Call to Order and Roll Call
The3rd meeting of the 2012 SS HB 1 Implementation and Oversight Committee was held on Wednesday, September 19, 2012, at 10:15 AM. This was an out-of-town meeting held at the Women and Children’s Campus of The Healing Place located at 1503 South 15th Street, Louisville, Kentucky. Representative John Tilley, Chair, called the meeting to order, and the secretary called the roll.
Guests: Representative Susan Westrom, Danny Jones, Cumberland River Regional Mental Health, Developmental Disabilities, and Substance Abuse Center, Corbin, Kentucky; Mike Porter, Executive Director, Kentucky Dental Association; Bert Guinn, Greater Louisville Medical Society; Pearl Ray LeFevers, Cumberland River Regional Mental Health; Sarah Nicholson, Kentucky Hospital Association; D. J. Beyer, Executive Director, Kentucky Board of Dentistry; and Frankie Spencer, Morehead Inspiration Center and Morgan County Magistrate.
Approval of Minutes of July 23, 2012 and August 15, 2012 Meetings
Representative Stivers moved approval of the minutes of the July 23 and August 15, 2012, meetings, and Representative Belcher seconded. The minutes were approved without objection.
Effect of HB 1 on Substance Abuse Treatment in Kentucky
Discussing the broad scope of drug treatment were: Van Ingram, Executive Director of the Kentucky Office of Drug Control Policy; Karyn Hascal, President of Mission Advancement, The Healing Place; Steve Shannon, Executive Director of the Kentucky Association of Regional Mental Health-Mental Retardation Programs (KARP); Mark Jorrisch, MD, FASM, Medical Director of the Methadone Education and Rehabilitation Center (MORE Center); Pastor Bernard Foschini, Director of Teen Challenge of Western Kentucky; and Robin Peavler, MD, FACEP, American Board of Addiction Medicine Certified Addictionologist.
Ms. Hascal provided an overview of The Healing Place, founded by Jay Davidson and doctors representing the Jefferson County Medical Society, which has been in existence in the Louisville area for a over 22 years. The Healing Place is a long-term, social model recovery program for drug and alcohol addiction. The program involves one alcoholic or drug addict reaching back to help another alcoholic or addict. It is a 12 step program and is long term, meaning that it is six to nine months. The Healing Place program is a model of empowerment, empowering, and allowing those going through the program to make mistakes, learn from them, and make better decisions. It operates as a therapeutic community in that each individual in the program has a chore such as cooking, cleaning and maintaining the facility, landscaping, and supporting the operations of the facility on a daily basis. The Healing Place has three campuses in Kentucky: two in Louisville, the Women and Children’s campus and the Men’s campus, and a campus in Campbellsville, Kentucky that is part of the Recovery Kentucky Initiative.
The program does not charge the client any out-of-pocket fee or insurance payment, and the client can stay at the facility as long as needed. Funding is derived primarily from private donations from individuals, corporations, and foundations, with less than 25 percent derived from public sources. There are contracts with the Department of Corrections at the women’s facility in Louisville and the Campbellsville facility to provide recovery services for individuals who are on parole or coming out of an institution and who have not had services while in the institution. The Healing Place offers a broad range of services such as overnight emergency shelter for housing and food, a detoxification program, intensive recovery programs and transitional living such as finding housing, jobs, reunification with family, and parenting classes. The programs and models have been researched by the University of Kentucky Center on Drug and Alcohol Research for a number of years and most recently found that The Healing Place model has a 75 percent success rate, five times the national average, which means that three out of four individuals who complete the program are still sober and clean one year upon leaving. Ms. Hascal invited a client, “Kenny,” to talk to committee members about his life experiences and experiences at The Healing Place.
Kenny said that at the age of 30 he was diagnosed with degenerative disk disease, and his doctors placed him on 80 milligrams of oxycontin for pain relief. He was diagnosed with thyroid cancer shortly thereafter, and obtaining prescription pain medication was easy. He was not able to obtain the amount of oxycontin he needed for the pain and would devise ways to obtain more from his and other doctors. Between the ages of 30 and 40, he was dishonest and involved in criminal activity. He would make copies of his MRIs, put another person’s personal information relating to his MRI on it, then make it look like an original. He would then send that person whose name was on the MRI, along with the MRI, to a doctor he knew would provide a prescription for the oxycontin. A prescription of 120 oxycontin pills with a street value of $70.00 per pill or $8,400 was real motivation. It was common knowledge which doctors in the Louisville area would provide a patient with what was needed. Kenny became involved with The Healing Place when his intervention came from Louisville’s Department of Narcotics at the age of 40, and after talking with his attorney and looking at ten years in a federal prison, he determined he needed long term treatment. The Healing Place had changed his life, and after going through the twelve step program, he felt like a new person. He is employed at The Healing Place and has some benefits.
