Lawmakers advance doctor pain pill limits - VTDigger

Lawmakers advance doctor pain pill limits

Lawmakers moved forward Friday with a bill that could put limits on the amount of opiate painkillers a doctors could prescribe.

Sen. Claire Ayer, D-Addison, chair of the Senate Health and Welfare Committee, described the legislation as taking “an upstream approach” to the opiate crisis.

The bill, S.243, gives the commissioner of the Department of Health authority to set limits on how many opiate painkiller pills a doctor can prescribe at a time and how to track the distribution of those medications through a statewide database system.

The legislation directs the commissioner to determine the rules on opiate drugs in consultation with a panel of medical professionals — which includes representatives from many Vermont medical associations, ranging from substance abuse experts, to pharmacists, to dentists, to a licensed acupuncturist.

Claire Ayer

Sen. Claire Ayer, chair of Senate Health and Welfare.

The governor highlighted a pill limit for minor procedures as one of his priorities for the session in his final State of the State address in January. In that speech, he called for a 10-pill limit, but lawmakers were leery of using a specific number.

In a statement Friday, Gov. Peter Shumlin hailed the build-out of Vermont’s opiate addiction treatment system in recent years as “staggering,” but said there is a need for structural adjustments.

“But we will never fully address this crisis until we attack the source of the problem: F.D.A. approved opiates that are handed out like candy,” Shumlin said. “There is no medical reason that someone who undergoes a minor procedure should be sent home with 80-100 highly addictive opiate pills.”

Shumlin has also taken on prescription drug availability on a national stage. In February, he led a push for creating nationwide prescribing protocols for opiates at a National Governors Association meeting.

But the proposal ran into some opposition from the medical community.

In a memo issued last week, the Vermont Medical Society raised concerns that a “one-size-fits-all” policy could potentially result in “unintended consequences for patients.”

Medical professionals also resisted a proposal to require them to check with the Vermont Prescription Monitoring System, a database that tracks the prescription of certain types of medications to patients, every time they prescribe a drug, saying that it would be time consuming. The bill also gives the panel and the commissioner the authority to make rules guiding those requirements.

Ayer said that the committee decided to defer ultimate decision-making authority on pill limits for different types of procedures to the medical community. “We’re a citizen’s legislature,” she said, noting they prefer those decisions be made by experts.

Health Commissioner Harry Chen said Friday it is important to “make some efforts to change the culture, and the culture really has been abundant prescribing.”

Chen said that although the bill does not include Shumlin’s specific State of the State call for a ten-pill cap on initial prescriptions after minor procedures, the legislation does express a desire to move away from over-prescribing.

“The number ten is no longer in there, but there’s certainly a clear expression of intent that there will be some limitations,” Chen said.

Under the current system, the same type of procedure may result in a wide range of painkiller prescriptions, Chen said. He’ll work with providers to try to find some standards.

The prescription opiate limit was part of a wide-ranging 29-page bill that passed Health and Welfare Friday.

The bill also increases a fee that pharmaceutical companies pay on medications that are covered by Medicaid, Dr. Dynasaur or VPharm from 0.5 percent to 1.24 percent. The revenue will in part go to funding an analysis of methods of pain management that don’t involve pharmaceuticals.

The legislation also establishes a telemedicine pilot program under which certain patients who are in recovery can receive some treatment from a specialist remotely through a telemedicine portal based at a health care provider.

The pilot could help to make treatment more accessible for people who have limited access to transportation, Ayer said.

Elizabeth Hewitt

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  • Jim Vires

    One unintended consequence will be the requirement for patients with ongoing pain issues to make numerous trips to the doctor to get a new prescription written. This cannot be done over the phone and might present a challenge to people with limited ability to travel if it be from pain, lack of transportation, or finances.

