Thank you for this opportunity to speak to you. We in this room and all physicians agree that controlled prescription drug misuse and diversion is significant and growing. I commend Governor Beshear and the Kentucky legislature for addressing this problem.
We also agree that all patients with pain should receive optimal, safe care. This is crucial when caring for our most vulnerable patients in long term care and hospitals. Failure to manage pain can be the tipping point that determines a patient’s future: returning home or not returning home.
While agreeing with the intent of the law; I have grave concerns about its unintended consequences including patient safety, barriers to appropriate pain management, and its impact on care delivery.
This is best illustrated by a recent patient. He is a nursing home patient with chronic brain injury; non-verbal; unable to use his arms and legs, who requires total nursing care. He became acutely ill with fever and abdominal pain. The ER doctor described him as wincing and moaning with pain. Acute kidney infection was diagnosed and he was given antibiotics and morphine in the ER.
When admitted to a hospital room, his nurse calls me for pain medication. Before July 20, I would review the situation, background, assessment, and recommendation on the phone with his nurse and if appropriate ordered pain medication; probably morphine. This involves high level critical thinking in a complex patient, multiple clinical possibilities, and morphine a high alert drug.
Post July 20, there is an added level of complexity layered on.
Stop seeing patients in the office, make them wait for the 1 ½ hours it will take me to drive to the hospital, perform a complete history and physical, document a complete history and physical, query KASPER for all available data on this patient, formulate a written treatment plan for pain management, and obtain written informed consent.
Can this patient give informed consent?
How do I obtain informed consent?
What if his health care surrogate cannot be located?
What if his health care surrogate refuses to give permission?
What if this patient is a ward of the state?
Some office patients will reschedule their appointments and their care will be delayed.
I continue to see office patients and allow the patient to suffer with pain until I can get to the hospital.
All humans experience error; an important patient safety principle. Rate of error is increased by human factors such as distraction, stress, fatigue, and rushing.
Either option I choose creates distraction, stress, and rushing in this scenario and makes me more error prone.
Post July 20, any office patient who needs a new controlled prescription now requires me to perform a complete history and physical, document a complete history and physical, query KASPER for all available data, formulate a written treatment plan, and obtain written informed consent;
If a chronic controlled prescription refill, there are strict requirements also issued by the KBML.
These requirements accumulate through the day and will delay seeing the patient in the hospital until even later.
Another impact; we handle multiple nursing home faxes daily such as this recent one:
The resident states: my pain is getting worse; joints, muscles, and general. No pain relief with Percocet and Oxycontin.
Uncontrolled pain is a frequent fax or call from the nursing home.
Pre July 20, I would have increased oxycontin; requiring writing the order, faxing the order, writing the controlled prescription, faxing the controlled prescription, mailing the original, documenting this and seeing the patient on nursing home rounds.
This is high level decision making involving a complex patient and high alert meds.
Post July 20 there is an added layer of decision making.
If I increase the oxycontin, is this a new prescription or a refill?
If a new prescription: I am required prior to the initial prescribing of a controlled medication to perform a complete history and physical, document a complete history and physical, query KASPER for all available data, formulate a written treatment plan, and obtain written informed consent.
Now do I stop seeing office patients and drive to the nursing home or not? Do I go to the nursing home first or do I go to the hospital first?
I care for approximately 86 out of 92 patients in one nursing home. There are only 5 physicians in Daviess County who continue to see an estimated 600 nursing home patients. All others have stopped due to complexity of care and regulatory burdens.
I have concluded that complying with House Bill 1 will not allow time for me to go to the nursing home and I will have to stop caring for my nursing home patients.
I do not know who will care for them. I am not sure anyone will.
A personal comment from me, a Family Physician who is proud of what I done for the past 32 years; the tone of House Bill 1 makes me feel somewhat like a criminal just for trying to control pain in my patients, many of whom suffer from pain daily.
The majority of physicians are just trying to do a good job and control pain; a complex, challenging clinical problem.
I propose that we re-think House Bill 1, utilizing the patient safety concept of a fair and just culture instead of the blame and shame culture of House Bill 1.
I think that we can all work together to reduce controlled prescription misuse and diversion while improving pain management and health care delivery in Kentucky: A Win/Win for everyone by concentrating the regulatory efforts on those high risk drugs and known mechanisms of diversion rather than on the medical and healthcare community at large.