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The Wisconsin Medical Society and the Wisconsin Society of Addiction Medicine (WISAM) have raised concerns that a recent letter sent by the U.S. Department of Justice (DOJ) could have negative unintended consequences for patients trying to receive medically necessary treatment.
The letters were sent February 4 to more than 180 Wisconsin physicians, physician assistants and nurse practitioners who are “prescribing opioids at relatively high levels compared to other prescribers,” but did not specify if those comparisons reflected different types of patient populations that exist—a critical variable considering that some clinicians spend the bulk of their practices treating patients who experience pain or who are being weaned off addictive drugs, including opioids.
“We’re very concerned that these letters will alarm prescribers to the point that they may get out of the pain treatment arena altogether,” said Society President Molli Rolli, MD, in a press release distributed statewide today. “For years, Wisconsin’s physicians, elected officials and law enforcement leaders have collaborated to find the best ways to combat the opioids crisis; these letters seem to pivot into an area where physicians are threatened with criminal sanctions even if the treatment provided is medically appropriate.”
The DOJ letter admits that those receiving the letter haven’t been accused of any criminal wrongdoing: “Your prescriptions may be medically appropriate, and we have made no determination that you are violating the law.”
However, WISAM President Matthew Felgus, MD, said, “You have to get pretty deep into the letter to see that disclaimer. So essentially the letter is saying ‘you’re not doing anything illegal, but we’re watching you’—that’s a very new law enforcement attitude compared to what we’ve seen over the last several years, so it’s quite troubling.”
A recent report from the state’s Prescription Drug Monitoring Program (PDMP) shows that the total number of opioids and other monitored prescription drugs dispensed in Wisconsin has decreased 29 percent between 2015 and 2018—a drop of almost 1.5 million prescriptions.
“We’re making progress in reducing the amount of opioids being prescribed; at the same time, it’s important to remember that it’s already very difficult for some patients in Wisconsin to get quick access to legitimately needed care,” said Dr. Felgus. “Prescribers receiving this letter may think twice about continuing to see patients who have pain treatment needs—and those patients risk turning to street drugs when they can’t see a physician who is trying to wean them off opioids altogether.”
Both Dr. Felgus and Dr. Rolli emphasized that physicians are grateful for law enforcement efforts to help combat the opioid epidemic and suggested that the state’s Medical Examining Board—made up of 10 physicians and three public members—is best-suited to determine if a physician should face sanctions for providing inappropriate care.
“We hope to continue to collaborate with law enforcement on efforts like Wisconsin’s Dose of Reality initiative and drug take-back days, which have resulted in literally tons of unused prescription drugs being turned in to law enforcement offices for destruction, and that what appears to be a more punitive stance in the DOJ letter is an anomaly rather than a new standard,” said Dr. Rolli.
Heading to The ASAM 50th Annual Conference April 4-7? While in Orlando, make plans to participate in a Wisconsin Chapter meeting on Saturday, April 6th, 5:30-6:30 pm EST. We look forward to seeing you there!
January 30, Wisconsin Health News
Opioid-related overdose deaths appear to be leveling off in Milwaukee County, according to a recent report.
If trends continue, the projected likely number of fatal opioid-related overdoses last year will be 9 percent lower than in 2017, according to the Milwaukee Community Opioid Prevention Effort.
The report estimated that for every overdose death, five additional people received an anti-overdose drug and survived.
The report also called for efforts focused on reducing drug use, working with providers to prevent those taking pain medications from developing opioid use disorder and connecting people with treatment.
"While much effort has been put into addressing the opioid crisis, and projected fatal and non-fatal overdoses appear to be decreasing, more is needed," the report noted.
The Milwaukee Community Opioid Prevention Effort is sponsored by the city of Milwaukee, The Medical College of Wisconsin's Department of Emergency Medicine and the Zilber Family Foundation.
December 20, WMS Medigram
The Wisconsin Medical Society has urged the state’s Medical Examining Board (MEB) to be flexible when approving courses related to opioid prescribing so that more physicians can receive useful education befitting their particular specialties. The input was given at a public hearing before the MEB on a new administrative rule related to an extension of the opioid prescribing continuing medical education (CME) course requirement until November 2021.
