that the profession protects itself to the detriment of the public,'' says Ervin Gonzalez, a Coral Gables lawyer who has represented patients in malpractice lawsuits. ``The profession closes in and has star chamber-type proceedings that no one knows about or hears about. I think it should be in the sunshine. I think it should be transparent.''
Gonzalez says doctors generally are allowed to continue to practice while the Department of Health brings such actions. That due process is a fundamental right, but ''after there is a probable cause finding and evidence of a legitimate risk to the public, then I think the public should know,'' he says.
That means making the physician's name public at that point so patients can decide for themselves. ''It's a matter of great public importance, I believe,'' Gonzalez says.
According to the state's Medical Quality Assurance Division, 127 complaints were received in fiscal 2007 concerning Florida's 3,571 licensed psychologists. In 12 cases, investigators found there was probable cause that state rules had been violated. Final outcome: No licenses revoked, one suspended and 11 psychologists were fined.
State officials have asked that the John Doe Ph.D. file be sealed completely, but the judge has yet to make a decision and a hearing last month was postponed. The state statute governing such cases requires that the psychologist's name be kept confidential in court documents and proceedings be closed to the public. But nothing in the statute says that the entire file must be sealed.
The attorney for the Health Department in the case, Cynthia L. Jakeman, did not respond to a request for comment.
Pomm says PRN has a ''very strict'' program of testing and compliance, and the doctors are highly motivated because they don't want to lose their licenses. He says 87.2 percent of medical doctors and osteopathic physicians successfully complete the program and never relapse -- a far better success rate than most rehab programs.
''We see 9.3 percent relapse one time, 1.7 percent relapse two times only and 1.8 percent three times or more. These are very good rates,'' says Pomm.
However, ''before July 1, 2005, there was a loophole,'' in which practitioners who had successfully completed the program and were thought to have relapsed could not be forced to take a urine test. ''We fixed that with legislation,'' says Pomm. Under the present PRN program, if a practitioner misses a urine test or a group counseling session, ``we basically pull them out of practice.''
In the case of John Doe Ph.D., court filings hint at multiple problems. One document indicates he successfully completed a PRN program in January 2006. In a filing in a custody battle for his children, he said he had been ''clean'' of ''hard-core'' drugs from August 2000 to April 2006, ``when he began taking a prescription of oxycodone for chronic neck, back and right knee pain.''
On Aug. 5, 2006, he said he was in an opiate detox program. Less than three weeks later, his ex-wife notified PRN of seeing drug paraphernalia in his home.
When the Health Department sued John Doe Ph.D., it stated ''probable cause existed to believe that respondent was unable to practice psychology with reasonable skill and safety,'' which appears to indicate that the department was asking the psychology board to suspend his license. However, in the minutes of that board's regular meetings, available on the Internet, there is no indication of any Broward psychologist being suspended for drug allegations.
Arthur Levin of the Center for Medical Consumers in New York says ''it's just crazy'' for regulators to protect the identity of a healthcare practitioner who refuses to cooperate. Levin appreciates the need for confidentiality. ``I live with somebody who is in recovery. But it's a little different in the case of a professional.''
Some believe impairment problems are not as critical with a psychologist as they would be with, say, a heart surgeon, but Michael Herkov, a clinical psychologist and a professor at the University of North Florida, says psychology also involves life-and-death decisions.
''Psychologists don't just listen,'' says Herkov. ``Bartenders listen. Psychologists are involved in the diagnosis and treatment of mental disorders. . . . More people die each year from suicide than do from homicide. Decisions have to be made. Do you have to be hospitalized immediately? . . . These are situations with serious consequences.''
Court records show it's unusual for the Department of Health to sue a John Doe to demand the taking of mental and physical exams. There are only four such cases in Miami-Dade and Broward counties over the past five years. The other two cases in Broward involve John Doe, MD and Jane Doe, LPN (licensed practical nurse).
In Miami-Dade, the lone such case involves a Jane Doe, RN (registered nurse). There is no indication of what the case was about or how it was resolved.
When a consumer hears rumors about a practitioner and drug use, such allegations are virtually impossible to check out.
Some months ago, a person called a Miami Herald reporter and named a Miami-Dade cosmetic surgeon who continued to practice while having drug problems. The caller gave detailed information, such as saying the surgeon relapsed six times in rehab programs.
On the Department of Health website, the surgeon is indicated as having a ''clear/active license.'' No disciplinary actions are listed.
When a reporter asked Pomm about the surgeon, he said he couldn't say anything about specific doctors.
Attached you find an article from the Sunday edition of the Miami Herald regarding the issue of impaired healthcare professionals.
Despite the apparent criticism of an opaque system that appears (for the public at least) to protect impaired practitioners Dr.Pomm points out the obvious success rate of the monitoring system.
I think that we need to proactively monitor our own profession and report those who truly need assistance and support.
We should not leave it up to the public or the lawyers to judge us but be proactive in the pursuit of protecting our patients and our profession.
I am looking forward to your comments.
Yours
Bernd
==============================================================================
Posted on Sun, Mar. 16, 2008
Healthcare practitioners with drug problems hidden by the system
BY JOHN DORSCHNER AND PATRICK DANNER
In August 2006, the former wife of a Broward psychologist sent a letter to state authorities saying she had visited his home 'and saw cocaine paraphernalia, an empty bottle of Oxycontin and a small Ziploc bag . . . with `whitish-beigy' colored small rocks,'' according to a court document.
That event started an investigation and later a lawsuit against ''John Doe, Ph.D.'' The psychologist's name has not been revealed. The Department of Health won't say if he's still practicing. ''Everything about this case is confidential,'' says spokeswoman Eulinda Jackson.
