Combating Prescription Drug Abuse and Diversion
The AMA believes that it is up to physicians to be leaders in preventing and reducing abuse, misuse, overdose and death from prescription drugs through ensuring appropriate prescribing practices as one part of a multi-pronged public health strategy. We need a comprehensive public health approach to combatting the nation’s prescription opioid abuse and growing heroin epidemic. These are complex problems, and the AMA is working with multiple stakeholders to effectuate change in how to address these issues. We believe the following critical components are necessary: enhancing education for physicians and patients about appropriate prescribing practices; increasing access to treatment programs for opioid use disorders, including medication assisted treatment programs (MAT); ensuring that patients in pain receive the care they need and reducing the stigma of pain; recognizing that opioid use disorder is a medical condition, reducing the stigma of this disorder, and increasing coverage for and access to medication assisted treatment and related services; increasing access to naloxone and other overdose prevention measures, and expanding Good Samaritan laws; and increasing funding and staffing for up-to-date, interoperable, at the point-of-care prescription drug monitoring programs (PDMPs) that are integrated into a physician’s workflow.
The AMA supports:
- Full funding and staffing for up-to-date, interoperable, at the point-of-care prescription drug monitoring programs that are integrated into a physician’s workflow;
- State-based tools and resources that support identification and assessment of state-based addiction treatment gaps and appropriate targeting of funding and resources to expand access in concert with efforts to decrease the supply of diverted prescription drugs;
- Federal funding for a national framework to support accessible state-level take-back locations to remove unneeded prescription drugs including controlled substances from medicine cabinets;
- Positive incentives to promote physician education that provides current best prescribing practices and is tailored to meet a physician’s practice/patient population needs;
- Enforcement actions to halt “pill mill” activities and rogue online pharmacies that are coordinated with public health efforts to expand access to addiction treatment and recovery in order to ensure that those suffering from addictions do not resort to illicit drug use, such as heroin; and
- A public health approach that places a premium on treatment and includes promoting widespread adoption of drug courts.
The AMA has long held that the central principle of balance—between preventing controlled substance abuse, trafficking, and diversion and ensuring access to necessary pain medication—should guide policy-makers as they craft solutions to address these complex problems. From the outset of this crisis, the AMA has advocated for solutions that provide physicians with patient specific up-to-date information at the point-of-care in order to support appropriate prescribing.
While NASPER, a grant program to fund the creation of state prescription drug monitoring programs (PDMPs), passed in 2005, it was not until 2009 that funds were approved to support the program. While the majority of states now have a PDMP, most became operational only in the past couple years. Unfortunately, only a handful of PDMPs are real-time and few are readily available at the point of care as part of a prescriber's workflow. The NASPER Reauthorization and full appropriation offer an opportunity to make a strong commitment to combating prescription drug abuse and diversion.
The AMA is developing updated continuing medical education (CME) to promote appropriate prescribing for pain management and to combat drug diversion under the Prescriber Clinical Support System for Opioid Therapies initiative (PCSS-O) funded by the Substance Abuse and Mental Health Services Administration. The AMA strongly supports positive incentives to promote physician education as well as strategies that integrate and embed education into a physician's practice.
The AMA developed several webinars on topics related to the intersection of pain, substance use disorders, and opioids, also as part of the PCSS-O collaborative. Webinars developed by the AMA are archived.
Other education activities include:
The AMA produced an educational video vignette on prescription drug abuse which provides an overview on prescription drug abuse and offers tips for physicians on how to educate and counsel patients. This activity is part of AMA's Educating Physicians on Controversies and Challenges in Health (EPoCH) program.
The AMA supported the launch of NIDAMED which is devoted to educating physicians on issues surrounding substance abuse. As part of NIDAMED, AMA partnered with Prescriber Clinical Support System for Opioid Therapies NIDA Centers of Excellence via AMA's ISTEP program. These Centers of Excellence for Physician Information are charged with the task of developing innovative drug abuse and addiction curriculum resources with the goal of helping to fill the gaps in current medical students/resident physician curricula.
In conjunction with the Obama Administration's National Plan to Combat Prescription Drug Abuse and Diversion, the AMA hosted extremely well-attended education sessions at the AMA's 2011 Interim Meeting, and at its 2012 State Legislative Strategy Conference. Materials forthcoming.
Passage of H.R. 1725, the "National All Schedules Prescription Electronic Reporting Reauthorization Act of 2015" (NASPER 2015) and full appropriations is urgently needed to ensure that physicians across the country have a critical tool at the point-of-care to combat prescription drug abuse while ensuring patients with legitimate need of pain management continue to have access. Unfortunately, the appropriations to fully fund, modernize, and optimize NASPER prescription drug monitoring programs (PDMPs) have not kept pace with the rapid escalation in abuse and diversion of prescription drugs. Fully-funded PDMPs would provide more physicians with access to reliable, real-time information about prescriptions patients have obtained (and filled) from other prescribers, particularly controlled substances.
In a January 7, 2014 letter, Dr. Stack responded to additional questions stemming from the November 2013 House Energy and Commerce Hearing: “Examining Public Health Legislation to Help Local Communities”
AMA urged immediate passage of H.R. 3528 (NASPER 2013) and full appropriations with a strong emphasis on the public health focus of NASPER in a November 2013 statement to the House Energy and Commerce Committee.