    • Jan van Eck

      Assuming your recited unintended consequence becomes the case, then it will be even worse. Take the situation of an injured person (industrial accident to limb, for example a crushed hand in a machine) which has left irremediable pain. Each individual prescription will require payment of a separate co-pay or deductible. Absent bulk buying, the costs of pain meds to the injured person in chronic pain now shoots up by some 1,000 percent. Meanwhile, the injured is without income other than disability under SSI, or the equivalent. So yet another unintended consequence is further impoverishment of injured persons in pain. Just lovely.

      This is what happens when government bureaucrats start telling physicians how to run their practices. Not functionally all that much different from the situation where bureaucrats driven by bizarre religious interpretations proceed to insert themselves into the gynecological examination room.

    • Don Dalton

      It’s my understanding that the bill only addresses acute, not chronic, pain issues.

      • Neil Johnson

        Instead of our lawmakers trying to be doctors, they could just monitor the doctors through their licensing. That is what the licensing is for.

        It’s all in writing, any pharmacist can tell you or provide the documentation of over prescription. We don’t need more laws, we need our licensing board to do their job. Just the phone call of the licensing board to any doctor would surely change practices, wouldn’t even need to investigate.

  • John Skalecki

    So Shumlin is a MD now? Imagine that! He knows how much pain medication needs to be prescribed for any given medical procedure. Am I the only one who sees the insanity here? The lawmakers should not be allowed to dictate what a doctor prescribes, period.
    Pill limits? Bad idea again. Less pills just means higher doses. If Shumlin gets his way you will see the overdose rate skyrocket even more. Gimme a break!!!!!! You just cant make this stuff up.

  • Gary Shattuck

    For a bit of historical perspective, here are a couple of excerpts from letters written by state officials in 1967 (both are in the state archives in Middlesex):

    In a letter dated December 13, 1967, John F. Stephens, Secretary of the Vermont Board of Pharmacy writes:

    “Pharmacy is well controlled compared with the medical profession in this state. I can show you letters I have written to physicians informing them of the law of this state, as well as the law of the land. One physician authorizes refills “for duration of illness,” and this can lead to severe abuse, another physician lets his secretary sign his name to RX’s, another physician tries regularly to find ways to circumvent the fed narcotic law. He even wrote one RX, to dispense Class A Narcotics in lots of fifty until his patient had exhausted the 200 quantity he has authorized.
    Physicians in this state need education as to the laws of the land and state….”

    And from Lieutenant Robert Iverson, Vermont Department of Public Safety, dated November 13, 1967:

    “The majority of the cases which have caused the greatest concern is the wide spread and increasing use of the hallucinogenic, stimulant and depressant type drugs. Information that high school students and teenagers have been using these harmful drugs has been traced to the fact that Vermont now supports a large number of the ski bum type individual and out-of-state students who bring the use of these harmful drugs with them into the State of Vermont. Once in Vermont they have found that they may continue their drug activities and can also encourage local and so-called town teenagers to join them in their drug activities. These shiftless ski bums, part-time college students and drop-out students now roam throughout Vermont all year long. Their attitude seems to be one of dropping out of the square society, a role of non-contribution and many of them are characterized by their unshaven faces, filthy clothes and generally unkempt nature. Their philosophy is to encourage other youths to drop out of society and experience their new found values through the use of drugs.”

    • Jim Candon

      In the late 1970’s and early 1980’s the state police diversion unit saw the move by drug seekers to Schedule II and III Rx painkillers, what we now call Rx opiates. At that time the drug seekers would find naive doctors to whom they could fake pain and then receive Rx painkillers. The drug seekers would then use the drugs, sell the drugs or a combination of both.
      The diversion unit also discovered a surprising amount of Rx drug abuse within the medical care field itself, involving physicians, pharmacists and nurses.

      • Gary Shattuck

        And that is consistent with historical facts, finding that no less than 16% of all doctors in the country were addicted by the early 20th century. One would suspect that in this highly scrutinized time things have changed, but it looks like we will never know unless pharmacy records are examined more closely than they were when you were doing diversion work.

