ARIZONA STATE LEGISLATURE
CHRONIC DISEASE AND PAIN MANAGEMENT TASK FORCE
Minutes of the Meeting
Tuesday, January 3, 2006
9:30 a.m., Senate Hearing Room 1
Members Present:
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Senator Carolyn Allen, Chairman |
Representative Doug Quelland, CoChairman |
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Senator Robert Cannell |
Representative Rick Murphy |
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Kathryn Bond |
Robert Kronenberg |
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Dr. Stephen Borowsky |
Penny Rickhoff |
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Theresa Dando |
Dr. David Rosenfeld |
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Dr. Marge Drugay |
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Members Absent:
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Senator Jim Waring |
Barbara Roberts |
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Dr. James John Badge |
Dr. George Stavros |
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Dr. Paul Howard |
Dr. Lisa Stearns |
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Dr. Richard S. Randall |
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Staff:
Beth Kohler Lazare, Senate Health Committee Analyst
Chairman Allen called the meeting to order at 9:42 a.m. and attendance was noted.
Presentations on Pain Management Policies
Tim Miller, Executive Director, Arizona Medical Board (AMB), told the Committee that last week, he had been contacted by a consultant of the AMB pertaining to issues with their pain management guidelines and the need to update them. He stated that the plan in regards to updating these guidelines was to write them internally within the AMB, with plans to hold a public meeting in February for anyone who would like to discuss the guidelines.
Senator Allen stated that distinguishing between physicians who administer pain management correctly and those who do not, should be the focal point of this task.
Mr. Miller replied that the AMB should step out of the way of physicians who administer pain management properly and focus its attention on those physicians who do not. He told the Committee that the majority of doctors were good, competent physicians who do the right thing. Therefore the AMB did not want this very small percentage of incompetent physicians to factor into what is put into the guidelines for pain management. Mr. Miller acknowledged that the guidelines need to work for pharmacists and nurses as well as the physicians.
In response to Theresa Dando, Mr. Miller stated that the public forum planned for February would be advertised via the AMB website.
In response to Dr. Marge Drugay, Mr. Miller remarked that he believed the AMB website had a forum in which the public could correspond with AMB.
In response to Dr. Rosenfeld, Mr. Miller explained that there were no requirements in Arizona for continuing education in regards to pain management. He added that only statute could require such criteria and not the AMB.
Dr. Borowsky said that the guidelines that Mr. Miller spoke about have been the key to pain management. He remarked that States with better pain management were ones who adopted the Federal guidelines on this matter.
Mr. Miller remarked that the Model Policy for the Use of Controlled Substances for the Treatment of Pain set forth by the Federation of State Medical Boards (Attachment A), had been updated recently.
Jack Confer, Executive Director, Board of Osteopathic Examiners (BOE), stated that the guidelines for prescribing controlled substances for the treatment of pain in relation to the BOE (Attachment B) were published in January of 2000. He told the Committee that when these guidelines were issued, the BOE was experiencing problems and had ordered disciplinary action on some of its members. Mr. Confer added that since the publishing of these guidelines, problems for the Board have decreased dramatically.
In response to Theresa Dando, Mr. Confer stated that traditionally, osteopathic doctors were more or less family practitioners which has dramatically changed over the last ten years.
Senator Allen said that during training for Osteopathy, students should receive the guidelines set forth by their Board in January of 2000.
Joey Ridenour, Executive Director, Board of Nursing, submitted a handout to the Committee (Attachment C) containing frequently asked questions regarding pain management. She explained that the nurse was often the health professional most involved in the ongoing pain assessment. She added that although the nurse did not prescribe these medications, the nurse was capable of titrating the dosage of or increasing or decreasing the frequency of, medication within the guidelines set by the physician and the pharmacist. Ms. Ridenour submitted an advisory opinion on The Use of Controlled Substances for the Treatment of Chronic Pain (Attachment D).
Dr. Borowsky stated that at the first annual Arizona Pain Society meeting in October, nurses and nurse practitioners accounted for the majority of the 150 attendees, showing the overwhelming involvement of nursing in pain management.
In response to Penny Rickhoff, Ms. Ridenour told the Committee that some nurse practitioners have a license to dispense pain medication.
Hal Wand, Executive Director, Board of Pharmacy, submitted a handout of the Arizona Administrative Code for pharmacists in regards to dispensing pain medication (Attachment E). He stated that younger pharmacists seemed to be looking for ways to not fill prescriptions due to their corresponding liability with the Drug Enforcement Agency (DEA) and inability to access the patients chart.
In response to Representative Quelland, Mr. Wand said that clinical pharmacists did have access to patient charts but the retail pharmacists did not. He remarked that there were approximately 12 pharmacists in the State that could initiate and monitor patient’s therapy.
In response to Senator Cannell, Mr. Wand stated that most pain management education was taught in pharmacology which is a two semester course, in the junior year of pharmacy school. He opined that generally, some pharmacists knew more about pain management than the people prescribing the medications. Mr. Wand remarked that if a Hospice were having trouble getting a prescription filled with a pharmacist, it would likely be due to the nurse faxing the prescription in, which would be a technical violation of DEA regulations.
