…Michigan continues to be the top among states enacting policies promoting delivery of effective pain management…
The “State” of Pain in Michigan
Michigan has policies recognizing that pain management—including the use of controlled substances—is part of quality medical practice. State regulations require healthcare facilities, such as hospitals, nursing homes, and hospices, to make pain assessment and treatment an expected element of patient care. The state has established the Michigan Automated Prescription System—a prescription monitoring program—recognizing the need to reduce abuse and diversion* while making sure medication is available for patient care.
*Diversion: The use of drugs for other than medically necessary or legal purposes or for non-medical or not medically authorized purposes. It involves, but is not limited to, physicians who sell prescriptions to drug dealers or abusers; pharmacists who falsify records and subsequently sell the drugs; employees who steal from inventory and falsify orders to cover illicit sales; prescription forgers; and individuals who commit armed robbery of pharmacies and drug distributors.
Since the 1990s the Michigan legislature has passed a body of legislation intended to improve access to pain management services, enhance the quality of care available for Michigan citizens, and provide direction to prescribers on the use of opiates without fear of prosecution. This legislation has been regularly reviewed and updated to address the changing face of pain management and the expanding opioid crisis. This legislation includes:
- Lengthening the period of time to fill Schedule 2 prescriptions, and providing for prescriptions to be partly filled incrementally for terminally ill patients (Section 333.7333 amended March 27, 2018—changes designed to help deal with opioid crisis but still help patients)
- Requiring healthcare professionals to complete continuing education in pain and symptom management as a condition of relicensure (Section 333.16204)
- Creating the Advisory Committee on Pain and Symptom Management (Section 333.16204a) (now part of Prescription Drug and Opioid Abuse Commission)
- Providing legislative support to address pain and symptom management issues and enacting legislation that supports the treatment of pain (Section 333.16204b)
- Providing legislative support for the use of controlled substances as being appropriate in the medical treatment of pain and enabling regulatory agencies to prevent the abuse and illegal diversion of controlled substances by creating an electronic monitoring system (Section 333.16204c)
- Requiring the department of consumer and industry services, in consultation with the department of community health, to develop, publish, and distribute an informational booklet on pain to include specific content. The department, in conjunction with the controlled substances advisory commission, is required to develop and conduct an educational program for health professionals that covers specific topics (Section 333.16204d)
- Addressing “rights and responsibilities of patients or residents” (Section 333.20201, amended in 2016 and 2017) (LARA, 2018a)
Prescription Drug and Opioid Abuse Commission
In 1998 Michigan established the Advisory Committee on Pain and Symptom Management (ACPSM) to address issues pertaining to pain and its management throughout the state. In 2000, ACPSM identified their areas of greatest concern, to include lack of education and training for healthcare professionals; lack of information throughout all levels of the public; concerns around Schedule II drugs (misinformation and fear of addiction); lack of availability; reluctance to prescribe for fear of disciplinary action; and patient difficulty in proving disability to insurers.
Over the next 16 years the ACPSM maintained evolving goals and was able to distribute pain management resources for healthcare providers; administer physician and public surveys to assess pain management knowledge, attitudes, and practices; implement a public service announcement campaign for the public; complete work on the Model Core Curricula on Pain Management for medical schools; and develop a pain management tool kit for both healthcare professionals and the public.
Along the way, Michigan was recognized as being at the forefront of dealing with pain management issues. In 2001 it was one of the first states to remove the term “intractable pain” from its statute, making its provisions apply to pain in general. In 2013 Michigan was one of only fifteen states awarded an “A” grade by the University of Wisconsin Pain and Policy Studies Group (PPSG) for its efforts to establish balanced pain policies. The state had maintained that grade since the PPSG began report cards in 2006 (PPSG, 2013a,b).
In 2016 the Michigan Advisory Committee on Pain and Symptom Management was abolished by executive order of the governor when he folded “all of the authority, powers, duties, functions, responsibilities, and records of the ACPSM, the Controlled Substances Advisory Commission, and the Prescription Drug and Opioid Abuse Task Force into the newly created Prescription Drug and Opioid Abuse Commission. The governor noted that the ACPSM had accomplished its original goals and that action was now needed to “combat the severe and complex prescription drug abuse epidemic that faces [the] state” (Executive Order 2016-15; LARA, 2013b,c; MDHHS, 2009).
Michigan’s Automated Prescription System
Of Michigan’s approximately 60,000 prescribers, about 30 percent as of mid-January were registered and using the MAPS system.
Traverse City Business News, March 2018
The Michigan Automated Prescription System (MAPS) is the prescription monitoring program for the State of Michigan. MAPS is used to track controlled substances, schedules II to V drugs. It is a tool used by prescribers and dispensers to assess patient risk and it is also used to prevent drug abuse and diversion at the prescriber, pharmacy, and patient levels. On April 4, 2017 the State of Michigan replaced the MAPS platform with PMP AWARxE (LARA, 2018c).
In its 2016 Prescription Drug Overdose Status Report for Michigan, the CDC notes that opioid pain relievers, such as oxycodone, hydrocodone, fentanyl, and hydromorphone, are responsible for three-fourths of all prescription drug overdose deaths and caused more than 16,200 deaths in the United States in 2013. Nationally, deaths involving opioids had quadrupled since 1999.The sharp rise in prescription opioid overdose deaths closely parallels an equally sharp increase in the prescribing of these drugs. Opioid pain reliever sales in the United States quadrupled from 1999 to 2010.
