Suboxone in the News

By now most of you may have read the New York Times article titled "Addiction Treatment With a Dark Side" highlighting opioid dependence treatment and the use of Suboxone. Several issues I have in regards to the article: Opioid Dependence is a complex chronic disease requiring the skilled utilization of multiple treatment modalities INCLUDING Suboxone. Therefore, physicians should be first educated about the management of this disease BEFORE they start prescribing. An eight hour course is good but simply not enough. Suboxone was NEVER marketed as THE solution for the treatment of opioid dependence. Yes, if used inappropriately or abused , Suboxone can exert adverse side affects INCLUDING accidental overdose. By the way, so do many other medications and OTC products, including Tylenol. Data obtained from the U.S. Centers for Disease Control and Prevention show that more than 300 people die annually as a result of acetaminophen poisoning. Beginning in 2006, according to the CDC, the number of people who died after accidentally taking too much acetaminophen surpassed the number who died from intentionally overdosing to commit suicide. The American Association of Poison Control Centers (AAPCC), a nonprofit that receives federal funds, shows about 113 people dying each year as a result of overdosing on medicines with acetaminophen. Since 2006, acetaminophen has accounted for more fatalities than all other over-the-counter pain relievers combined, according to AAPCC data. Since its introduction in the US market I have repeatedly stressed the point that physicians should be trained and educated about the complex management of opioid dependence and warned about " Suboxone mills" run by unscrupulous physicians in search for a new revenue resources. RB has responded to these warnings and their representatives visited these offices trying to influence the adverse prescription habits of those "physicians". In the article the author questions the addition of Naloxone to Buprenorphine and appears to minimize the abuse potential of generic Buprenorphine. In my daily practice I witness every day attempts by new patients to obtain generic Buprenorphine DESPITE the fact that their insurance will cover Suboxone. Reason: abuse potential, diversion opportunities. In my opinion we need to continue educating physicians about the management and treatment of opioid dependence as a chronic disease and to convince our patients to seek qualified providers of those services. Yes, there are and will be abuses of this medication which has saved the lives of thousands of patients but those pale in comparison with the quality of live gained for so many of my patients. Yours Bernd

Medical Marijuana

I just returned from a speaking engagement in Los Angeles where I also visited Venice Beach. There, I found several "clinics" offering medical evaluation services to obtain a medical marijuana ID Card in order to legally purchase marijuana for medical purposes. At this "Doc in a Box" clinic a licensed California physicians is available for consultation as a medical cannabis specialists. "Patients" should have a documented medical record of diagnosis and treatment or a physician referral. During the exam the physician should document in the patient’s medical record that the patient has a serious medical condition and that the medical use of marijuana is appropriate. Needless to say that the definition of a "serious medical condition" seems to be very flexible and most people lining up at those "clinic" were mostly young, healthy looking and able-bodied applicants. None of those I observed were confined to a wheelchair, using canes or crutches. These clinics will mushroom in each of those states offering medical marijuana treatment solution and will offer legal access to a drug for a vulnerable young population. Are we really that naive to believe that medical marijuana will be confined to those who have serious medical conditions? Yours Bernd

