MPA | Pharmacy News

Combating the Opioid Epidemic

Posted on March 15, 2018 in: Patient Safety

By Marla Ekola, Pharm.D., BCPS, MBA, director of pharmacy, Memorial Healthcare, Owosso and Whitley Shaver, Pharm.D. candidate 2018, Ferris State University

In March 2016, Gov. Snyder created the Michigan Prescription Drug and Opioid Abuse Commission. In October 2017, the Trump Administration declared the opioid epidemic a national public health emergency. In Dec. 2017, Lt. Gov. Calley signed into law several bills which change how prescribers prescribe, dispense and administer controlled substances. These laws work to decrease opioid prescribing and increase utilization of the Michigan Automated Prescription System (MAPS). The new updated MAPS not only provides real-time prescription information but also has added features that help prescribers make informed decisions about medication use. While most of these laws focus on prescribers, their impact will definitely be felt in the pharmacy world as well. Here are some of the highlights and effective dates of these new laws.

New Michigan OPIOID Laws 

Requirement

Date Effective

Pharmacists can fill C-II prescriptions in increments

Immediate Effect

When treating a patient for opioid-related overdose, the prescriber must provide the patient with information about substance use disorder prevention or treatment services

Immediate Effect

Prescriber must have a bona fide prescriber-patient relationship to prescribe a controlled substance. The Department of Licensing and Regulatory Affairs is required to promulgate rules defining what constitutes a bona fide prescriber-patient relationship by the effective date. If rules are promulgated by an earlier date, then the effective date will be the date in which rules are finalized. 

March 31, 2019

Prescriber must register with MAPS before prescribing or dispensing a controlled substance

June 1, 2018

Prescriber must review the patient’s MAPS report if prescribing more than a three-day supply of an opioid

June 1, 2018

Prior to prescribing methadone or buprenorphine for substance abuse, a prescriber must review the patient’s MAPS report

June 1, 2018

Before prescribing an opioid, the prescriber must provide information to the patient regarding the dangers of opioids

June 1, 2018

Before prescribing an opioid to a minor, the prescriber must obtain parental consent and a signature and counsel the patient and guardian on the risk of addiction and overdose.

June 1, 2018

For the treatment of acute pain, no more than a seven-day supply may be prescribed within a seven-day period

July 1, 2018

 

The Department of Licensing and Regulatory Affairs (LARA) will be providing funding for integrating the new MAPS with the electronic medical records (EMR) and pharmacy dispensation systems of hospitals, physician groups and pharmacies across the state to help combat the misuse of prescription drugs. Thanks to efficiencies in the implementation of the new MAPS system and additional federal grants, the state will cover full integration and one year of licensing fees for users that apply for the LARA funding within the next two years. However, if a health-system signs the terms and conditions, and their EMR vendor is enabled quickly, they may end up getting more than a year’s worth of licensing fees covered as the initiative runs until Aug. 31, 2019. It is advantageous to integrate early. Hospitals can apply with LARA and request software integration here.

Treatment Options

With these changes come several questions, including how to treat patients who will no longer be on these opioid medications. While there are several non-opioid pain management alternatives available, the treatment of addiction and opioid withdrawal has fewer options.

Opioid withdrawal alone is not life-threatening. It often presents similarly to a severe case of influenza.1 However, the severe discomfort associated with withdrawal acts as a barrier to sobriety for many patients. Along with symptom management, medication-assisted treatment (MAT), which combines Federal Drug Administration (FDA)-approved medication and psychosocial intervention, can assist in overcoming the barrier.

Some non-opioid medications can be used to reduce withdrawal symptoms and can be prescribed by any practitioner. The following chart lists these medications as well as the specific withdrawal symptoms they are used to treat.

 

 Adjunctive Medications to Use in Opioid Withdrawal

Medication to Treat Withdrawal

Withdrawal Symptom(s)

Alpha-2 adrenergic agonists

Clonidine

Tizanidine

Tachycardia, increased blood pressure, anxiety, chills, piloerection

Benzodiazepines

Temazepam

Diazepam

Insomnia, anxiety

Loperamide

Diarrhea

NSAIDs

Pain

Antiemetics

Prochlorperazine

Ondansetron

Nausea, vomiting

 

 Medications for the Treatment of Opioid Use Disorder

Medication

Methadone

Buprenorphine

Buprenorphine + Naloxone

Brand name(s)

Dolophine, Methadose

Subutex

Bunavail, Suboxone, Zubsolv

DEA Schedule

C-II

C-III

C-III

Action at Opioid Receptors

Agonist

Partial agonist

Partial agonist + antagonist

Requirements to prescribe

DEA-certified OTP

Prescriber with DATA waiver

Prescriber with DATA waiver

DEA = Drug Enforcement Administration; OTP = opioid treatment program; DATA = Drug Addiction Treatment Act

While these treatments should only be initiated in certified opioid treatment programs or by physicians with a Drug Addiction Treatment Act (DATA) waiver, opioid-addicted patients are commonly treated for non-addiction conditions in the hospital. If a patient on these medications ends up in your healthcare system, there are several important things to remember. To provide opioid agonist treatment for a patient during an acute hospital stay, there are steps that must be taken by the inpatient healthcare providers to ensure the safe and effective treatment of the patient. These steps are detailed in the chart below.