The severity of the epidemic varies widely across U.S. states and regions, and in Michigan the drug overdose death rate for 2013 (15.9 per 100,000 population) exceeded the national rate (13.8 per 100,000 population) (CDC, 2016).
CDC and other agencies have worked to identify and evaluate interventions to reduce prescription opioid overdose deaths, and the 2016 report focused on two key policies concerning state prescription drug monitoring programs (PDMPs), the electronic systems that track the dispensing of controlled substances to patients. The two policies supported by emerging evidence, expert consensus, and extensive review of the primary drivers of the epidemic are:
- Requiring timely data submission to the PDMP
- Requiring universal PDMP use by prescribers
PDMPs are promising tools, allowing healthcare providers to see patients’ prescription histories so as to inform their prescribing decisions; however, a PDMP is useful to healthcare providers only if they check the system before prescribing. The CDC noted that, as of October 31, 2105, Michigan required dispensing data be submitted to the PDMP within 24 hours but did not require prescribers to consult the PDMP before initially prescribing opioids (CDC, 2016).
CDC believes these are only key pieces in a much larger, multi-sector approach to preventing prescription drug abuse and overdose. Other important PDMP practices suggested for states included making PDMPs easy to use and access; linking them to electronic health records systems already in place; and enabling various tracking capabilities. In addition, the Department of Health and Human Services (DHHS) supports, among other things, expanding the use and distribution of naloxone to reverse an overdose (CDC, 2016).
Going into effect in Michigan in March, June, and July 2018 are a number of new laws addressing some of these very issues. Under the new laws, prescribers of schedules II to V controlled substances must have a bona fide relationship with the patient, will be required to check MAPS prior to writing a prescription for more than a 3-day supply of a controlled substance, and will have to obtain more information from patients and provide or arrange for followup care. The laws contain other details about the writing of prescriptions and specifies penalties for failure to comply (MI Executive Office, 2017; Kraus, 2018; Lane, 2018).
In addition, in 2016 the use of naloxone was expanded when the state issued a standing order for naloxone for pharmacies, allowing them to distribute naloxone without a specific prescription, thus making it more readily available to law enforcement officers, first responders, healthcare professionals, and ordinary citizens (MI EO, 2017).
Michigan Medical Marihuana Program
The Michigan Medical Marihuana Program (MMMP) is a state registry program within the Bureau of Medical Marihuana Regulation at the Michigan Department of Licensing and Regulatory Affairs. The MMMP administers the Medical Marihuana Act, passed by Michigan voters in 2008 (LARA, 2018d). (The spelling of marihuana within the act is consistent with its spelling in the Michigan Public Health Code.)
State law allows medical use of marijuana under specified conditions, although the law does not protect marijuana plants from seizure or protect individuals from prosecution if the federal government chooses to take action against patients or caregivers under the federal Controlled Substances Act.
In Michigan, patients must have a physician’s recommendation to be eligible to use medical marijuana legally. A qualifying, debilitating medical condition must be listed on the attending physician’s statement. Severe and chronic pain and severe and persistent muscle spasms are among the conditions approved under the state’s medical marijuana program (MCL 333.26421-333.26430).
In September 2016 three new laws went into effect that created a licensing and regulatory framework for medical marijuana. Changes included amendments and clarifications of the original 2008 bill and enactment of the Medical Marihuana Facilities Licensing Act whose framework was implemented in December 2017. More information is available on their website at: http://www.michigan.gov/lara/0,4601,7-154-78089---,00.html (MI Senate Fiscal Agency, 2016).
Joint Commission Pain Management Standards
In early 2016 the Joint Commission embarked on a revision of its accreditation standards on pain management that involved a technical advisory panel, learning visits at hospitals, and a standards review panel (Joint Commission, 2018a). On January 1, 2018 the Joint Commission released its new standards for hospitals, which require they:
- Establish a clinical leadership team
- Actively engage medical staff and hospital leadership in improving pain assessment and management, including strategies to decrease opioid use and minimize risks associated with opioid use
- Provide at least one non-pharmacologic pain treatment modality
- Facilitate access to prescription drug monitoring programs
- Improve pain assessment by concentrating more on how pain is affecting patients’ physical function
- Engage patients in treatment decisions about their pain management
- Address patient education and engagement, including storage and disposal of opioids to prevent these medications from being stolen or misused by others
- Facilitate referral of patients addicted to opioids to treatment programs (JC, 2018)
Integral to both the original guidelines established in 2001 and the new ones released in 2018 are the following:
- Hospitals must have a process to address pain assessment when necessary.
- Hospitals must have a process upon clinical determination to either treat patient pain or refer patients for pain treatment, which may include nonpharmacologic or pharmacologic approaches.
- Hospitals must have a process for the clinician to reassess and respond to a patient’s pain based on reassessment criteria (JC, 2018)
More information about the history of the standards and a discussion of some myths that arose about the standards can be found on the Joint Commission website at: https://www.jointcommission.org. Specifically, the Joint Commission “does not endorse pain as a vital sign,” “has never endorsed use of pain ‘satisfaction scores’ for…other than an organization’s internal quality improvement,” has “never required the use of drugs to manage a patient’s pain,” and has “never required organizations to mandate that clinicians measure pain on a numerical scale or treat patients to ‘zero pain’” (JC, 2018b).