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
Pharmacists can fill C-II prescriptions in increments
When treating a patient for opioid-related overdose, the prescriber must provide the patient with information about substance use disorder prevention or treatment services
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
Prior to prescribing methadone or buprenorphine for substance abuse, a prescriber must review the patient’s MAPS report
Before prescribing an opioid, the prescriber must provide information to the patient regarding the dangers of opioids
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.
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.
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
Alpha-2 adrenergic agonists
Tachycardia, increased blood pressure, anxiety, chills, piloerection
Medications for the Treatment of Opioid Use Disorder
Buprenorphine + Naloxone
Bunavail, Suboxone, Zubsolv
Action at Opioid Receptors
Partial agonist + antagonist
Requirements to prescribe
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
o Confirm enrollment
o Verify dose
o Inform OTP of hospital admission
o May delegate documentation to nurse or pharmacist
Opioid agonists may be used for opioid-dependent patients to prevent withdrawal if the following apply:
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
CRC Recovery, Inc.
Ann Arbor Treatment Services, LLC
Harbortown Treatment Center
The Brighton Center
Premier Services of Michigan, LLC
John D. Dingell VA Medical Center
Nardin Park Recovery Center
S.T.A.R. Center, Inc.
Metro East Substance Abuse Treatment Corporation Harper/ Chalmers Clinic
New Light Recovery Center, Inc.
Wayne State University Physicians Group – Tolan Park Research Program
Sunshine Treatment Institute, PLLC
Institute of Supportive Services, Inc.
Biomedical Behavioral Health
Sacred Heart Rehabilitation Center, Inc.
Michigan Therapeutic Consultants, PC
Northern Michigan Substance Abuse Services, Inc.
Cherry Street Services, Inc.
Rainbow Center of Michigan, Inc.
Victory Clinical Services III, LLC
Victory Clinical Services
Victory Clinical Services Lansing
Red Cedar Clinic
Ultimate Solutions, Inc.
Rainbow Center of Michigan
Passion of Mind Healing Center
Recovery Unlimited Treatment Center
Eastside Outpatient Services, PLLC
Metropolitan Rehabilitation Clinics, Inc
Sunrise Treatment Center
Victory Clinical Services IV
Quality Behavioral Health