President Jacob Manteuffel, MD, FACEP, Updates Members On National and State Strategies Dealing With the Opioid Epidemic

The opioid abuse epidemic took center stage at the 2017 American College of Emergency Physicians (ACEP) Council Meeting.  After some passionate testimony, the Council adopted a resolution creating ACEP policy in support of the development and study of Supervised Injection Facilities (SIFs) for people who inject drugs as a potential public health intervention.  ACEP joined the American Medical Association (AMA) in adoption of similar policy in 2017.  There are over 100 SIFs worldwide, while none are currently operating in the United States.  The data regarding such facilities worldwide notes decreased rates of HIV, Hepatitis C as well as soft tissue infections.  These facilities offer clean needles for injection and a safe, supervised setting for injection for those addicted to opiates.  The cost of SIFs is mitigated by the savings from decreased disease, decreased overdose and decreased utilization of emergency medical services.  Many SIFs also have counseling services and information services with access to substance abuse rehabilitation programs.  President Trump’s recent declaration of the opiate epidemic as a public health emergency may allow for funding for these unconventional approaches to opiate abuse that are proven to reduce harm.  The ACEP Council’s adoption of this resolution is an appropriate change in policy from avoiding an association with the stigma of opiate abuse to recognizing that substance abuse is a disease that requires a multi-faceted approach to treatment.  Not surprisingly, on my very first shift after I returned from the council meeting I had a patient encounter with opiate abuse.  The patient had crashed his car at low speed after injecting heroin in his vehicle and becoming unresponsive.  The 37 year old patient claimed to have relapsed for the 4th time this year, each visit resulting in a trip to our emergency department.  I listened to the police officer at bedside reprimand him for his indiscretion, followed by his mother asking him to change his code status to DNR if he continued to abuse opiates.  He was not interested in substance abuse treatment as he did not feel he had a problem.  I know he would benefit from access to a SIF.  He would not be coming to our emergency department, and maybe he would listen to counseling or treatment options in a less confrontational environment if he were willing to use such a facility.

Also on the national scale, the American Hospital Association (AHA) developed its toolkit entitled, “Stem the Tide: Addressing the Opiate Epidemic”.  This was developed to provide guidance and resources to hospitals and health systems on how to work with patients, clinicians and communities to stem the opioid epidemic.  The toolkit highlights successful inventions such as the Alternatives to Opiates (ALTO) program from a New Jersey emergency department, which has shown a nearly 40% reduction in cases requiring opiates.  The ALTO program uses targeted non-opioid medications, trigger point injections, nitrous oxide, and ultrasound guided nerve blocks to tailor its patients’ pain management needs and avoid opioids whenever possible. Examples include kidney stones, acute low back pain, broken bones, acute headache and migraine pain.  The ALTO program was presented by its developers at the 2017 ACEP Leadership and Advocacy Conference earlier this year.  The toolkit also highlights the need for clinical education as well as guideline implementation.  The Michigan College of Emergency Physicians (MCEP) has spent more than 5 years addressing this issue and developed our own opiate prescribing guidelines, disseminating them to emergency departments in the state of Michigan in 2012.  MCEP has also featured clinical education on opiate prescribing over the past several years at our educational conferences.  MCEP has been and will continue to be a front runner in health care with regard to opiate abuse policy, education and legislative efforts.

Leaders from MCEP have engaged state legislators on a continual basis over the years and more regularly with the multiple bills that have been introduced in the Michigan House of Representatives and Senate related to physician prescribing of opiates.  Dr. Rami Khoury, MD FACEP testified in front of the House Health Policy Committee in April to inform the committee of our efforts to battle the opioid epidemic and emphasize our desire to be part of the solution.  Thereafter leaders of MCEP met with key individual legislators and their staff to offer insight as to the unintended consequences some of the proposed legislation may cause as well as to answer questions about typical prescribing habits from the emergency department (ED).  What duration of prescription is reasonable after an ED visit for a fracture or other painful emergency?  Should a physician log into the Michigan Automated Prescription System (MAPS) before every opioid prescription is written?  Should physicians be mandated to register for MAPS?  Legislation has been proposed addressing each of these issues and we were able to provide information to educate legislators on the practical limitations of mandating emergency physician practice.

One thing that appears to be clear at this time is that there will likely be a mandate regarding registration for MAPS.  Mandate for use may be mitigated by the incorporation of the MAPS system to existing electronic medical records (EMRs) allowing for real-time information of patient controlled substance prescriptions with an abuse risk calculator available without logging into a separate system or account.  The State of Michigan has agreed to cover costs of integration of MAPS into EMR until August 1st, 2019.  The MAPS system migrated to a new platform in the spring of 2017 allowing for real-time prescription monitoring without the approximate 2 week lag time of the old system.  In addition, running a report now takes seconds as opposed to the 5-10 minute search of the old system.  The new MAPS platform will notify you when you search for a patient if a patient is a “Suspected Pharmacy/Prescriber Shopper” given the number of prescriptions they have from different prescribers filled at different pharmacies.  Registering for MAPS now however is slightly more complicated than previously with multiple physician identifiers required.  To register for MAPS you will need your: 1) Drug Enforcement Agency (DEA) number, 2) physician license number, 3) controlled substance license number, 4) NPI number, and 5) primary employer address.  Residents will enter the DEA number of the facility in which they are training.  Professional license numbers and controlled substance license numbers can be located at: www.michigan.gov/verifylicense.  NPI numbers can be located at: www.npinumberlookup.org. Register for MAPS at: https://michigan.pmpaware.net/login.

Another useful feature of the new MAPS system is the ability to review your prescription history over the past 2 years.  When logged into MAPS, click on “RxSearch” and then “MyRx”.  A MCEP member contacted our leadership a few weeks ago to notify MCEP membership that he received a home visit from the DEA regarding prescriptions written fraudulently in his name. This has prompted other MCEP members to review their prescription history and other possible fraudulent activity has been noted.  With this new functionality of MAPS, MCEP will address how to report fraud with the State of Michigan and have fraudulent prescriptions removed from profiles.  I encourage the members of your practice to also review their history to help prevent diversion of prescription medications.  It is also interesting to note that the State of Michigan does not quantify the number of pills written but the “Days Supply” instead.  For example, if one were to prescribe 10 diazepam tabs with a prescription stating: 1 PO Qhs PRN, the “Days Supply” is 10.  However if one were to prescribe 15 diazepam tabs with a prescription stating: 1 PO Q8hr PRN, the “Days Supply is 5”.  This is the information the State of Michigan is tracking.

I do believe we can be part of the solution to the opioid epidemic as emergency physicians.  One of the first steps is to register for MAPS sooner than later as it will likely be a requirement in the near future.  We can use the MAPS system and become familiar with it and look forward to the integration with our institution’s EMRs.  We should review our prescription histories for possible fraudulent activity and prevent diversion.  With these small steps we can begin to do our part in the complicated battle with opiate abuse we encounter on a daily basis.

*Editor’s Note: Due to MCEP’s recent web-site upgrades and the importance of the topic, we decided to incorporate some of the content from a recently published electronic President’s Report into this article.

 

 

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