Current rules require physicians holding a U.S. Drug Enforcement Administration number to complete two of the 30 required hours of CME per biennium in an MEB-approved course related to the state’s opioid prescribing guidelines. The current requirement expires in November 2019. The MEB is extending the requirement for another CME reporting biennium while broadening the subject matter scope to “an educational course or program related to opioid prescribing.”
The Society was the only organization to testify before the MEB on the rule proposal.
Flexibility in the types of courses that can gain MEB approval would make the requirement more relevant to certain physicians who, while not being active opioid prescribers, often take care of patients dealing with the aftermath of opioid addiction or abuse. The Society also suggested that the Board could incentivize physicians taking coursework in Medication Assisted Treatment (MAT) by making those courses eligible to satisfy the requirement should they be submitted for CME approval. The MEB welcomed the comments and indicated that such flexibility would be useful as Wisconsin continues to grapple with this issue.
The MEB unanimously approved the rule proposal, which now moves on to standard Governor’s office and legislative review.
Each of the webinars available in the Society’s opioid prescribing series has been approved by the MEB for fulfilling the 2018-2019 CME requirement, including two 2-hour webinars presented by Michael McNett, MD. The other programs vary in length and may be combined to satisfy the mandate. Click here to learn more.
December 19, Wisconsin Health News
A state commission has designed a care delivery model to increase access to treatment for substance use disorder. But critical parts of the model, like how it'll be paid for, still need work.
The report from the Commission on Substance Abuse Treatment Delivery was released at the final meeting of the Governor’s Task Force on Opioid Abuse in Friendship last week.
The commission, created by Gov. Scott Walker in January, met with Medicaid officials, provider associations and others as it developed the model.
The report describes a system of regional “hubs,” with staff specialized in addiction providing high-intensity, medication-assisted treatment, and “spokes” that offer less intensive treatment in the community.
Vermont first developed the hub-and-spoke model, and other states have adopted similar models.
“The model can be viewed as a draft, and a goal to move towards, as it will benefit from further input from additional stakeholders and from individuals with lived experience of addiction,” the report notes.
The report recommends that the treatment initiation process begin within 24 hours of a person seeking care to minimize withdrawal. That capacity isn’t available in the current system, the report notes, describing it as a “long-term goal.”
But a starting point could be emergency departments, where doctors could provide patients with a one- to three-day prescription for buprenorphine, a drug used to treat opioid addiction.
Care teams that provide support throughout treatment and recovery and address the social determinants of health are another critical part of the model. The makeup of the teams could vary, and the report doesn’t specify how they’d be paid for and what requirements they'd need to meet.
Hubs will have to be able to quickly accept transfer patients that spoke clinics can't support. Spokes will also need access to specialized resources to support patients, which could be provided by either the team or the hub. “All services should be available locally across the state,” the report notes.
The report's roadmap toward implementation includes coordinating funding and a call on healthcare payers to change how they pay for care to ensure providers participate in the model. That could include increases in reimbursement rates and incentives for care coordination and delivery.
It’ll also require a “comprehensive monitoring and program evaluation plan" to track performance.
Health information technology and telehealth will play a large role as will regulatory changes aimed at breaking down barriers to accessing medication-assisted treatment, according to the report.
Matt Felgus, MD WISAM President
The impact of substance use disorders is in the news every day -- there is no escaping the effects this has on patient care whether you are a physician, nurse, pharmacist or therapist. However, not all of our colleagues are comfortable with this unavoidable reality, which is why it is so important for all of us to stay informed and to serve as points of contact along the way.
I've heard some of you, especially newer WISAM members, say that you don't feel you know enough about addiction to be able to serve as a point of contact for your colleagues. But the fact that you've joined WISAM and are reading this now makes a huge difference in moving our respective fields forward in this critical subject. Keep connected and keep learning!
