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Board seeks comment on rule changes to require controlled substances CME

 Comments on this article:

I have been in practice for many years and have had to keep a DEA license to maintain hospital privileges even though I have never had to use it.  Requiring someone like me to do this just seems to be taking things to the extreme and for me to spend 3 hours doing this even makes it worse. Why don’t you try making this voluntary for a few years and let the practicing physicians vote on it.

By John Faris on Feb 09, 2016 at 10:57am

Having recently transferred to NC from Vermont, a state with epidemic levels of opioid abuse (mostly from diverted prescription medications), this rule change is timely.  Vermont has introduced this requirement to it’s licensing process and it has not been especially onerous.  As the source of these wayward medications come from a variety of specialties, and since patient education opportunities may arise even in specialities that may not be involved in prescribing controlled substances, this universal change is reasonable.  Communities facing opioid addiction crises struggle to adequately confront the problem for a multitude of reasons, and preventing the problem would be far superior.  My strong recommendation, however, would be that the board provide easy access to acceptable courses relevant to several specialties.  Having web-links to free and effective resources readily available through the NCMB website would greatly reduce the barriers to clinicians successfully fulfilling such a requirement.

By John DiMichele on Feb 09, 2016 at 12:03pm

I prescribe opiates for post-op pain maybe once or twice a year.  This would be a zero value and onerous requirement.

Further, do you have any evidence that there is a correlation between taking this type of CME and improved prescribing practices?

Opiate prescribing in NC either originates in pill mills, or is driven by Press Gainey patient satisfaction scores.  If you want to cut down on inappropriate prescribing, motivate major hospital systems to acknowledge drug seeking and remove satisfaction scores submitted by drug seekers from the metrics used to reward or punish providers.

By Sandra Brown on Feb 09, 2016 at 12:17pm

This is a ridiculous general requirement.  I have sent an email to the link above and encourage one and all to do so.

By Celia Entwistle, MD on Feb 09, 2016 at 12:22pm

As a child psychiatrist, I prescribe CIIs much; however, I do not prescribe ANY opioids or practice chronic pain management. I would hope that whatever course we must take would be practical and useful and not just to fill a requirement.  Having a clinician who NEVER prescribes a certain medication like an opioid take a course every year on controlled substances which centers on narcotics and chronic pain management isn’t going to benefit some of us; however, making the course more global so that it hits the highlights and not overly centered on one treatment area or medication would. Please make it useful for ALL of us!

By Anne-Marie Turnier on Feb 09, 2016 at 1:24pm

Ditto on the comments of Dr. Faris.  As a pathologist I have a DEA number (used as a doctor ID number by some managed care companies) but never write for controlled substances.  South Carolina has a controlled substance education requirement but the state provided the education material and test which made it easy for doctors such as myself to comply.

By Robert D Johnson MD on Feb 09, 2016 at 1:28pm

While I understand many objections to this requirement for physicians & other practitioners who do not prescribe opioids on a regular basis (if at all), it is only 5% of the 60 hour total. However, Dr Johnson may have the best idea if the board plans on proceeding with this motion.

By Kirsten Bray, MD, MPH on Feb 09, 2016 at 1:45pm

I think the board should provide a free online course that contains the specific content they want covered. I think that course should be adequately covered in a 1 hour format that can be completed yearly.

By Michael Bridges, MD on Feb 09, 2016 at 1:58pm

I had to do this for Tennessee and gratefully SC accepted it for their requirement. Hopefully NC will do the same so we don’t have to reinvent the wheel for every state. Would be better for the state or federal government to identify offenders and revoke their DEA number. We all seem to have to pay for the offenders. You can’t prescribe if the number is pulled. Problem solved.!

By Thomas V Bolling MD on Feb 09, 2016 at 4:22pm

The training is useless unless ancillary staff and hospitals are cooperative with refusal of narcotic requests.
When doing night hospitalist calls I get a slew of requests for narcotics between start of shift and 1 am. If you refuse you get called multiple times between 1 am and 6 am thanks to Press Gainey. Hospitals refuse to allow IV acetaminophen or Lidoderm patches “because of cost”. Patients rarely say they are “allergic” to acetaminophen iv because it negates other po narcotics. Hospital ERs have a vested interest in patients presenting multiple times for narcotics, since it bloats the ER visits.
So the training has to be all around. Furthermore those on excessive narcotics should not be driving. Just linking the driver’s license to the number of narcotics will go a long way in curbing abuse.