In response to a point of clarification and questions by Senator Stivers, Kenny said that his MRI with another individual’s personal information would be taken to a doctor. When the doctor looked at the MRI of the patient it was in fact his, not the individual patient in the doctor’s office. His goal of choice prescription was 120 pills of 80 milligrams oxycontin. The stable of patients would go to pain management clinics in Louisville. There were about eight such doctors, and all the doctors the prescriptions were obtained from are no longer practicing physicians. Kenny would call for an appointment with these doctors and the appointment times staggered. These were initial new patient visits so that if the appointment with the first doctor did not work out with a prescription for the 120/80s, then the individual would go to the other appointments until an appointment resulted in the choice prescription written, and then the other appointments would be cancelled. The stable patient would continue to see that doctor for prescriptions, and the medications would be collected and dispersed. This was occurring in the early 2000s. A KASPER report may have been requested but not to the level it is today. Doctors wanted the money as bad as the patient or drug addict; they were all greedy. Kenny said that 120 pills was the maximum that could be obtained at one time, and he both used and sold the pills.
In response to questions from Representative Belcher, Ms. Hascal indicated that The Healing Place focuses on accepting clients from the 13 counties surrounding Jefferson County, although they will accept clients from all over the country since the organization is not limited by public funding. All programs are full and have waiting lists.
Steve Shannon talked about the Community Mental Health-Retardation Centers (CMHCs) throughout the state that are the public safety net for mental health, substance abuse addictions, and intellectual and developmental disability services. In fiscal 2011, the centers served 179,000 individuals or about one for every 25 Kentuckians. About 18,000 of those individuals had a primary diagnosis of substance abuse or addiction. The centers employ over 9,000 individuals, or about one out of every 200 working Kentuckians. The agency is established by statute, and the system was created as a result of federal legislation in 1963. The agency receives funding from the state general fund, a substance abuse prevention and treatment block grant from the federal government, and a small portion from Medicaid for services to pregnant and postpartum women only. Also, a federally mandated Medicaid program for children called EPSDT, Early and Periodic Screening, Diagnosis and Treatment, allows services to adolescents. Some funding is received from the Administrative Office of the Courts for drug court, and the agency is in the process of negotiating contracts with the Department of Corrections to develop outpatient services. Substance abuse is the number one public policy issue facing the Commonwealth because it impacts employment and education, among other things. The Centers for Disease Control indicates that overdose deaths have reached epidemic levels.
The CMHCs’ prevention services are an evidence-based practice that saves dollars in the corrections system, law enforcement, and the Department for Community Based Services, and they increase employment. As House Bill 1 becomes more fully implemented, there will be a need or demand to address medical and social detox at a hospital supervised by a doctor. There is a great need for adolescent residential programs. Outcome measures from independent studies reflect that the outcomes are effective through the drug and alcohol research. One of the concerns of the agency is whether House Bill 1 will result in more individuals being incarcerated or accessing treatment. He emphasized the need for treatment rather than incarceration.
In response to questions from Senator Stivers regarding adolescent treatment centers, Mr. Shannon said that CMHC is operating one adolescent treatment center in Mount Sterling and one in Louisville, and the approximate ages range from fourteen to eighteen. A lot of the abuse and addiction is related to marijuana, a gateway drug. The program in Mount Sterling is designed for 16 weeks while Medicaid managed care is 30 days. Each center holds about 16 individuals. In response to a question by Chair Tilley, Mr. Shannon said in Mount Sterling the mental health center administers this treatment program, and in Louisville it is Seven County Services. In other areas of the state, the treatment program would be considered outpatient treatment rather than residential treatment.
Doctors Mark Jorrisch and Robin Peavler discussed medications to treat opiate addition. Dr. Jorrisch is an internal medicine physician, and within that practice he prescribes suboxone. Addiction is a brain disease and has a biologic basis with genetic and environmental influences on how the brain works. Methadone, which is not the same as methamphetamine, is specifically for opioid addiction treatment. The treatment of choice for pregnant women addicted to opioids is opioid replacement therapy using methadone. Obstetricians refer individuals, and some referrals come from the criminal justice system. He did not recall referrals from other medical treatment providers. Kentucky is a strong advocate of medication-assisted treatment, and the regulations that exist for methadone clinics are sufficient. House Bill 1 is unlikely to affect methadone clinics because methadone patients come to the clinics every day, are seen regularly by a physician, and annual reviews are required by the physician who has to be credentialed in addiction medicine or addiction psychiatry.
