On the second day of the new legislative session, Vermont Commissioner of Health Harry Chen, M.D., testified to the House Human Services Committee about the administration’s proposals to address prescription drug abuse.  The specifics of the proposals have not been provided yet, but they are expected to be spelled out in a bill that Rep. Ann Pugh, Chair of the House Human Services Committee, will introduce. 
 
Several of the recommendations involve the Vermont Prescription Monitoring System (VPMS), which, as many VMS members know, is a database created in 2009 by the Department of Health to monitor use of controlled substances dispensed by Vermont pharmacies.  Pharmacies report all prescriptions for controlled substances to the database on a weekly basis and physicians and other prescribers can register with the system and access information about the prescriptions for controlled substances that their current patients are receiving.  The information reported by the pharmacies to the database includes the name of the patient, the prescriber, the pharmacy, the drug and the dosage.  The database does not include any information about the patient’s diagnosis or about other non-controlled drugs that the patient may be taking.  Currently law enforcement has only limited access to this information, through the Commissioner of Health or through licensing boards.   
 
VMS plans to focus on this issue at the next VMS Council meeting on Saturday, Feb. 11, from 9 a.m.to 12 noon at Fletcher Allen Health Care in Burlington.  At that time, the Council will consider an updated VMS resolution that will clarify and update VMS policy on this important issue.  See link below for the current VMS policy, adopted in 2008. 
 
The proposals discussed verbally in the committee are outlined below.  VMS is concerned about the following proposals, which may be addressed when the specific details of the proposal become available: 
 

1. A proposal to require CME for physicians and other prescribers of controlled substances who have registered with the DEA that addresses addiction and best practices for prescribing controlled substances; 
2. A proposal to require prescribers to log in and check VPMS when they write prescriptions for controlled substances; and,
3. A proposal to allow the two drug diversion officers of the state police, and their supervisors, to access VPMS as part of a bona fide investigation without judicial review or a warrant.

 
VMS Concerns and Rationales
 
Mandated CME addressing prescribing controlled substances and addiction for physicians with DEA registrations 
 
Last year the Vermont Board of Medical Practice (VBMP) was authorized by the legislature to create a CME requirement for physicians in connection with license renewal, and the board is currently in the process of drafting rules to implement this new requirement.  The legislature required the board, through the rules, “to require evidence of current professional competence in recognizing the need for timely appropriate consultations and referrals to endure fully informed patient choice of treatment options,” including pain management services.  VMS believes that the VBMP should have an opportunity to complete its rulemaking process before the legislature imposes additional CME content-specific requirements, as it believes VBMP can design an effective CME program that is targeted to physicians’ specialties and practices. 
 
The VMS Education and Research Foundation, led by Dr. Cy Jordan, M.D., has obtained a grant to perform a statewide survey and needs assessment of the type of education and support that would be helpful to physicians who are prescribing controlled substances.  The survey is scheduled to be conducted in April of 2012 and should provide useful information for designing educational initiatives.   
 
Mandated VPMS check before prescribing a controlled substance
 
Physicians and their office staff are already burdened with administrative tasks and adding another one may discourage physicians from treating patients with chronic pain in their offices.   Vermont currently does not have enough pain specialists or pain clinics to address the need for treatment for more complex patients.  The state should look for ways to make it easier for primary care physicians to safely treat patients with chronic pain.  It is time consuming to manage care for chronic pain patients who may need urine screening, pill counts and pain treatment contracts. 
 
VPMS has the potential to be a helpful tool for physicians.  VMS members report however, that the system not easy to use at this time.  Members have reported that it takes too long to log on and that the system is not always available.  Before the legislature mandates physicians to check VPMS, the system must be easy to use and incorporate in practices’ routines.  Ideally there would be a single log in and password for all state registries. 
 
VBMP is also in the process of updating its policy on the Use of Controlled Substances for the Treatment of Chronic Pain, and intends to make recommendations with respect to use of the prescription monitoring system as part of evidence-based best practices.  VMS believes that the legislature should allow VBMP to set the professional standard of care, with respect to use of the VPMS. 
 
Prescribing controlled substances is hard and time-consuming, if government makes it more difficult and imposes more hurdles, physicians may stop prescribing controlled substances in their offices for difficult patients and may stop providing in-office addiction treatment in situations where continued care for these patients becomes too difficult or exceeds physicians’ expertise.  
 
Direct Access to Law Enforcement
 
VMS’ concern about allowing direct access to law enforcement has been that the clinical information in the database is limited to the drug dosage, and because it is incomplete, it may lead to investigations of physicians who are prescribing larger doses of controlled substances to patients with terminal pain.  There is also the potential for a chilling effect on prescribing controlled substances for patients who need them.  VMS prefers that the information be reviewed by a clinician such as the Commissioner of Health or VBMP prior to releasing the information to law enforcement. 
 
Preliminarily, VMS expects to support the following proposals that were made by the Commissioner of Health to the House Human Services Committee: 
 

• A proposal to allow the DVHA Medical Director, Michael Farber, M.D., to access VPMS to review use of controlled substances by patients in connection with prior approval of buprenorphine treatment;
• A proposal to allow the Chief Medical Examiner, Stephen Shapiro, M.D., to access VPMS when he is investigating deaths related to drug use or misuse;
• A proposal to enter an interstate compact that would allow sharing of VPMS data with other states (This is expected to allow physicians to check whether patients are receiving controlled substances from pharmacies in other states.); 
• A proposal to incorporate education about addiction and pain into the medical school curriculum;
• A proposal to improve prescribing controlled substances in primary care through Academic Detailing and Clinical Microsystems;
• A proposal to provide education for the public about proper disposal of controlled substances and opportunities for drug take-backs; 
• A proposal to require IDs at pharmacies in order to pick up prescriptions for controlled substances;
• A proposal to increase training for law enforcement;
• A proposal to provide increased education for prescribers concerning enrollment in VPMS and accessing it as part of best practices;
• A proposal to provide tools, education, technical assistance, and consultation for prescribers of controlled substances about best practices;
• A proposal to create a study group to report to the legislature on creating a unified pain management program in Vermont;
• A proposal to work with insurers to establish and spread best practices for prescribing controlled substances; and,
• A proposal to require high-risk patients to obtain controlled substances from one pharmacy and one prescriber.

 
Background information

• VMS’ 2008 policy on Prescription Drug Abuse and Diversion

Links to additional information about VPMS, including frequently asked questions for prescribers:

• http://healthvermont.gov/adap/VPMS_about.aspx
• http://healthvermont.gov/adap/documents/VPMS_providerFAQ.pdf

 
VMS is encouraging its members to review that above proposals and contact the Society with questions and suggestions.  The organization is also seeking members willing to contact legislators to discuss these issues, meet them in person or testify before them.