The Louisiana Commission on Preventing Opioid Abuse held its second meeting this week. The Commission has a February 2017 deadline to deliver a report to the Legislature discussing eight areas of action, referred to by the Commission as “topics,” which were previously divided up by Commission co-chairs Eric Torres of the Louisiana State Board of Medical Examiners and Malcolm Broussard of the Louisiana Board of Pharmacy. The first and eighth topics will be addressed by Broussard and Torres, the remaining six are currently being researched by a diverse set of boards and organizations, some of which were tapped by the Legislature for participation and others volunteered.
At the first meeting, Torres and Broussard emphasized the tight timeline to make the recommendations and encouraged the assigned topic teams to share information and get to work immediately. On Monday, the results of those initial discussions within teams were shared with the public and the entire group.
Below is a progress report on each topic (full documentation at the bottom of this page):
Topic 1: Identify and evaluate the causes of opioid abuse in Louisiana.
- To be determined at a later date by Commission staff.
Topic 2: Evaluate responsible use of opioid medications, including the adoption of “Guidelines for Prescribing Opioids for Chronic Pain.”
- Dr. Paul Hubbell, topic leader, urged the notion that chronic pain specialists and addictionists need to be certified and comply with the guidelines for chronic non-cancer pain as laid out by the Louisiana State Board of Medical Examiners.
- Dr. Hubbell also explained that his team wants to “tighten up definitions” regarding who is able to prescribe opioids for more than 12 weeks.
- Further, the topic 2 team said that it would like to include dentists and primary care doctors especially in the effort to raise awareness since those specialists tend to prescribe significant amounts of opioids without having a chronic pain background.
Topic 3: Evaluate and recommend reasonable alternatives of medical treatment to mitigate the overutilization of opioid medications, including integrated mental and physical therapy health services.
- Shelley Esnard, topic 3 leader, said non-opioid therapies should be “tried and optimized” before a patient is considered for opioids and once they are on opioids. The team also referred to the CDC’s Guideline for Prescribing Opioids for Chronic Pain, which emphasizes that opioids are not a first line or routine therapy for chronic pain.
- Esnard also stated that mental health should be priority for chronic pain patients, with early referral to a psychotherapist by a prescriber who is not trained enough to apply good evidence based cognitive behavioral psychology.
- Other suggestions for reasonable alternatives included: recognizing physical therapy as a “primary treatment path” for chronic pain; increasing training for and utilization of Medication Assisted Treatment (MAT) for opioid-dependent patients; and ensuring providers are educated regarding utilization of the Prescription Monitoring Program data and how to recognize and report potential and actual misuse, abuse, and addiction.
Topic 4: Recommend policies and procedures for more effective interagency, intergovernmental, and medical provider communication, cooperation, data sharing, and collaboration with other states, federal government, and local partners (non-profit agencies, hospitals, health care and medical service providers, and academia) to reduce opioid use.
- Commission co-chair Eric Torres led this topic, as no one else volunteered. His group began by saying that increasing awareness of the aforementioned CDC guidelines could be pushed by partnering with universities to develop a curriculum and then requiring all doctors to complete a certain number of chronic pain-focused CME hours to renew their licensure.
- Further, Torres explained that his group would want to have agencies encourage prescribers to use the PMP (i.e. PDMP) and make it more useful by incorporating a program called NARX-CHECK, which analyzes an individual patient’s record and provides a numerical risk score for opioid abuse. This could potentially be too expensive for the state to afford, although Federal grant money could be available.
- Torres’ group also stated a desire to see an Opioid Collaborative Group similar to the PMP Advisory Council in order to better communicate the gravity of opioid abuse as part of the mission of the PMP. This would likely meet quarterly and would have an expanded membership to include payor representatives.
- Further, topic 4 participants wanted to expand the use of and training for naloxone among first responders to reduce overdose deaths.
Topic 5: Evaluate and recommend policies and procedures for improved access and more effective opioid abuse treatment and prenatal care for pregnant women with substance abuse problems, including but not limited to clarifying current services available for those women, increasing the number of providers properly trained to provide care to this group, and effective ways to achieve treatment over incarceration.
- The topic 5 team provided an extensive list of both short-term and long-term policies to meet the needs of pregnant women amidst the opioid epidemic (complete proposal at the bottom of the page).
- In the short term, topic leader Robin Gruenfeld said her team prioritized: use of the national Quality Family Planning Guidelines by all providers to pregnant women; verbal screenings for substance abuse in primary care and obstetrics; universal screening for substance abuse (using something like SBIRT) for all reproductive age women; universal screening for pregnancy for women using opioids in primary care; improving access to birth control and other reproductive health services; and improving care of babies born addicted (NAS) and referral to MAT for addicted pregnant women and addicted women soon after they give birth, among other services.
- In the long term, the topic 5 team proposed: conducting a study to determine if the 2014 changes to Louisiana’s prescription drug monitoring program database have had any effect; researching the personal, social, and structural influences that increase NAS risks; getting the DHH Office of Behavioral Health to work with Louisiana Medicaid to seek federal CMS approval for Medicaid reimbursement of Methadone treatment for pregnant women; and encouraging Healthcare payors, including government and private, to consider adequately reimbursing for care and care coordination services associated with high-risk pregnancies.
Topic 6: Evaluate medical professional training needs and the efficacy of educational materials and public education as an outreach strategy to raise public awareness about the dangers of misuse and abuse of opioid drugs.
- Topic leader Dr. SreyRam Kuy led the team and discussion of prescriber training, which most Commission members say is a key starting point to curb initial opioid prescriptions among Louisianans.
- Dr. Kuy explained that the group found that there was “no need to reinvent the wheel” on education for doctors about opioids, since many states (New Mexico, Maryland and Massachusetts emerged as examples) have already launched programs from which Louisiana regulatory bodies could borrow.
- The team believes that actionable items include CME programs on: best practices in prescribing opioids for chronic non-cancer pain; the use of opioids after acute injury or surgery; the use of opioids in special populations (pregnant women, pediatrics, elderly, and cancer survivors); alternatives to opioids; when to initiate treatment for addiction; and the proper prescribing of buprenorphine available throughout the state.
- Further, Dr. Kuy’s team proposed evidence based treatment requirements for residential treatment programs (would only require an order of the Secretary) to embrace the use of maintenance medications in residential treatment programs.
- Also, public education on the availability of Narcan Nasal Spray and OTC for naloxone.
Topic 7: Assess alternatives to incarceration and medical treatment of opioid addicted individuals suffering from severe substance abuse disorders.
- Topic leader John DeRosier led this discussion, which focused on this group’s finding that “currently the single best alternative to incarceration is the Louisiana Drug Court program” run through the Louisiana Supreme Court
- The team noted that the cost of the program is significantly less than incarceration but that it is only in 30 parishes and referrals need to be streamlined.
Topic 8: Recommend any appropriate changes to relevant legislation, administrative rules, or pharmaceutical use to mitigate opioid abuse.
- To be determined at a later date by Commission staff.
The next meeting of the Commission will be on January 19th at 1:30 PM at the Louisiana Department of Health Bienville Building Room 118 in Baton Rouge.
Relevant group documents in order of topic number:
Image Credit: NOLA.com