        Question: what is the diversion unit doing today? What are they uncovering? What have been the results of their investigations? Do they even exist? They seem to be missing from the conversation….

        • Jim Candon

          The state police were told more than 10 years ago to stop doing random inspections of the scheduled drug files ( drugs with the potential to be habit forming and subject to abuse like OxyContin and Percodan) within Vermont pharmacies. This was done in contradiction of their “duty” to do so as directed in Title 18, section 4218, Vermont Statutes Annotated. And subsequent to that the legislature further eroded any compliance inspections by denying the state police access to the Vermont Prescription Monitoring System.
          Efforts today by the state police to prevent the diversion of dangerous Rx drugs are done “with both hands tied behind their backs”.

  • rosemarie jackowski

    Chronic pain patients are being thrown under the bus for political reasons. Politicians should stay out of the doctor/patient relationship.

    Ironic that this is happening is a State where Assisted Suicide is legal – but pain relief is under attack.

    • I have had 13 spinal surgeries, I crushed vertebrae in a matter in 1997. ,I became a patient of pain management center on tilley drive in south burlington 12 years ago..I was prescribed methadone, they tried to put a spinal stimulator in five different times. Did not work, I still have paddle on spine, and leads on my spine..but no pain relief. My doctor unfortunately became ill, the office immediately cut me 40 mg a day, month later cut me 40 mg more, within 2 months half the dose I have been on up to 12 yrs…never failed urine sample, never failed pill count…I am in constant pain..I was told that I couldn’t be put on suboxone clinic because pregnant iv drug users and iv drug users take presidency over chronic pain patients….so thanks guys

  • David White

    May I suggest writing some legislation that would effectively ban POLITICIANS from making any MEDICALLY related decisions at all.

  • Mary Martin

    Please leave this decision on prescription dosage with the professionals. Yes, abuses have occurred but that is not the norm for our highly qualified medical community. When all the legislators have completed medical or pharmaceutical courses, they can readdress this issue with the knowledge they need. Meanwhile, stay out of the doctor’s office.

    • Don Dalton

      Abuses have occurred? Do you have any idea of what is going on in Vermont, in Maine, in Kentucky, in Florida, all over this country? My mother in Florida was addicted to pain killers, a situation that caused her great anguish since, being the wife of a minister, she felt she’d descended into being an addict.

      Why are people defending drugs so ardently? What’s going on? I don’t get it. Do you have any idea about what’s happening?

      In Appalachia, they call it “pharmageddon”– how prescription drugs have devastated whole communities. Interestingly, that’s also the title of a book by David Healy, MD, that chronicles how the drug industry pushes drugs on us.

  • Renée Carpenter

    “The legislation directs the commissioner to determine the rules on opiate drugs in consultation with a panel of medical professionals — which includes representatives from many Vermont medical associations, ranging from substance abuse experts, to pharmacists, to dentists, to a licensed acupuncturist.”

    Good start to a problem with deep roots, and that requires deeper exploration. The Health Commissioner and VT Medical Association(s) have a particular framework of thinking that isn’r necessarily as inclusive as it must be to resolve problems with health CARE, including addiction to pharmaceuticals.

    How health insurance coverage works–by not including complimentary practices that can alleviate pain through non-medical methods–has a lot to do with obstacles to health care solutions, including the over-prescibing of pharmaceuticals.

    Please notice that in the list I cited here there is only one acupuncturist–while all “medical” practitioners are identified with plurals; no naturopaths, chiropractors, homeopaths, nutritionists, physical therapists, massage therapists, or any other of a long list of complimentary practitioners.

    Allopathic or western medicine may dominate in our society, which is supposed to be a democracy. Many of us–although we may (or may not) be in the minority (or silent majority)–maintain our good health less expensively in the long run by relying on so-called “alternative” health care practitioners to compliment our “Primary Care Physician” as required for referrals. Those of us limited by cost of practices not covered by insurance reimbursements could, perhaps, have avoided deeper pain or significant illness if the system were different.