Harm Reduction Coalition letter to HHS supporting overdose prevention language in "FY 2013 Senate Labor Health and Human Services-Education (LHHS) Appropriations" report and the "Food and Drug Administration (FDA) Safety and Innovation Act," October 1012
AMA January 12, 2016 comments on CDC Proposed Guideline for Prescribing Opioids for Chronic Pain
AMA May 20, 2015 comments to NIH on Draft National Pain Strategy
AMA April 28, 2014 comments to DEA regarding Rescheduling of Hydrocodone Combination Products from Schedule III to Schedule II
April 28, 2014 coalition letter to DEA Administrator urging delay in finalizing proposal to reschedule hydrocodone from Schedule III to Schedule II until long-term care exception or special procedure is developed.
The AMA has expressed concerns with rescheduling combination medication that will worsen access to needed pain treatment in long-term care.
In a February 19, 2013 letter, the AMA communicated its strong support for the DEA’s proposed rule that would govern the secure disposal of controlled substances
December 13, 2013 sign-on letter sent to HHS regarding hydrocodone rescheduling
The AMA has communicated its support for most elements of the Obama Administration's Plan to Combat Prescription Drug Abuse and Diversion.
In order to strengthen and improve state PDMPs, we have urged the Obama Administration to direct the Veterans Administration to share information with state PDMPs. We have also recommended that the Centers for Medicare & Medicaid Services direct Medicare Prescription Drug plan sponsors to also share information with state PDMPs and urged the Substance Abuse and Mental Health Services Administration to require reporting of methadone treatment to PDMPs.
Leadership from the AMA's Board of Trustees met with other key stakeholders as part of a Roundtable hosted by the Administration to identify technical barriers and strategies to ensure PDMPs are up-to-date and available at the point-of-care, and are part of a physician's work-flow. Challenges remain to making this a reality, but the NASPER Reauthorization and appropriations will provide needed resources to facilitate upgrade and modernization of existing PDMPs.
The AMA has also actively participated in providing comments related to the Food and Drug Administration's proposed elements to assure safe use of certain categories of opioids.
The AMA has also asked the DEA in the past, and the Administration recently, to waive or provide discounts on DEA registration fees for prescribers who take certified CME related to pain management prescribing and combating abuse and diversion, or who have qualifying specialized training.
The AMA has also supported agency efforts to increase access to detoxification treatment programs.
The AMA is working at the state level with state medical associations, national medical specialty societies and other physician and patient advocates to address the prescription drug abuse and diversion crisis. The following links provide information on AMA state level efforts and efforts by other stakeholder groups as well. To request additional information, please contact the AMA Advocacy Resource Center’s Daniel Blaney-Koen at Daniel.Blaney-Koen@ama-assn.org.
AMA urges Missouri Legislation to enact an effective, public health focused prescription drug monitoring program.
The American Medical Association has joined with organizations representing physicians, pharmacists, supply chains and other stakeholder groups to develop a consensus document highlighting the "red flag" warning signs of prescription drug abuse and diversion. By illuminating the challenges of prescribing and dispensing opioids, the groups aim to prevent the misuse and diversion of controlled substances while ensuring access to the medicines for patients with legitimate needs.
National Governors Association. The AMA recently provided a comprehensive set of recommendations to the National Governors Association (NGA) as part of the NGA's work in its Policy Academy Prescription Drug Abuse Project.
National Conference of Insurance Legislators. As part of the AMA's national advocacy to help combat prescription drug abuse and diversion, the AMA recently provided extensive recommendations for best practices to the National Conference of Insurance Legislators (NCOIL). The AMA also sent a follow-up letter to NCOIL re: Proposed Best Practices, and provided a statement to NCOIL on proposed best practices to address opioid abuse, misuse and diversion.
Federation of State Medical Boards. For the first time since 2004, the Federation of State Medical Boards (FSMB) is significantly revising its Model Pain Policy, and the AMA recently provided detailed comments that balance physicians’ needs to manage pain while avoiding diversion and substance misuse. In achieving that balance, the AMA believes that the nation’s challenges in combating prescription drug abuse and diversion must be focused on public health solutions that promote physician education and public awareness.
National Association of Boards of Pharmacy. AMA has supported implementation of the National Association of Boards of Pharmacy software program "InterConnect" that provides HIPAA compliant interoperability for state PDMPs.
Physicians can use the AMA's medication disposal guide to remind patients to dispose of expired, unwanted and unused medicines properly. A training module from the AMA provides tips on educating and counseling patients about the dangers of prescription drug diversion.
One of the most important outcomes from the recent AMA Interim Meeting was a renewed focus on national drug control policies and the responsible prescribing and use of prescription pain medication. This is a hot issue—and a difficult one for all of us. But there is hope in some recent developments, writes AMA Board Chair David O. Barbe, MD, in an AMA Viewpoints blog post.
On Aug 12, 2012, Steven J. Stack, MD, chair of the AMA Board of Trustees, wrote "Prescription abuse laws can create a no-win situation for doctors," an opinion piece that appeared in American Medical News.
In a April 5, 2012 opinion piece for The Hill's "Congress Blog," Peter Carmel, MD, president of the American Medical Association, writes that a nationwide electronic prescription drug tracking initiative could help curb drug misuse.