Senator Allen told the Committee that these meetings were anti–euthanasia. She stated that she simply wanted people on their death bed to be able to spend their remaining time comfortably.
Discussion of the “National All Schedules Prescription Electronic Reporting Act of 2005”
Mr. Wand submitted a handout to the Committee entitled Model State Prescription Monitoring Programs (Attachment F). He stated that some states only monitor C2’s, which would be drugs such as morphine, percocet and oxycontin, yet some states monitor all drugs including ones used for diarrhea. He remarked that the Arizona Pharmacy Board has a grant for $50,000 that allows them to conduct shareholder meetings. Using Nevada’s monitoring program as an example, Mr. Wand stated that any controlled substance prescription filled in that state was sent to their pharmacy board electronically when it is filled. He explained that the reason behind this was to identify people who visit multiple doctors and pharmacies to obtain large quantities of pain medication outside of the normal dosage range for one patient. He added that Nevada has had this monitoring plan in place since 1994. Mr. Wand stated that Governor Napolitano sent a letter to the Board of Pharmacy asking to add sudafed to the list of medication to be recorded if a prescription monitoring plan were to be implemented in this State. He opined that doing so would be difficult, but not impossible. He stated that it would cost a State approximately $300,000 to $400,000 a year to run the prescription monitoring program. In addition, 60 million dollars had been appropriated by the Federal Government to this program. He pointed out that this left every American State with more than one million dollars for this program.
In response to Senator Cannell, Mr. Wand remarked that a doctor could go to a pharmacy and view the prescriptions he or she wrote, but could not view prescriptions written by anyone else regarding the same patient. He stated that the monitoring program in Nevada had an intervening program for patients detected to be misusing pain medication.
Mr. Wand responded to Penny Rickhoff by telling the Committee that when a pharmacy mails prescriptions into Arizona from outside of Arizona, they are required to have an Arizona pharmacy permit and they are called “non-resident pharmacies.”
In response to Representative Quelland, Mr. Wand remarked that healthcare providers sometimes denied payment for pain medications. He added that the majority of Prescription Benefit Managers were not regulated.
Mr. Wand responded to Representative Murphy by saying that an on sight physician would write the policy for a healthcare provider, but a clinical pharmacist usually handles the phone calls regarding payment for medications. Representative Murphy remarked that if these clinical pharmacists were suggesting different types of medications than were being recommended by the patient’s doctor, this could possibly be practicing medicine without a license.
In response to Dr. Marge Drugay, Mr. Wand told the Committee that most websites that send out e-mails advertising online ordering of controlled substance such as pain medication were largely private individuals who were not licensed and the medications were obtained mostly from other countries. He added that sometimes these medications were real and sometimes they were not, or “placebo.” Mr. Wand opined that 88 percent of the drugs ordered through these websites were either counterfeit or sub potent.
Tim Miller told the Committee that the Medical Board considers any physician working at a Health Maintenance Organization (HMO) making decisions, which ultimately affect the care of the patient, as practicing medicine.
Public Testimony
Catherine Niemiec, President / Founder, Phoenix Institute of Herbal Medicine and Acupuncture (PIHMA), submitted a handout about acupuncture (Attachment G) and told the Committee that she was a lawyer by training who fell in love with Chinese herbal medicine and later became a Licensed Acupuncturist. She said that PIHMA graduates are the first acupuncturists at Banner hospitals throughout the valley. Ms. Niemiec stated that 43 percent of conventional physicians refer to acupuncturists. She remarked that acupuncture was used for pain, chronic disease, acute ailments and prevention. She added that in 1979, the World Health Organization cited over 40 conditions treatable with acupuncture including migraines, toothaches, back pain and more. Ms. Niemiec told the Committee that the World Health Organization compared the use of acupuncture to painkillers stating “the portion of chronic pain relieved by acupuncture is generally in the range of 55-85%, which compares favorably with that of potent drugs and far outweighs the placebo effect. She added that acupuncture was also incredibly useful for the treatment of addiction. She remarked that acupuncture aided in the detoxification and withdrawal from painkillers and other substances used to cope with pain. Ms. Niemiec urged the Committee to consider the use of acupuncture and Oriental Medicine as an addiction-free adjunct to pain care.
Penny Rickhoff suggested that if physicians were required to receive continuing education about pain management, it would be a good idea to add knowledge of alternative medicines such as acupuncture to the curriculum.
Dr. Borowsky remarked that alternative pain management should be considered and added to any new policy regarding pain management.
Dr. Rosenfeld stated that acupuncture itself was mainstream enough for most physicians to use as an alternative, but it was the other forms of alternative medicines such as bio-feedback that were more difficult to locate for referrals.
John Durbin, Alzheimer’s Association, asked the Committee to consider advanced dementia care and the fact that the last two to three years of these patient’s lives, they are not able to report pain.
There being no further business, the meeting was adjourned at 11:08 a.m.
Respectfully submitted,
Jeff Turner
Committee Secretary
(Tapes and attachments on file in the Secretary of the Senate’s Office/Resource Center, Room 115.)
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Chronic Disease and Pain Management
Task Force
January 3, 2006
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