    If one wants to bring down the cost of health CARE, then insurance companies need to be compelled to cover all health CARE practices.

  • Randy Jorgensen

    Doctors don’t like being told how to treat their patients, especially from politicians. Although I can’t say for sure this will most likely cause more doctors to decide to practice in other states. Doctors are highly educated, as such are also highly mobile.

    Folks aren’t getting hooked on pain meds from “minor” procedures like a hernia surgery, they’re getting hooked on pain meds for chronic pain, such as knee problems where surgery is required and you need to take the pain meds before you can even start PT, then often continue them while in PT.

    “Medical professionals also resisted a proposal to require them to check with the Vermont Prescription Monitoring System, a database that tracks the prescription of certain types of medications to patients, every time they prescribe a drug, saying that it would be time consuming.”

    This is just silly, checking the database takes minutes to do, there is no reason doctors can’t be doing this. The premise that it’s too time consuming is nothing more then an excuse. Why wouldn’t the doctors want to do the RIGHT thing for the care of the patient by checking the database in the first place.

    • rosemarie jackowski

      The Prescription Drug monitoring data base is a violation of patient privacy. That data base puts every patient at risk of having their home invaded. Imagine – a list of names and addresses of homes where there could be prescription drugs. What could make things easier for addicts and dealers. Unintended consequences.

      Please don’t tell me that web sites cannot be hacked.

  • Gayle Hansong

    I am sorry but the idea of having legislators determining what doctors should prescribe for their patients is as ridiculous as convening the AMA and asking them to create legislation governing the transportation budget.

  • Don Dalton

    Health Commissioner Harry Chen is correct when he says that the culture has been one of abundant prescribing of opioids, and that culture should be changed.

    I’m not for government interference. But if we do nothing, then pharma has a green light to keep pushing the envelope for more and more prescriptions. I think those who complain about government interfering with doctors are short-sighted: we have a huge problem of opiate abuse on our hands, and surely a little reigning in of this wild abuse of opioids is a reasonable measure. The medical profession hasn’t been very good at getting a handle on this: the AMA opposes reasonable measures (like requiring physician education for opiate prescription) and opposes more physician access to anti-opiate drugs, too. That smells like pharma influence to me. The AMA never did any due diligence in the first place to assess whether the papers used to justify increased opiate use really said what the drug reps said they did. It turns out they did not, and it’s now widely acknowledged that the medical profession was misled by these papers.

    But OK, let’s say we leave physicians alone. Those who say we shouldn’t interfere in this very modest way, tell me how we’re going to get a handle on opioid abuse? The problem is getting bigger, not smaller, so what would you do?

    • Jan van Eck

      Mr. Dalton, I would say that your thoughtful analysis, above, is trenchantly accurate. Yet, you are looking at your narcotics-abuse problem through a very local lens. Your Windham County has these problems due to local leadership failures; you have this entrenched set of politicians, government officials, and businessmen (collectively, “the power elite”) that is perfectly comfortable with the situation as it exists. Those folks, whom you elect or appoint, like it the way it is. Your solution is, ultimately, to dump your power elite.

      Society has two classes of druggies. One group, perhaps 5% of the population, is predisposed to substance abuse, and my guess is that there is nothing that can be done about it; it is an irreducible class. The other group are those sunk into depression and despair, that their lives are such a hopeless mess. A lot of that is the absence of any path forward to achievement and self-respect. You attain that by worthwhile, properly paid work.There is nothing like a decent paycheck to change one’s mental set. But here is where you run into a brick wall; your power-elite has no interest in economic expansion, and couldn’t care less if a big chunk of your County workforce is perpetually unemployed. Right now, your true county workforce unemployment rate is roughly 24%. So don’t be surprised that those in despair start doing drugs.

      Once that raw truth starts to sink in, then you can mobilize your neighbors to kick the power elite out and install serious people who recognize that the path forward is through attacking the economic stagnation and decay that envelops you. And that will not be easy, insofar as the local bankers in your County have zero motivation to be commercial lenders in that vein. It is just about at the tipping point where the damage is irreversible, so you do not have the luxury of time. Windham County is in very deep trouble.