It is important for the pharmacy team to take the lead in helping these patients safely transition into and out of health-systems. Knowing limitations to prescribing, dispensing and discontinuing these medications can help ensure that our patients are cared for.

 Inpatient Use of Methadone and Buprenorphine for Opioid Use Disorder2,3 

Patient enrolled in an Opioid Treatment Program (OTP)

Patient NOT enrolled in OTP

Physician must:

  • Determine patient is enrolled in OTP
  • Contact OTP to:

o Confirm enrollment

o Verify dose

o Inform OTP of hospital admission

  • Document verification and OTP location in progress notes

o May delegate documentation to nurse or pharmacist

Pharmacist must:

  • Confirm proper documentation exists in patient chart

Opioid agonists may be used for opioid-dependent patients to prevent withdrawal if the following apply:

  • Patient is being treated for a condition other than addiction
  • Withdrawal would complicate the primary medical problem

 

NOTE: Inpatient physicians do not need a DATA waiver to prescribe opioid agonists for inpatient use

 

As patients transition out of the hospital, a prescription for buprenorphine would only be acceptable if the prescriber has a DATA waiver and intends to continue treatment of the patient’s opioid dependency out of his/her office-based practice.

Opioid Treatment Programs (OTPs) in Michigan4

City

Program Name

Phone number

ANN ARBOR

CRC Recovery, Inc.

(734) 585-7970

Ann Arbor Treatment Services, LLC

(734) 544-1523

BENTON HARBOR

Harbortown Treatment Center

(269) 926-0015

BRIGHTON

The Brighton Center

(810) 229-9220

DEARBORN HEIGHTS

Premier Services of Michigan, LLC

(313) 277-3293

DETROIT

John D. Dingell VA Medical Center

(313) 576-1000

Nardin Park Recovery Center

(313) 834-5930

S.T.A.R. Center, Inc.

(313) 493-4410

Metro East Substance Abuse Treatment Corporation Harper/ Chalmers Clinic

(313) 371-0055

New Light Recovery Center, Inc.

(313) 867-8015

Wayne State University Physicians Group – Tolan Park Research Program

(313) 993-3964

Sunshine Treatment Institute, PLLC

(313) 368-4800

Institute of Supportive Services, Inc.

(313) 733-4528

FLINT

Biomedical Behavioral Health

(586) 783-4802

Sacred Heart Rehabilitation Center, Inc.

(810) 732-1652

GAYLORD

Michigan Therapeutic Consultants, PC

(989) 732-4357

Northern Michigan Substance Abuse Services, Inc.

(989) 732-1791

GRAND RAPIDS

NuPoint Services

(616) 243-6262

Cherry Street Services, Inc.

(616) 965-8390

GRANDVILLE

CRC Recovery, Inc.

(855) 380-8272

HIGHLAND PARK

Rainbow Center of Michigan, Inc.

(313) 865-1580

JACKSON

Victory Clinical Services III, LLC

(517) 784-2929

KALAMAZOO

Victory Clinical Services

(269) 344-4458

LANSING

Victory Clinical Services Lansing

(517) 394-7867

Michigan Therapeutic Consultants, PC

(517) 272-4357

Red Cedar Clinic

(517) 371-1111

LIVONIA

Ultimate Solutions, Inc.

(734) 513-2800

MADISON HEIGHTS

Sacred Heart Rehabilitation Center, Inc.

(810) 392-2167

MONROE

Rainbow Center of Michigan

(734) 243-8707

Passion of Mind Healing Center

(734) 344-5269

MOUNT MORRIS

Recovery Unlimited Treatment Center

(810) 785-4930

MOUNT PLEASANT

Michigan Therapeutic Consultants, PC

(989) 953-4357

MUSKEGON

Cherry Street Services, Inc.

(231) 767-1921

MUSKEGON HEIGHTS

Eastside Outpatient Services, PLLC

(231) 739-4359

OAK PARK

Metropolitan Rehabilitation Clinics, Inc

(248) 967-4310

PONTIAC

Sunrise Treatment Center

(248) 481-2267

ROSEVILLE

Biomedical Behavioral Health

(586) 783-4802

SAGINAW

Victory Clinical Services IV

(989) 752-7867

STERLING HEIGHTS

Quality Behavioral Health

(313) 922-7777

WARREN

Premier Services of Michigan, LLC

(586) 758-6670

WATERFORD

Biomedical Behavioral Health

(586) 783-4802

WIXOM

Therapeutics, LLC

(248) 525-6832


References

  1. American Addiction Centers. Drug Withdrawal Symptoms, Timelines, & Treatment. AmericanAddictionCenters.org. https://americanaddictioncenters.org/withdrawal-timelines-treatments/. Accessed March 2018.
  2. Substance Abuse and Mental Health Services Administration. Medication Counseling and Treatment. SAMHSA.gov. https://www.samhsa.gov/medication-assisted-treatment/treatment. Accessed February 2018.
  3. Department of Licensing and Regulatory Affairs, Board of Pharmacy. Pharmacy—Controlled Substances. Michigan.gov/lara. http://dmbinternet.state.mi.us/DMB/ORRDocs/AdminCode/1478_2014-140LR_AdminCode.pdf. Accessed February 2018.
  4. Substance Abuse and Mental Health Services Administration. Opioid Treatment Program Directory. SAMHSA.gov. https://dpt2.samhsa.gov/treatment/directory.aspx. Accessed February 2018.

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