Prescription Drug Monitoring Program Under Attack

The Florida Prescription Drug Monitoring Program is under attack. Launched in 2011 to track controlled substance prescribing, the database was designed to shut down pill mills and stop doctor shopping. According to Attorney General Pam Bondi the database is an important tool against drug abuse and that prescription drug-related deaths have declined for the first time in nearly a decade. But according to a law suit filed in Volusia county the Florida's prescription drug monitoring database program violates the state's constitution, invades the privacy of residents and subjects them to unreasonable searches. The constitutional challenge is part of a growing legal battle over how the State Attorney's Office for the 7th Judicial Circuit wound up with the prescription records for an estimated 3,300 residents and why that information was provided to five of six defense attorneys representing defendants related to a prescription fraud investigation. The American Civil Liberties Union said this week it could file federal complaints with the Department of Justice and the Department of Health and Human Services related to the disclosure of the prescription information. As a physician, supporter and PDMP user I submitted a letter to the editor to the Miami Herald which was published on 07/15/2013 pointing out that it was the illegal use of data obtained by an attorney which triggered this debate and that the PDMP does NOT violate patient privacy. I wholeheartedly agree with State Attorney Pam Bondi that "there are strong safeguards in place to protect people's prescription drug information within the Prescription Drug Monitoring Program by limiting access to that information, and those safeguards have not been compromised." These facts should be taken into consideration before attempting to dismantling the PDMP which is an essential tool to safe lives and protect the public from prescription opioid abuse and diversion. Yours Bernd

PDMP on Life Support

Attached a link to an article published in today’s Miami Herald titled “Statewide pain-clinic database may be abolished” focusing on efforts to shut down the Prescription Drug Monitoring Program (PDMP)in Florida. On Monday, the Florida Department of Health will hold a workshop in Tallahassee to discuss further limiting access to records of who writes and fills prescriptions for the most addictive drugs. The meeting comes in response to allegations last month that medical data for 3,300 Floridians had been “leaked.” The American Civil Liberties Union of Florida demanded a federal investigation, and critics pointed to the incident as evidence that the system was fundamentally flawed and had allowed an inevitable breach of privacy. It also proved a rare point of agreement between the ACLU and conservative lawmakers who have opposed the database for years, even as Florida gained a reputation as ground zero of a deadly prescription drug abuse epidemic. “I think this leak by the PDMP proves it is a risk for patients,” said state Rep. Rob Schenck, R-Spring Hill. “We should do away with the whole database.” But the leak is not due to a design flaw of the PDMP but the inappropriate use and misuse of data downloaded from the database. In this case a DEA agent queried the program for names of the doctors’ patients and got about 3,300 in return. That request led to six arrests, seven people whose identities had been stolen and 63 fake names used to get fraudulent prescriptions. The names of all those patients, including those not under investigation, were provided on computer discs to prosecutors and to the defense attorneys of those charged. They included clear warnings that the records were confidential. But one of those defense attorneys recognized a name on the disc — fellow lawyer Michael Lambert — and gave him a copy of all the names, despite the confidentiality warning. Lambert filed a lawsuit, alleging that law enforcement should never have received information about innocent patients. He demanded an injunction and asked the court to determine if the program is “an unconstitutional infringement upon the fundamental rights of the plaintiff and other Florida citizens.” In a subsequent complaint to the U.S. Department of Health and Human Services, the ACLU of Florida echoed Lambert’s objections. But no one asked an obvious question: was the “leak” made by the agent who included the names on the disc, or by the attorney who gave the disc to Lambert? As a result of this data leak Florida legislators and the ACLU are calling for the dismantling of the PDMP. Would Florida lawmakers also call for the dismantling of the electronic banking system because bank employees have access to financial data and some may even abuse this privilege? Lets not forget that the program is already on life support receiving a measly $500,000 annual funding out of a $74 billion budget, which was only granted in the final night of the 2013 session. In my professional experience the PDMP provides for accountability and transparency in the prescribing process for controlled substances. In my medical practice I identified at least a dozen patients who received controlled substances from several physicians and NONE of those colleagues were aware of it. Several of those prescriptions, if not identified, could have triggered accidental overdose and death. Instead of dismantling the system we should expand the program, fund an awareness campaign to educate physicians on how to use the program and to increase security measures to ascertain patient privacy. Now is not the time for rash decisions but rational thought and measured decision making. Lets not throw out the baby with the bath water. The PDMP save lives! Yours Bernd