      • Don Dalton

        It’s not just Windham county. This is a problem all across the country. Appalachia has been devastated, as has rural Maine.

        I agree with your solution: people need to feel worthwhile and we need jobs. I’m not so sure that there is a “natural” 5% of the population prone to substance abuse, and that nothing can be done for them.

        For those who say leave doctors alone, I’d say OK, provided that doctors can use any and all measures to treat addicts, with no restrictions. Why make doctors jump through hoops to treat addicts and in many cases deny them the means to treat them (yes, drugs to treat addicts are highly regulated and restricted) when they can hand out opioids like candy? Everyone is so concerned about the doctor-patient relationship, so fine: leave the doctors alone so they can treat addicts as they see fit.

        • Jan van Eck

          As to the residual, or “natural,” background level of persons inherently susceptible to substance abuse, you see this (in varying degrees) in certain populations. Specifically, Ireland has a long-standing problem with its indigenous population abusing alcohol, easily 5%. Whether or not that is genetic predisposition, I leave to epidemiologists to sort out (I suspect it is). The Irish natives are now also engaging in narcotics/pharma abuse, another big problem there. How to treat, and especially how to treat the fringe or “swing” populations that drift into substance abuse? Yes of course, you are perfectly correct, leave physicians alone to their discretion to deal directly with their patients. Government people who attempt to interpose themselves in that invariably end up behaving like dummies.

          Nonetheless, and regardless of the responsive attempts, I maintain that unless the population feels that their contribution to society and to their families is useful and meaningful (translation: a decent-paying job), you are trying to empty the polder with a bucket. Ain’t gonna work. And for the rest of you not motivated to get off your duffs and work for societal change (and leaving that power elite in situ), remember that those druggies are inevitably going to be breaking into your house, robbing your stuff, mugging your daughters, and costing you plenty in law and jail budget charges on your taxes. Druggies are very, very expensive. They are quite literally the wages of sin.

          • Don Dalton

            I would not be so quick to paint the Irish as disposed to abusing alcohol or drugs. Yes, that’s the popular myth, but I wonder how true it is? Don’t Italians and Germans, for example, drink too? Irish natives engaged in narcotics/pharma abuse? Where did that come from? I’m Irish, and proud of it. And no, I am not and never have been an addict of anything.

            I’m also not so sure that addicts can be painted into the “morally defective” group, as you seem to. Was my mother morally defective when she became addicted to painkillers? As she is the widow of a minister and is in every way the model of virtue and honesty, be careful how you answer that. What about pharma? Does pharma get off scot-free in all this, even though they pushed to get doctors to prescribe more and more opioids and used deceptive marketing to achieve those ends?

            I do not believe that there is a morally defective group among us that falls into drug use and gets what they deserve. I believe it could happen to anyone, although some people are more susceptible than others. I believe it could happen to any of our children, no matter how well we bring them up, if drugs out are there and school kids are into them (and yes, they’re in the schools too.) I’m talking about the hard stuff, the opioids. It would take just a little slip up for young people who may not have an accurate perspective on what they’re getting into to make a huge mistake that costs them and their families dearly. It may be a period of rebellion that’s a way of telling parents to “stuff it” that turns even the best child down a bad path.

            I believe that the situation is so serious that we should put long-overdue restrictions on access to opioids, just as we now put restrictions on drugs used to treat opioid addicts– which makes no sense, but there it is. It’s hypocritical to complain about the doctor/patient relationship with opioid prescriptions but to make no complaint at all about the restrictions placed on doctors who want to treat addicts.

  • I think this bill is about 10 years late. Doctors have moved to a pain management model and have already decreased the opiate prescriptions – hence the friendly heroin dealers that have moved in to fill the void.

    • Jim Candon

      Not so if you were to check the latest stats published by the Vermont Prescription Monitoring System.

