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Combating Prescription Drug Abuse and Diversion

Since 2005, the AMA, along with many other stakeholders in the health care community, has supported and helped secure passage of the National All Schedules Prescription Electronic Reporting Act (NASPER) as an essential tool in combating prescription drug abuse and diversion. Since then, the sense of urgency has only increased and the AMA continues to work on a number of fronts to combat diversion and drug abuse while at the same time preserving access to medically necessary treatment for pain.

Background

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.

Physician Education

The AMA developed and maintains continuing medical education (CME) to promote appropriate prescribing for pain management and to combat drug diversion. The AMA strongly supports positive incentives to promote physician education as well as strategies that integrate and embed education into a physician's practice.

Current CME
The AMA developed a 12-hour Pain Management CME Program online in 2003, revised in 2007 and again in 2010. To date, approximately 155,000 CME certificates have been issued for the online version of this program, and 65,000 for the print version, with an additional 26,000 certificates issued to non-physicians, primarily physician assistants.

The 2013 revision of the online training, totaling 14.5 AMA PRA Category 1 CreditsTM is now available. Access to the course materials is free. Physicians can complete the modules that address the specific needs of their practices and patients. Those who are interested in obtaining CME credit must register, and a $6.00 fee will be charged per module.

Upcoming Training
Through July 2014, the AMA is scheduled to develop and release 12 webinars on topics related to responsible opioid prescribing as part of the collaborative for the Prescriber Clinical Support System for Opioid Therapies led by the American Academy of Addiction Psychiatry and joined by the American Dental Association, American Medical Association, American Osteopathic Academy of Addiction Medicine, American Psychiatric Association, American Society for Pain Management Nursing, and the International Nurses Society on Addictions. Webinars that have already been offered by the AMA and other partners 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.

Federal Legislative Activities

Passage of H.R. 3528, the “National All Schedules Prescription Electronic Reporting Reauthorization Act of 2013” (NASPER 2013) 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.

Letter to Representative Edwards supporting H.R. 4169, the "Stop Overdose Stat Act of 2013"

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.

Letter to Senator Edward Markey supporting S. 2645, “the Recovery Enhancement for Addiction Treatment Act,” (TREAT Act) July 2014

Letter to the FDA urging rejection of the Citizens Petition seeking changes to the labeling of opioid analgesics, April 2013

Letter to Senator Rockefeller on efforts to combat prescription drug abuse and diversion, October 2012

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

Letter to Rep. Slaughter supporting H.R. 2939, the “Pharmaceutical Stewardship Act of 2011," January 2012

Letter to Rep. Whitfield supporting H.R. 866, the “NASPER 2011 Reauthorization,” October 2011

Letter sent to Reps. Emerson, Serrano, Moran, and Sen. Durbin supporting funding for National Youth Anti-Drug Media Campaign, June 2011

Letter to Sen. Dodd supporting S. 660, the “National Pain Care Policy Act,” May 2009

Letter to Sen. Hatch supporting S. 660, the “National Pain Care Policy Act,” April 2009

Letter to Rep. Capps supporting H.R. 756, the “National Pain Care Policy Act of 2009,” March 2009

Letter to Rep. Rogers supporting H.R. 2994 the “National Pain Care Policy Act,” October 2007

Letter to Speaker Hastert supporting S. 45 and H.R. 869, the "Drug Addiction Treatment Expansion Act," July 2005

Letter to Rep. Whitfield supporting H.R. 1132, "National All Schedules Prescription Election Reporting (NASPER) Act of 2005," July 2005

Letter to Sen. Session supporting H.R. 1132, "National All Schedules Prescription Election Reporting (NASPER) Act of 2005," July 2005

Letter to Rep. Souder supporting H.R. 869, the “Drug Addiction Treatment Expansion Act,” May 2005

Letter to Sen. Sessions supporting S. 518, the "National All Schedules Prescription Electronic Reporting (NASPER) Act of 2005, April 2005

Letter to Rep. Whitfield supporting H.R. 1132, "National All Schedules Prescription Election Reporting (NASPER) Act of 2005," April 2005

Federal Agency and Administration Activities

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.

State Advocacy

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 supports Louisiana naloxone bill 

AMA concerns with California bill mandate on e-prescribing of controlled substances

AMA supports Maine naloxone bill   

AMA letter to Ohio State Medical Association in support of a public health focus to combat prescription drug abuse and diversion 

AMA supports Tennessee naloxone bill  

AMA supports Delaware naloxone bill  

AMA supports Minnesota naloxone bill

A Legislator's and Regulator's Guide to Combating Prescription Drug Abuse

AMA prescription drug monitoring issue brief

AMA Advocacy Resource Center legislative tracking (search under "pharmaceuticals")

National Conference of State Legislatures drug diversion resources

National Alliance for Model State Drug Laws (NAMSDL)

Collaboration with Other Stakeholders

The AMA continues its national outreach.

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. 

AMA letter with recommendations to NGA

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.

Full AMA letter to the FSMB 
Follow-up letter to FSMB re: model pain policy 

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.

Helpful Links

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.