Dr. Peavler is a board certified Addictionologist and emergency medicine doctor practicing 23 years. Pain pill addiction kills 95 Kentuckians per month and is now the leading cause of accidental death. In the last 12 to 15 years, there has been an amazing increase in the number of patients coming into the emergency room for pain. Pain has become the fifth vital sign. Emergency room doctors have begun giving a secondary diagnosis as drug seeking behavior (DSB). Although the United States has five percent of the world’s population, its residents consume 95 percent of the pain pills manufactured in the world. Addiction is a scientifically proven disease that permeates all levels of society. He referenced an article by Dr. Malcolm Butler discussing how doctors have contributed to this epidemic. Pain medication addiction it is not about the “high” but once an individual is addicted he or she needs more and more medication. If the person has no medication, he or she becomes very sick or dope sick with such symptoms as aching, vomiting, diarrhea, and chills, and it takes more medication to keep from becoming sick.
The average pain medication addict spends $3,200 per month on pills. Dr. Peavler said that he treats with suboxone and counseling, which studies have shown is effective in treating addiction and requires a medical doctor to be a central part of the recovery from beginning throughout the disease. Suboxone does not give a euphoric effect to those who have addiction and dependence, but it stabilizes the patient’s brain as he or she becomes normal again. Counseling and psychosocial services, the twelve step programs, and the spiritual cleansing can be utilized because the patient is clear-headed and understands the life skills being learned in the programs. Suboxone can be weaned over time so the brain actually undergoes the biochemical change back to normal or near normal.
House Bill 1 has increased the medication assisted treatments. There are 11 treatment clinics that see 2,500 ongoing patients per month and 250 new patients each month. Patients are held accountable. There is room for about 2,000 to 3,000 more patients in the private sector clinics using suboxone and unlimited amount of counseling.
In response to statements by Senator Jones for input from the panel concerning the prescribing and administering of suboxone and the issue of training for those who prescribe it, Dr. Peavler indicated that there are physicians who obtain licensure by a special eight hour course online that allows a special drug enforcement administration number to be issued to write prescriptions for suboxone. It is very important to have parameters of how this drug is prescribed. A physician cannot just prescribe three or four prescriptions for suboxone of 120 pills because of diversion on the streets. Eight-five percent of suboxone bought on the street is bought for the purpose of self treatment. The Kentucky Board of Medical Licensure issued an opinion as to how suboxone should be prescribed, and he and Dr. Jorrisch are working through the Kentucky Society of Addiction Medication (KSAM) on how to strengthen or reinforce the prescribing of suboxone.
Dr. Jorrisch agreed that there needs to be parameters and guidelines. He said that some practices are primary addiction specialty practices that can provide a certain amount of care on site, but there is a larger number of physicians who are not in primary specialty practices but who just have the eight hour certification. The expectation should not vary except that the specialty practice will be able to provide onsite those services for which the nonspecialty practice will have to utilize outside resources. In rural areas, those resources of pain and addiction specialists, physiatrists, and counselors are limited.
Senator Jones indicated that one solution is to require physicians who write prescriptions for suboxone to attend the Clinical Applications of the Principles in Treatment of Addictions and Substance Abuse (CAPTASA) conference. There needs to be some level of on-going continuing education for those treating opioid addiction in an outpatient setting other than taking an eight hour online course.
In response to a question by Senator Jones regarding board certification of physicians in the state by the American Board of Addiction Medicine (ABAM) or the American Society of Addiction Medicine (ASAM), Dr. Shannon indicated he believed there are approximately 2,300 to 2,500 nationwide, and that in Kentucky the number is 100 or less. Senator Jones encouraged the medical licensure board to look at the quality of care that is provided to patients who are prescribed suboxone and provide feedback to the committee. A heightened level of training and education is needed before physicians are allowed to prescribe suboxone. Dr. Jorrisch cautioned about a one size fits all paradigm. He said there needs to be flexibility or general guidelines in what physicians can do. Physicians are intimidated since the passage of House Bill 1 when prescribing pain drugs and need to better understand the differentiation as to what is criminal or not criminal, and what is a guideline and what is a standard of care. Mr. Ingram stated that as of September 17, there are 336 providers who have the license to prescribe suboxone. One year ago there were 250.
