Oct. 31, 2019: State Advocacy Update

As part of the AMA's work in support of promoting clinical practice guidelines specific to cancer treatment, palliative care, and end of life (as opposed to arbitrary thresholds), the AMA opioid microsite includes resources from the American Society of Clinical Oncology (ASCO) and American Academy of Hospice and Palliative Medicine (AAHPM).

These resources include educational offerings on pain management, protecting access to treatment for patients with cancer, pain management in the hospice setting, tools to address opioid prescribing and more.

If your medical society would like to add additional resources to the microsite, please send an email to the AMA Opioid Task Force at [email protected].

In light of harms to patients, inappropriate actions against physicians, and guidance from the U.S. Centers for Disease Control and Prevention (CDC) against using CDC recommendations as justification for arbitrary opioid prescribing policies, the AMA recently urged Walmart to rescind its "refusal to fill" opioid dispensing policy.

"We remind you that the CDC advised recently that 'some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations.' The Walmart 'refusal to fill' policy is a prime example," wrote AMA Executive Vice President and CEO James L. Madara, MD (PDF). "We have every confidence in physicians and their pharmacist colleagues carrying out their legal responsibilities under state law and the [Controlled Substances Act]. Health care professionals are well-equipped to protect their patients without an inappropriate 'refusal to fill' policy based on arbitrary thresholds intruding on the physician-pharmacist-patient triad."

The AMA and medical societies also continue to object to Walmart sending physicians "blacklist" letters that state Walmart and its corporate pharmacy partners will no longer fill any controlled substance from the physician.

"We are not aware of any state law or regulation that gives a corporate entity the authority to take action against a licensed health care professional," wrote Dr. Madara. "If a state legislature has enacted an opioid prescribing restriction or other law, then the health care professionals in that state are required to follow the law as a matter of professional licensure. We are not aware of any medical or pharmacy board abrogating its licensing oversight in favor of a national corporate entity using an unknown algorithm, and we therefore urge you to rescind your policy. Simply put, this policy is interfering in the practice of medicine and pharmacy."

If you have a story to share about a patient being denied medication by Walmart please contact us at [email protected].

The way patients in the Transgender Surgery Center are cared for at Mount Sinai Beth Israel in New York City has led to some innovative revelations to help end the nation's opioid epidemic.

"Gender affirmation surgery is a significant and invasive surgery and the last thing we want is to treat the gender dysphoria but have the patient end up physically dependent on opioid analgesics post-surgery," said Erick Eiting, MD, Vice Chair of Operations for Emergency Medicine at Mount Sinai Downtown.

Similar to other surgical settings, Dr. Eiting and his colleagues work to limit the amount of prescriptions administered during a patient's hospital stay through non-opioid pain management strategies. These efforts continue post-operatively to address the potential risk of chronic pain and subsequently the risk of developing an OUD.

While Dr. Eiting says they still are collecting data, the outcomes appear positive.

"We saw that this was working for our transgender patients and thought why not expand this more broadly to see if these clinical pathways would help other surgical patients?"

In addition to the work of reducing opioid exposure, Dr. Eiting also explained efforts to overcome other barriers faced by the LGTBQ community.

Many of the LGBTQ patients that Dr. Eiting sees have experienced housing instability, for example.

"Many of my patients are estranged from their families and have lived or are living on the street, they're uninsured or underinsured, and so finding treatment options that work for them is a complicated equation," he said. "We have to find the right destination where patients can actually get access to treatment—the same treatments exist for everyone in theory, but often my patients can't do 28-day programs without risking loss of employment and if they end up on a six-month waiting list for a program, that means going untreated for that time which can be a death sentence."

Dr. Eiting, an emergency medicine physician, also highlighted the increase in the number of physicians in the emergency department now trained to start a patient on buprenorphine—and that half of the physicians now have a DATA-2000 waiver.

"There's a lot of institutional policy in place before anyone writes a prescription for opioids, but the stigma still exists. There is a judgment about SUD being a moral failing that we need to overcome, and how we get there is having everyone trained to understand that addiction is a medical condition for which there is substantial treatment."

Part of that treatment also includes having all patients entering the ED screened for a potential SUD, distributing naloxone and starting a universal hepatitis C monitoring program last June which helped them to discover that about 30% of patients who test positive for Hepatitis C do not identify any markers "These people usually have an undiagnosed opioid use disorder and so we have revaluated how we handle that."

Ultimately the success of programs like the ones being run out of the emergency department at Mount Sinai are about having a multi-pronged approach and understanding that everyone who walks in your door is coming from different circumstances and requires a plan of treatment that acknowledges that. "This applies to LGTBQ patients, African American and Hispanic communities, Asian communities and all others in our community. "We try to do everything we can think of to meet patients where they are at."

To read more about what the AMA is doing to end the opioid epidemic, please visit https://www.end-opioid-epidemic.org/.

Have you experienced any barriers to care? Do you have a story to tell? We want to hear from you: [email protected]

Dr. William E. Kobler, Member, Board of Trustees, testified before an Indiana Interim Study Committee on legislative trends of Nurse Practitioner scope of practice, explaining that most of the changes over the past few years have modified current practice or prescriptive authority within the collaborative or supervisory relationship. In the past five years no states have moved to allow Nurse Practitioners full, immediate independent practice.

In his testimony Dr. Kobler emphasized the importance of physician-led team-based care, "team leaders should be the ones with the most education and experience in health care delivery teams." "Based on their education and training, physicians are best suited to practice independently and lead other members of the health care team."

Using the AMA's geomaps, Dr. Kobler also illustrated that regardless of the autonomy allowed by state law, "there is a strong correlation between where physicians and nurse practitioners choose to practice. Both tend to practice in the same large urban areas."

• Oct. 31, 2019: Advocacy spotlight on Federal court protects rights of immigrant kids
• Oct. 31, 2019: National Advocacy Update