The case is another example of how far state regulators will go to protect healthcare professionals.
''Doctors like to protect other doctors,'' says Sidney M. Wolfe, a physician with the Washington-based Public Citizen consumer group which has published a series of studies on how lax regulatory groups are in disciplining healthcare professionals.
In the case of the unknown psychologist confidentiality is key in order to get professionals to seek help, says Raymond Pomm, head of the group that handles the impaired physicians' program. ``If we don't protect them, they won't come knocking on the door.''
But court records reveal John Doe, Ph.D. refused to participate. Pomm's program, Professional Resource Network, asked him to respond to his ex-wife's allegations. He didn't. In October 2006, PRN sent him a certified letter. He didn't respond. Over the next year, PRN kept repeating the request.
Finally, in November, the Department of Health sued ''John Doe Ph.D'' in Broward Circuit Court to compel him to submit to a mental and physical test. Wherever his real name appeared in court documents, it was blacked out. The psychologist has yet to respond.
''It's always been troubling to me that the profession protects itself to the detriment of the public,'' says Ervin Gonzalez, a Coral Gables lawyer who has represented patients in malpractice lawsuits. ``The profession closes in and has star chamber-type proceedings that no one knows about or hears about. I think it should be in the sunshine. I think it should be transparent.''
Gonzalez says doctors generally are allowed to continue to practice while the Department of Health brings such actions. That due process is a fundamental right, but ''after there is a probable cause finding and evidence of a legitimate risk to the public, then I think the public should know,'' he says.
That means making the physician's name public at that point so patients can decide for themselves. ''It's a matter of great public importance, I believe,'' Gonzalez says.
According to the state's Medical Quality Assurance Division, 127 complaints were received in fiscal 2007 concerning Florida's 3,571 licensed psychologists. In 12 cases, investigators found there was probable cause that state rules had been violated. Final outcome: No licenses revoked, one suspended and 11 psychologists were fined.
State officials have asked that the John Doe Ph.D. file be sealed completely, but the judge has yet to make a decision and a hearing last month was postponed. The state statute governing such cases requires that the psychologist's name be kept confidential in court documents and proceedings be closed to the public. But nothing in the statute says that the entire file must be sealed.
The attorney for the Health Department in the case, Cynthia L. Jakeman, did not respond to a request for comment.
Pomm says PRN has a ''very strict'' program of testing and compliance, and the doctors are highly motivated because they don't want to lose their licenses. He says 87.2 percent of medical doctors and osteopathic physicians successfully complete the program and never relapse -- a far better success rate than most rehab programs.
''We see 9.3 percent relapse one time, 1.7 percent relapse two times only and 1.8 percent three times or more. These are very good rates,'' says Pomm.
However, ''before July 1, 2005, there was a loophole,'' in which practitioners who had successfully completed the program and were thought to have relapsed could not be forced to take a urine test. ''We fixed that with legislation,'' says Pomm. Under the present PRN program, if a practitioner misses a urine test or a group counseling session, ``we basically pull them out of practice.''
In the case of John Doe Ph.D., court filings hint at multiple problems. One document indicates he successfully completed a PRN program in January 2006. In a filing in a custody battle for his children, he said he had been ''clean'' of ''hard-core'' drugs from August 2000 to April 2006, ``when he began taking a prescription of oxycodone for chronic neck, back and right knee pain.''
On Aug. 5, 2006, he said he was in an opiate detox program. Less than three weeks later, his ex-wife notified PRN of seeing drug paraphernalia in his home.
When the Health Department sued John Doe Ph.D., it stated ''probable cause existed to believe that respondent was unable to practice psychology with reasonable skill and safety,'' which appears to indicate that the department was asking the psychology board to suspend his license. However, in the minutes of that board's regular meetings, available on the Internet, there is no indication of any Broward psychologist being suspended for drug allegations.
Arthur Levin of the Center for Medical Consumers in New York says ''it's just crazy'' for regulators to protect the identity of a healthcare practitioner who refuses to cooperate. Levin appreciates the need for confidentiality. ``I live with somebody who is in recovery. But it's a little different in the case of a professional.''
Some believe impairment problems are not as critical with a psychologist as they would be with, say, a heart surgeon, but Michael Herkov, a clinical psychologist and a professor at the University of North Florida, says psychology also involves life-and-death decisions.
''Psychologists don't just listen,'' says Herkov. ``Bartenders listen. Psychologists are involved in the diagnosis and treatment of mental disorders. . . . More people die each year from suicide than do from homicide. Decisions have to be made. Do you have to be hospitalized immediately? . . . These are situations with serious consequences.''
Court records show it's unusual for the Department of Health to sue a John Doe to demand the taking of mental and physical exams. There are only four such cases in Miami-Dade and Broward counties over the past five years. The other two cases in Broward involve John Doe, MD and Jane Doe, LPN (licensed practical nurse).
In Miami-Dade, the lone such case involves a Jane Doe, RN (registered nurse). There is no indication of what the case was about or how it was resolved.
When a consumer hears rumors about a practitioner and drug use, such allegations are virtually impossible to check out.
Some months ago, a person called a Miami Herald reporter and named a Miami-Dade cosmetic surgeon who continued to practice while having drug problems. The caller gave detailed information, such as saying the surgeon relapsed six times in rehab programs.
On the Department of Health website, the surgeon is indicated as having a ''clear/active license.'' No disciplinary actions are listed.
When a reporter asked Pomm about the surgeon, he said he couldn't say anything about specific doctors.
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