Faith based organizations such as Teen Challenge also partner in treating substance abuse. Pastor Foschini, Director of Teen Challenge of Western Kentucky, stated that Teen Challenge is a nationwide ministry. The minimum age for the western Kentucky center is 17. There are over 218 Teen Challenges across America and nearly 1,000 worldwide. The western Kentucky center has capacity for 40 students, receives no funding from the government except that students may sign up and receive food stamps, and charges a $1,000 insurance fee and $500 per month thereafter. The program depends on donations from local churches and individual donors. Approximately 30 percent of the clients are directly from jail and are indigent, and about half of the center’s population is the result of pill abuse. He graduated Teen Challenge in Pennsylvania when he was 25 years old. The duration of the Teen Challenge program is 12 months, and after that time students are allowed to remain on campus in a less supervised environment and during which they may get jobs and pay rent. The program encourages a person to have a relationship with God, teaches life skills, and has a re-entry program if needed.
Prescription for Tragedy – Kentucky’s Addicted Babies
Laura Ungar discussed a recent exposé she wrote in the Courier journal investigating the growing problem of drug addicted newborns. Hospitalizations for addicted newborns rose from 29 in 2000 to 730 last year. A Journal of the American Medical Association study indicated that hospitalizations nationally rose about 330 percent from 2000 to 2009. She recently visited the University of Louisville hospital neonatal intensive care unit and discovered that more than half of the 16 babies were suffering from neonatal abstinence syndrome. According to the hospital’s statistics, 132 newborns have been treated for addiction to opioids or narcotics. The UK Medical Center reported seeing 90 to 100 addicted babies per year, with Kosair Children’s Hospital caring for 65 addicted babies in 2011. These are difficult visits, as the babies cry out in pain with ridged blotched skin and are going through the same withdrawal symptoms as adult addicts, including diarrhea, excessive or high pitched crying, excessive sucking, fever, and hyperactive reflexes. Financially, the national overall health costs for addicted newborns rose from $190 million in 2000 to $720 million in 2009, resulting from an average 16 day hospital stay costing $53,400 per infant, with Medicaid paying in eight of ten cases. While medical research is developing, early studies indicate that neurological behavior problems and attention deficit and hyperactivity disorders are more likely with these babies. State health officials have indicated solutions to this pill addiction need to be a priority but that answers are illusive due to ongoing funding issues and continued drug problems in society. However, drug treatment centers work.
In response to questions by Senator Stivers concerning how mothers became addicted, Ms. Ungar cited a number of factors, including initial marijuana or alcohol use during the early teenage years. Some mothers have indicated that their addictions came about as an illicit or illegal situation where they began buying pills on the street. None of the women she interviewed said that prostitution was a means to pay for their chemical dependence, but she was sure that it occurs. She said that many recovering addicts told her in her interviews that they were never asked by prescribers about their or their family’s addiction history.
Mary Burnett, Program Director of the Independence House Pregnant and Postpartum Women’s Residential Treatment Program, and Danny Jones, Executive Director, Cumberland River Comprehensive Care Center in Corbin, Kentucky, discussed their treatment programs for pregnant and postpartum women addicted to substances. Mr. Jones said that Independence House was started four years ago with a three year federal grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) for a residential treatment program for pregnant and postpartum women addicted to substances. The grant ended last October, but Independence House has managed to remain open. Medicaid pays for pregnant and postpartum women’s outpatient services but does not pay for residential services. There is a lack of funding, although the program was given a $250,000 grant by the Office of Local Development earlier in the year and is receiving support and assistance from First Lady Beshear. In developing the program, he worked with Dr. Robert Walker and the University of Kentucky. The committee was provided a report by Dr. Walker that contains information of what has been accomplished in the first three years of the program.
Ms. Burnett explained that the program begins with an initial 40 days of intensive treatment where the women do educational therapy groups all day--except for lunch breaks--using a holistic approach addressing substance abuse issues. Upon completion, if appropriate, the women remain at the facility long term until they deliver, as some residents do not have a place to go after treatment due to homelessness or continuing drug situations in their home environment. Others come from good homes and already have life skills and supportive families. Upon delivery, mother and child remain at the home for 30 days, with the mother having the responsibility of taking care of her baby and performing all the chores of Independence House. The program receives many referrals from the legal system, with authorities reluctant to release them from jail unless they go to treatment. Among the home’s residents, the average age of first use of drugs is seven with habitual use beginning as teenagers due to peer pressure, with residents coming from all walks of life, rich and poor. Out of fifteen women in the program, the primary drug of only one individual is alcohol, while the others are prescription drugs. She has taken a survey of the women asking such questions as to what lengths they would go to obtain drugs, where they got them, or how much was paid for the drugs, and she determined that individuals who sell the pills see it as a business endeavor. They go out of out-of-state to obtain the pills. The new laws and regulations have decreased the number of pills on the street, and medical professionals have become more cautious in their prescribing, although persons crossing state lines remain problematic. Ms. Burnett invited the committee to tour the Independence House and talk with residents.