As one who started in the field as a drug counselor and finished addiction psychiatry training in the late 90s at the crest of the 'patients can't get addicted to opioids if they are using them only for pain' era, I can say from experience that your involvement matters more than you think. And for this I thank you and honor your willingness to join with us.
And for those of you who have been on the front lines of addiction treatment for years, deep gratitude to you as well. WISAM is an amazing organization with tireless, committed officers, committee chairs, administrative staff and members. It's been an honor to represent and work alongside of you all. Let's keep moving things forward!
Have a wonderful holiday season. And Best Wishes for 2019!
Matt Felgus, President
Marijuana was among the big winners at the polls in November, with voters in counties across the state signaling their support for legalization. Backers also have a friend in Gov.-elect Tony Evers, who has said doctors should be able to use cannabis to treat patients.
Meanwhile, CBD, which is extracted from hemp plants, has been heralded as a cure-all for everything from seizures to chronic pain to better sleep. State lawmakers recently approved its use, but questions over its health benefits - and legality - remain.
A Jan. 8 Wisconsin Health News panel in Madison will take a closer look at the legal and health issues around marijuana and CBD oil – and their future in the state. Confirmed panelists include:
Learn more and register to attend.
December 18, Wisconsin Health News
More than $1.3 million in state grants will support medication-assisted treatment programs for inmates living with opioid use disorder at 16 county jails, according to a recent Department of Health Services statement.
Grant recipients are working with jails in Bayfield, Brown, Columbia, Dane, Dodge, Grant, Kenosha, Iowa, Manitowoc, Racine, Rock, Shawano, Sheboygan, Walworth, Waushara and Vilas counties.
The money, provided under a law enacted earlier this year, is available through June 30. Up to $750,000 is available in future state fiscal years.
Editor's note: the following excerpt is taken from "For One Rural Community, Fighting Addiction Started With Recruiting The Right Doctor" heard on NPR's Weekend Edition Sunday, Sunday, December 9, 2018.
The story features Mark Lim, MD, an active member of WISAM/ASAM who has presented at WISAM annual conferences and recently led a session in WISAM's 2018 Webinar Series. He is board certified in both Addiction Medicine and Family Medicine, and serves as the Medical Director of NorthLakes Community Clinic in Ashland, Wisconsin.
Dr. Mark Lim says he is surprised he's here in this 8,000 person port-town on Lake Superior. He'd dreamed of living in a big city since he moved to the U.S. from the Philippines. When he got the call about the job, he was hesitant at first. "I didn't know where that was on a map," he recalls.
But he saw this part of Wisconsin, where the death rate from drug and alcohol abuse is nearly twice as high as the state average, as a place where he could make a difference.
Lim's been board certified in addiction medicine since it was officially recognized as a subspecialty in 2016, but he's been working in the field since about 10 years ago when he started working in an addiction practice in Maine.
He took the Wisconsin job, with one stipulation: He would start a program to address addiction as a whole. His expertise would be just one part of the treatment approach.
"If I'm just going to be the Suboxone doctor I'm not doing the full practice of addiction," Lim says. Read full story.
December 3, Wisconsin Health News
A Milwaukee task force finalized recommendations Friday on how to reduce drug misuse and overdoses.
The recommendations from the City-County Heroin, Opioid and Cocaine Task Force aim to guide efforts in Milwaukee County. The task force hopes to implement the changes through grants and collaboration.
Alderman Michael Murphy, who co-chairs the task force, noted that more than 400 people died last year from overdoses. He recently received new data from the Milwaukee County Medical Examiner’s Office showing a decline.
“Right now, god willing, if things hold, we’ll see a 25 percent reduction compared to last year,” he said. “So that’s a great story.”
Murphy wants to determine what’s working and support those programs. The task force plans to continue to meet and follow up on the recommendations.
“Sometimes, being in government, you look at reports and you wonder if they just gather dust after they’re done,” he said. “We don’t intend to have that happen.”
Among the changes the report recommends are:
Wisconsin Society of Addiction Medicine563 Carter Court, Suite B,Kimberly, WI 54136