By Divis Khaira on Feb 09, 2016 at 8:45pm

There is no need for extra education on medical prescribing of opiates. They are clearly prescribed as needed by responsible physicians.
What results more often now, is that those patients who need them cannot receive them because of strict prescribing practices—from one who works in a university setting. The abuses arise outside of the physicians pervue, and thus to reiterate some of the other comments… It would be wiser to do NOTHING further with respect to the NCMB. It is needless regulation and burdensome on physicians. We know how, why, and when to prescribe opiates, whether inpatient or outpatient.
If one is concerned about abuse of opiates simply control their distribution. If that’s the goal, Only allow 3, 5, 7 days prescription at a time. That would make more sense. However, it will not change outcomes. Where is the evidence that regulation or more education (than we already have) makes opiate abuse any less? 
Fentanyl is now being mass produced by drug cartels along with heroin. Thus it seems senseless to abuse physicians with more requirements. Please allow us to practice responsible medicine. If we elect to take CME that includes opiate education then let it be. To mandate it seems an err in good judgement.

By Jason L Huffman,MD on Feb 09, 2016 at 9:54pm

The state should provide the necessary CME online and for free to make compliance easy and accessible to all physicians.  The current nebulous requirement is difficult to meet for physicians not involved in direct patient care.

By Myrosia Mitchell, MD on Feb 10, 2016 at 5:00am

From the Forum editor:

Thanks to everyone who has taken the time to provide comments. Keep them coming and don’t forget to send an email to .(JavaScript must be enabled to view this email address) to participate in the formal comment process.

I wanted to clarify a couple of points about the draft rule changes:

1. A number of licensees have indicated that they do not prescribe controlled substances and object to a rule that would require them to obtain CME in controlled substances prescribing. Please note that the rules would apply only to individuals who have prescribed controlled drugs. If you do not prescribe any controlled drugs, you would not need to complete CME on the topic. However, if you prescribed any controlled drugs (even a single prescription)during the previous CME cycle, you would be subject to the requirement. Please note that the requirement applies to controlled substances generally rather than opiates specifically.

2. Some commenters have raised questions about the specific types of CME courses that will be needed to satisfy the requirement. The draft rule is deliberately broad in this regard. Many, many existing free and low cost CME courses in controlled substances prescribing will satisfy the new requirement.

By Jean Fisher Brinkley on Feb 10, 2016 at 2:32pm

Three hours per cycle over the long run seems a bit excessive, since this is for many just an issue of awareness . Could you accomplish the education goal with one hour?
Also, could the state provide a free cme module that targets what we need to know?
My main general concern with the whole initiative is that it ends up discouraging providers of occasional prescriptions, leaving patients in unnecessary pain and overwhelming pain clinics.

By S Ted Shaikewitz on Feb 11, 2016 at 3:44pm

One of the reasons I love practicing in North Carolina is that the license renewal and upkeep is pretty straightforward and easy.  I would not like this new requirement.  I agree with the others posting that it is a problem of a few providers and now we all have to suffer.  I also agree with those posting about narcotic use being related to Press Ganey scores.  It is well documented that high patient satisfaction leads to increased mortality, higher cost of care, and increased antibiotic/pain medication usage.

By Michelle Perno PA-C on Feb 15, 2016 at 4:24pm

I consider requiring CMEs for physicians who prescribe controlled substances only appropriate, but as many of the others have commented I think the board needs to have some free CMEs in place or have other materials made available. As a physician who prescribe controlled substances including stimulants for children I am very aware that there is a glut of controlled substances being prescribed and abused, many times prescribed inappropriately by the emergency room physicians or more commonly dentists.
I run a Suboxone clinic and many of the patient’s attribute their opiate use to indiscriminate prescription habits by some physicians and dentists.

I agree that Press Gainey is another reason that ED physicians ending up prescribing controlled substances when there is no need. Remember that 70% of controlled substances prescribed in the whole world is being consumed by Americans. I think,  considering pain as the 5th vital sign insisting that a patient’s pain level be assessed frequently is the biggest nonsense especially for drug seekers.

By Matthew Joseph M.D. on Feb 23, 2016 at 1:10pm

Throughout my 40 years of general practice in NC it has been typical of the Medical Board, when pressured by politicians or the press, to throw “make work” assignments at the problem.  Making front line physicians jump through more hoops to retain their license to practice is the result.  This proposal is another example of poor policy.  Instead, it would be far better for the Board to realize that the real problem here is the disastrous drug prohibition laws in the USA, laws based on religious dogma, NOT medical or social science. Drug prohibition is making millions for quasi-legitimate “pain clinics,” while inserting a huge wedge into the doctor-patient relationship. Doctors do not trust patients in pain, and patients do not trust doctors to properly care for their pain. The Board should take a definitive stand against drug prohibition, help the working physician deal with the ever-changing rules of prohibition, and help restore the doctor-patient relationship by discouraging drug testing, pill counts, and other ignominious practices that drive legitimate patients into black market heroin and other dangerous drug sources. Maybe then patients will trust us again and we can truly help them, unhindered by having to pay lip service to the very unhealthy policy of drug prohibition.  Perhaps the Board should create a CME course on the effect of drug prohibition on medical practice and how to lessen its impact on the doctor-patient relationship.  Now that is a CME course I would gladly take!

