As the opioid epidemic propels overdose deaths in Mississippi to a record high this year, doctors in the state agree that they need to be the first line of defense against prescription drug abuse.
But what that line of defense will look like has become the topic of a very contentious debate between the state Board of Medical Licensure, which governs all doctors, and several prominent physician associations.
In October, the Board of Medical Licensure released its new recommendations for prescribing opioids, one of the first regulatory moves by a state agency to combat Mississippi’s nascent epidemic. If implemented, these recommendations would govern how doctors prescribe these substances, potentially costing physicians their licenses if not followed.
Within days, the State Medical Association issued a letter, obtained by Mississippi Today, urging the board to delay enforcing the vast majority of the changes. In the weeks since, several prominent physicians have echoed these concerns, arguing that many of the board’s recommendations would do more harm than good.
“My concern is that (these recommendations are) going to cause delays in care. They’re going to cause fewer patients to be seen, and we’re going to see significant waits at urgent care centers and hospital emergency rooms. And I think that there will be some hesitation for physicians to write the prescriptions that their patients need, even if it’s for legitimate reasons,” said Dr. Paul Seago, Mississippi vice chair of the American College of Obstetricians and Gynecologists.
Among the Medical Licensure Board’s recommendations are a requirement to test patients for drug usage any time they receive an opioid or benzodiazepine prescription. The board also proposes restricting the dosage of these medications and curbing prescriptions for chronic pain.
But other recommendations are controversial because they don’t address the opioid crisis. One section requires doctors to perform a physical examination prior to prescribing any medication, which several health care providers argue will restrict the practice of telemedicine, which relies on audio or audio/visual consultations rather than in-person visits.
“I want to make sure (the regulations) are not a subtle way of pushing back, and that’s absolutely why I’m flying down there,” said Dr. Rebecca Hefner-Fogarty, who is the chief medical officer of Zipnosis, a telemedicine company based in Minnesota.
The heart of the struggle is that any regulations must be broad enough to make an impact but nuanced enough to avoid unintended consequences. And some doctors say that the rush to get new regulations out there hasn’t left room for nuance.
“We want to fix this. There’s no doubt in my mind that we want to fix this,” said Dr. Katherine Patterson, president of the Mississippi Academy of Family Physicians. “But we need to sit down and work through this. We’ve met with the board, but I’m afraid that our concerns are not being heard.”
Patterson and other doctors have an opportunity to make their concerns heard again on Wednesday during a hearing before the Board of Medical Licensure on its proposed recommendations. More than 30 doctors and registered nurses were scheduled to speak.
Dr. Randy Easterling, a member of the Medical Licensure Board and a member of the task force created last December by Gov. Phil Bryant to tackle the epidemic within the state, said he isn’t surprised to get push back from doctors. But he thinks their protests are missing the point. Opioids are causing a crisis in the state and health care professionals need to act now.
“What would be the medical community’s response if influenza was killing 90 to 100 people a day? So it baffles some of us who are trying to get our arms around this epidemic, which is the No. 1 public health crisis in America. And we would hope that the medical community, be it doctors, nurses or physicians’ assistants, would step up to the plate and do what they can to cut back on this,” Easterling said. “This is the most horrendous epidemic of drug addiction we’ve seen in our community and we absolutely have to responds to it.”
Use of prescription opioids, which include codeine, hydrocodone, morphine and oxycodone, has risen dramatically in Mississippi in the last decade. Last year the state ranked fourth nationwide for number of prescriptions per capita, up from sixth in 2012. In 2016, an average of 70 opioid pills were dispensed for each adult and child in the state, according to the Mississippi Bureau of Narcotics.
The number of overdose deaths in Mississippi for 2017 stands at approximately 200, just shy of last year’s record of 211. In September the total was 143. Of those, 78 were from prescription opioids. Another 28 were due to heroin, and 20 were due to fentanyl, according to the Bureau of Narcotics. Nationally, four out of five heroin users used prescription opiates first.
In August, the Governor’s Task Force released its report to great fanfare. These included 18 recommendations aimed at health care providers, and many of those formed the basis of the Medical Licensure Board’s recommendations.