Florida Gun Laws and Common Sense

Gov. Rick Scott signed a gun control bill Friday to close a loophole in firearm sales to some mentally ill people. According to the press release "Mental health and second amendment advocates worked together to produce this bill that does not affect persons voluntarily seeking mental health exams or treatments but rather closes a loophole in current law that could potentially put firearms in the hands of dangerous, mentally ill individuals who are a threat to themselves or others as determined by a court." The bill addresses a gap in Florida law that has allowed people who voluntarily commit themselves to a mental institution to buy a gun once they are released. The new law requires that before agreeing to voluntary treatment under the state’s Baker Act, individuals receive written notice that if treated, they may be prohibited from buying a gun or “applying for or retaining a concealed weapons or firearms license” while they’re deemed a danger to themselves or others. Their names are then added to a national data base that informs retailers of people prohibited from buying a gun. People who are involuntarily committed are already added to that list. A judge and a physician have to concur that an individual is no longer a danger to themselves or others to have their name taken off the national database. Scott said that since 2002, "just under 100,000 individuals have been disqualified from purchasing a firearm based on court adjudications of mentally defective or mental commitments." I applaud the Governor to his sudden realization and insight that " common sense parameters balance the rights of individuals to purchase firearms with society's reasonable expectation of public safety." I hope that he will apply the same parameters to allow physicians asking their patients if they store their guns safely to avoid an accidental shooting death within the confines of their home and family. Meanwhile, he continues to litigate in federal court seeking to prevent physicians asking their patients these common sense question. Yours Bernd

Healthcare in Florida

In healthcare there seem to exist two parallel universes:the one for normal earthlings crushed by 30% health insurance premium increases and the one for our politicians who pay peanuts for their own insurance. For example, Florida House members will pay just $8.34 a month for state-subsidized health care next year, or $30 a month to cover their entire family. That’s one-sixth of what state senators and most state employees will pay, and one-tenth of the cost to the average private-sector worker, according to the Kaiser Family Foundation. It’s also less than the $25 a month House Republicans wanted to charge poor Floridians for basic coverage such as a limited number of doctor visits or preventive care. Unless we enjoy living in a parallel universe we should NOT let them get away with it!!! Yours Bernd

Insurance Rate Increases

Blue Cross and Blue Shield of Florida (aka Florida Blue) has obtained the approval for a rate increase for several of their individual health insurance policies including BlueOptions-PPO-Individual-16842FL007, MyBasic NetworkBlue-PPO-Individual-16842FL008, BlueChoice-PPO-Individual-16842FL009, BlueSelect-EPO-Individual-16842FL012 and MyBasic BlueSelect-EPO-Individual-16842FL013. According to their web site the average increase will be 15.32% effective July 1st, 2013 and will affect 264,850 people. As a Florida Blue customer my rate increased almost 30% ! The reasons driving the dramatic premium increase include a 189.37% increase in costs for inpatient care compared to a 111.07% increase in outpatient care. It's of interest to note that the current Medical Cost Adjustment - the difference between what the insurer thought it was going to pay for medical services and what it actually paid during the current year - DECREASED by 466.64%! For the final rate determination the Florida Insurance Code requires that all individual and small group carriers obtain approval of their premium rates from the Office of Insurance Regulation (OIR). In addition, the Patient Protection and Affordable Care Act, otherwise known as Health Care Reform, requires that all weighted average rate increases in the individual and small group markets that exceed a stipulated threshold (currently 10%), must be assessed to determine if they are "reasonable". For individual and small group carriers issuing coverage in the state of Florida, the federal enforcement agency for the Patient Protection and Affordable Care Act, Health and Human Services (HHS), has delegated the authority to determine if rate increases are reasonable to the OIR. According to the OIR all Florida Blue's rate increases for individual and small group products either do not exceed the threshold, or have been determined to be "reasonable." Anyone who has received his/her new premium notice might have to get used to the new definition for "reasonable" rate increase. Its probably listed in the alternative Wikipedia published by the healthcare industrial complex which pays our politicians and corrupts our public life. Yours Bernd