  • I’d also like to give a shout out to Perdue Pharma, manufacturer of both Oxycontin and Suboxone. One helluva business model you got there, boys.

    • Neil Johnson

      Do they make the medicine to relieve constipation from using opiates too? Which is allowed to advertise on TV due to the lobbyists of Big Pharma? The circle of a drug dealers life.

      The Suboxone market paid for by tax payers? So now the addicts get free drugs?

  • Rich Lachapelle

    I dont understand all the hysteria about government getting involved in medicine which is the situation we have now with some therapeutic drugs being prescription-only and many popular recreational drugs and the illicit use of therapeutic drugs being prohibited by law.
    Certainly there are issues of patient privacy but these issues exist now with the government being involved in the financing of many aspects of health care in general.
    To get the government out of the drug business means legalizing all drugs and allowing the pharmaceutical companies to promote and market all their products free of interference. This would not be a good idea as we have already seen the result of heavy marketing of prescription pharmaceuticals in the major media. Our current junkie apocalypse NECESSITATES that we place MORE restrictions on prescribing practices. I have heard too many stories of decent people becoming addicts because they were introduced to drugs not from their high school pot dealer but from their physician because of an athletic or occupational injury or some dental work or surgery. The serious impact on our society from addicts criminally preying upon others to finance their habits demands that we regulate prescription practices more closely and patient privacy be damned if necessary.
    Our politicians refuse to hold junkies responsible for the crimes they commit because of their “disease” so what alternatives do we have other than to go after the sources, whether they be an orthopedic surgeon or some supplier named Jamaal from the Bronx.

  • Rich Lachapelle

    Every time a US citizen seeks to take advantage of their 2nd Amendment rights by purchasing a gun from a dealer there is a federal requirement for a criminal, mental health and domestic violence background check to determine whether that person is on the “prohibited” list. When someone wants to board a commercial airliner they must produce a government-issued ID and not be on the “no fly list”. We tolerate these intrusions on our rights and liberties because of the POTENTIAL FOR GREAT HARM that can result if the wrong person has access to these devices. We have already seen the great harm that results to the innocent crime victims of junkies financing their habits, to the grandparents having to raise the children of their junkie daughters and to our tax coffers when people who should not have access to powerful narcotics maintain their addictions. Anyone who argues for minimizing government intrusion on the distribution system of these powerful, addictive drugs should also promote the free exchange of firearms and the elimination of all airport security. The biggest problem is with increased availability of information on who has painkiilers on hand which could fall into the hands of drug seeking junkies. This needs to be remedied with STRICT, SEVERE criminal penalties for anyone targeting those who have legitimate prescriptions through burglary, assault or other thievery.

  • I think limiting pain medicine is total insane!! I am 53 years old and I am on disability, for several reasons, if I didn’t have my pain meds,I wouldn’t be able to do a thing, and all people are different about the pain that there in, and limiting pain meds,after an major operation ,is just not a good idea!! Do you realize the crime this limiting is going to go threw the roof!! And if people get taken off there pain meds,there going to go and by them off the streets anyways, and start using herion! ! A few years ago my large intestines ruptured, and put a hole in my small, in which then my bowel went threw my hole body,they had to pump it out of my stomach! !well anyways, they gave me 2 hours to live!! And yes I was in extreme pain, well it took the doctors 4 hours to take out some of my SM and lg.intestines And repair the rest, The next morning I woke up with a a bag hanging on my stomach!! I was in alot of pain,and had to stay in hospital for 29 days,getting pain medication every 4 hours!!! Now what would happen if I was only allowed 10 pills!!!I just couldn’t imagine!! I get prescribed hydrocodone, for all the pain I am in, 5 in a 24 hour period. Taken in people off and limiting is NOT a good idea!! Your perscriber,can give u a urine test to see if your taking them,it takes 5 mins, and when u go to a pharmacy, the Pharmist can see what your taking,and if your doctor shopping.

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