Chair Tilley referred committee members to a letter in the meeting packets from the law firm of Stoll Kenon Ogden regarding Dr. Ricky Collis and Dr. Dean Collis and the regulations concerning licensure of pain management facilities.
Misconceptions Regarding House Bill 1 and its Associated Regulations
Chair Tilley noted the summary of common misconceptions contained in member packets. Stephanie Hold, Assistant Director, Office of Inspector General, Cabinet for Health and Family Services, which oversees the KASPER system, and Mike Rodman, Executive Director, Kentucky Board of Medical Licensure (KBML), discussed the misconceptions regarding House Bill 1 and associated regulations.
Ms. Hold indicated that the Inspector General’s Office had compiled the list from actual calls and issues that have arisen that have been addressed in the office as well as from the KASPER Help Desk. There had been tremendous support and input from the stakeholder meetings. Mr. Rodman said that the KBML had also been meeting with stakeholders such as the Kentucky Medical Association, the Kentucky Hospital Association, Lexington Clinic, and others that have identified issues and offered solutions. She stated that technical staff has been increased to accommodate the operation of KASPER 24/7 with monitors in place and that this has been greatly improved with the number of down hours decreasing from 29 in July to two in September. Patient consent forms are not required for a provider to request a KASPER report. A KASPER report can be placed in a patient’s medical record and discussed by the physician with the patient. Practitioners with a valid Drug Enforcement Administration license must register with KASPER, although they may not have the need to write a prescription for a controlled substance. If a practitioner has an office out-of-state and treats patients in that state, the practitioner must follow the law and guidelines in that state.
Senator Stivers said the committee was concerned about the advice being given to physicians, and that a doctor had previously testified that he could not write a narcotic prescription unless he sent the patient or individual to have a urine test. The doctor indicated that his lawyer had advised him not to write the prescription. He said the regulation clearly states that a urine test only applies after 90 days of prescription. Mr. Rodman noted that the interval after a urine drug test is another question the board receives, and that a urine test is not required for initial prescribing but only after 90 days. Random intervals are required thereafter as determined by the physician. Mr. Rodman indicated that there is nothing in House Bill 1 or the regulations that prohibits a physician from prescribing controlled substances.
In response to a question by Senator Jones concerning the confusion in the medical community regarding controlled substances how they are reflected in the regulation, Mr. Rodman stated there is confusion because there are standards contained in statute and standards in the regulation, and physicians are accustomed to advisory language rather than regulatory language.
In response to questions by Representative Belcher, Mr. Rodman said that it is not true that emergency rooms can prescribe pain medication only for broken bones or chest pains, nor is it true that a physician can prescribe only one round of pain medication with no refills. He also said that ADD and ADHD medication are Schedule II controlled substances, and that comments from pediatricians and families concerning these medications may need to be addressed by the legislature. To prescribe these drugs, a KASPER report is needed with a monthly visit upon initial prescription to make sure the amount was appropriate, but thereafter it would be up to the physician. Mr. Rodman pointed out that there is flexibility in the board’s regulations.
In response to a question by Representative Gregory as to where individuals could be referred for addressing these misconceptions, Mr. Rodman indicated that identified misconceptions will be posted and available on the KBML website. Constituents can also call KBML.
The Governor’s Office Stakeholder Regulatory Outreach Activities
Kate Wood Foster discussed the Governor’s convening of a roundtable workgroup consisting of regulatory board and stakeholder representatives, which had had three previous meetings. The Governor fully supports House Bill 1. The administration has taken the position that House Bill 1 requires more deliberate and conscientious decisions in prescribing between the patient and prescriber. Comments have been requested from stakeholders in three areas: interpretation issues, recommended regulatory suggestions, and statutory changes. KBML and other licensure boards are working on refinements and expect those to be more public in the next few weeks. The boards will continue to receive comments as to whether the refinements will address their concerns. As an example, one recommendation has been for institutional accounts for hospitals and long-term care facilities that will make it easier for those institutions to utilize KASPER. The roundtable group will return comments to the stakeholders by the end of September and will be continuing its meetings with the groups.
The meeting adjourned at 12:50 p.m.