By James Stewart Campbell, MD. on Feb 23, 2016 at 1:31pm

For physicians who do not prescribe narcotics, some states have waivers for the physicians to sign.  Suggest implementing that rather than more CME requirements.

By Richard Abramowitz on Feb 23, 2016 at 1:36pm

I somehow doubt that this is an evidence based measure.

Three hours of this education is three hours less education of greater value to the physician.

By J Byron Walthall, MD, MPH on Feb 23, 2016 at 3:14pm

I agree that this should not be across the board and should be limited to those who are actively seeing patients and prescribing narcotics.  Checking a box (yes or no) on the application asking if the physician has prescribed narcotics in the preceding three years could suffice and if the answer is yes, demonstrating 2 or 3 CME hours dedicated to narcotic issues may be appropriate.

By Kevin Good, M.D. on Feb 23, 2016 at 4:03pm

The root cause of narcotic abuse seldom lies with physicians, and when it does, the NCMB has a process for dealing with it. Making this new rule seems totally unrelated to the issue, either in cause or effect. As an anesthesiologist I must have a DEA certificate. I can easily claim that my usual CME contains at least 3 hours of material related to narcotic use. I am aware that diversion is a caution and that CMS already addresses how hospitals(pharmacy, medical staff and administrative staff)must address narcotic accounting. The rules are already in place. To me this is a medical staff or, at best, a Medical Society discussion to simply remind those who are on the front lines to be aware and beware.

Similar “education” rules in Vermont, Tennessee, and South Carolina have had little if any provable effect on this social issue. Why would North Carolina want to institute a similar folly?  I would venture that the overwhelming number of physicians who prescribe narcotics, along with those who don’t, already know how to do this, and are aware of the potential physical and social consequences.“More education”  is not the answer.Thank you.

By John D Bell on Feb 24, 2016 at 6:53am

As an ophthalmologist, I use pain meds very infrequently.  Never in the context of chronic pain management.  CME on chronic pain management/opoid prescribing would not bring useful education to my practice nor any ophthalmologist I know.

By James A Bryan III on Feb 24, 2016 at 2:15pm

My emergency medicine literature has tremendous support for the value of using the controlled substances reporting system in addition to this much needed CME.  The mortality data now is so clear that I think the science shows that mandatory use of the database would have a dramatic impact towards improving public health.  Most everyone has dictation software these days, I can review a profile in under thirty seconds using website commands.

By Patrick Burnside on Feb 24, 2016 at 3:52pm

I am also licensed in SC, where 1 hour of this CME is required and offered (free) by the state. 

If the NCMB feels compelled to “just do something”, this approach is relatively painless and less intrusive than the proposal.

By J Byron Walthall, MD, MPH on Feb 25, 2016 at 8:12am

It is logical to believe that mandatory CME addresses on-going problem areas where physicians seemingly lack awareness.
Is this true with controlled substances in North Carolina?
If this mandate is simply to copy-cat other States, then the rational for imposing this upon the physicians of NC is onerous and irrational.
I do engage patients specifically for management of their pain. How often do I prescribe controlled substances? 1 to 2 times a year?
I have practiced in other States. Florida had some issue with this topic and I believe it helped shift consciousness among physicians in Florida. I sat in on many such mandatory courses for my Florida license. But, after several years, did this mandate make a positive difference? No. Yet, the mandate continues ad nauseum. Why is there never a termination date to mandated education? Where has common sense fled?
Since the NCMB actively seeks to establish a relationship with the physicians of NC, then mandate that the NCMB engage itself to take the time and absorb the expense required to let us all know what REAL issues have developed across the State. Board members should regularly attend CME programs and share concerns rather than create more regulation of what we all have to do every CME cycle.
If it is actually a matter of ignorance on the part of newly licensed physicians coming out of residency programs who do not seem to know the signs of addiction and drug abuse, then require new doctors to take a list of courses to make up for the deficiencies in their education. Reach out to the Directors of Medical Education in the hospitals.
After 31 years, I have no illusions left about the behavior of drug addicts or the tricks patients try to play in order to get controlled substances in a legal way rather than resort to buying them on the street from a drug dealer.
In conclusion, if there is a REAL issue across the State, then mandate; if there is NO REAL issue, then exercise restraint and the temptation to copy some other State. If mandatory steps are deemed to be necessary, then please set a termination date as well. Thank you for your time and attention to this opinion.

By Eric J Rentz, DO, CNMO, COMM on Feb 25, 2016 at 12:00pm