“These recommendations are vitally important,” said John Dowdy, director of the Mississippi Bureau of Narcotics and chairman of the Governor’s Task Force.
The letter from the Mississippi State Medical Association acknowledges these concerns, but urges the board to take a step back and, for the time being, implement just three provisions that they say would “have a significant impact on the prescribing habits of licensees to curb the number of opioids prescribed.”
Those three provisions include requiring doctors to check the state’s Prescription Monitoring Program before prescribing any opioid for acute pain or chronic non-cancer pain. The Prescription Monitoring Program keeps a database of all prescriptions for controlled substances and allows doctors to ensure patients aren’t seeing multiple doctors. The new regulations would also require doctors to check the Prescription Monitoring Program before prescribing a benzodiazepine for a chronic condition. Benzodiazepines, including valium, xanax and klonopin, are frequently used to treat psychiatric conditions such as anxiety.
The Medical Association also recommends limiting prescriptions to 90 days for benzodiazepines and to just seven days for outpatient opioid use, with several exceptions for chronic pain, cancer and palliative care.
“We want to do something that is very effective and can actually be accomplished, and that’s what we hope this three-pronged approach will do,” said Michael Mansour, president-elect of the state Medical Association. “We want to make sure we can actually take care of the patient and try to address the problem and not inadvertently cause more problems.”
If the Board of Medical Licensure is rushing into anything, it may have other good reasons. In July, several state agencies banded together and held a three-day summit on opioid and heroin use in Mississippi. Many of the speakers, including Easterling, emphasized the importance of state agencies self-regulating before legislators are forced to write regulations themselves.
“I’ve been very sore with my colleagues. If we don’t fix this they’re going to fix it for us. And that’s not something that’s going to be beneficial for the providers or the patients,” Easterling said in an interview with Mississippi Today in July.
But current issues with the recommendations already make the board’s recommendation’s vulnerable. Dr. Samuel Crosby of the Hattiesburg Clinic pointed to one section which seems to require doctors to check the Prescription Monitoring Program for all new patients, regardless of whether they need a prescription at all. Other requirements, such as the mandate that copies of the Prescription Monitoring Program reports be kept in a patient’s chart, are wastes of time, he said.
“So I’d be shocked if there’s not some changes brought forth,” Crosby said. “And I would much rather (these regulations) be handled through the licensure board, by doctors who understand it rather than politicians. If the final rules are reasonable, then I don’t think there will be anything to do legislatively.”
Mississippi’s burgeoning telehealth industry and its reliance on care from out of state doctors has sometimes found itself at odds with the Board of Medical Licensure, which governs Mississippi physicians. In 2015, the board tried and failed to impose new rules governing the practice of telemedicine through the Secretary of State’s office, a move that would have bypassed the legislature.
The language in Section 1.11 of the bill, which is the part requiring an in-person visit prior to a doctor prescribing any medication, is virtually identical to language in the changes proposed to the Secretary of State’s office in 2016.
But Easterling denies that the new regulations are a Trojan horse for restricting access to telemedicine. Any visit that includes both audio and visual components would be considered an in-person visit, he said.
“We have concerns about bad telemedicine,” Easterling said. “But we support good telemedicine. We’ve had rules and regulations for 20 years in order to prescribe medication, and you can absolutely use telemedicine for prescriptions.”
Dr. Rebecca Hefner-Fogarty of Zipnosis isn’t alone in her concerns. In another letter to the board obtained by Mississippi Today, Mike Ward, an executive with Carmart, a used car company with multiple locations in the state, argues that “the proposed language takes such a sweeping approach that even medications that are non-addictive and prescribed for simple, uncomplicated medical conditions would not be available via telemedicine.”
Doctors, of course, aren’t the only prescribers in the state. And Dr. William Grantham, president of the Mississippi State Medical Association, points out the new rules won’t make a difference until they are adopted by other boards, including the Board of Nursing and the Board of Dentistry.
“Otherwise, we are spinning our wheels,” Grantham said.