Posts Tagged health

Alabama Opioid Overdose and Addiction Council Issues Formal Report

Alabama Opioid Overdose and Addiction Council Issues Formal Report

MONTGOMERY — Co-chairs of the Alabama Opioid Overdose and Addiction Council, Attorney General Steve Marshall, Commissioner Lynn Beshear of the Alabama Department of Mental Health, and Acting State Health Officer Dr. Scott Harris, announced the issuance of the Council’s formal report of its findings.

The Council was created in August 2017 by an executive order of Gov. Kay Ivey, and tasked with developing a strategic plan “that establishes recommendations for policy, regulatory and legislative actions to address the overdose crisis in Alabama.” The Council and its subcommittees have met several times since then, and have submitted its formal plan to the Governor.

“Families, health care professionals and government officials at every level seek real solutions concerning the impact the opioid crisis has on Alabamians,” said Commissioner Beshear. “The next step in our effort will convene the Implementation Team of the Alabama Opioid Overdose and Addiction Council, as well as quarterly meetings of the full council to implement researched opportunities. We believe the work of the council offers preventive strategies, intervention and treatment options, and a community response that addresses this dire need. Working together, it will require organized sustained engagement of citizens and government with healthcare professionals.”

Dr. Harris said, “Opioid addiction and abuse is a tremendous problem that affects Alabama in many different ways. Our hospitals, schools, churches and prisons are all struggling to deal with the problems caused by addiction and by increasing numbers of opioid deaths. The comprehensive action plan the council has developed includes improvements to the Alabama Prescription Drug Monitoring Program that make it easier for prescribers to identify opioid abuse and to motivate abusers to find help for themselves, their families and communities. We are encouraged that the council has offered strategies that have the potential to reverse this crisis that affects so many Alabamians, and appreciate the input of so many individuals to find effective solutions.”

“After working with the dedicated people who have given so much of their time and concern to this council and its subcommittees, I am heartened that we can make progress to fight the terrible blight of opioid abuse in Alabama,” Attorney General Marshall said. “I want to thank Gov. Ivey for bringing us together in a commitment to search for solutions and work toward implementing them. I have been proud to serve with Commissioner Beshear and Dr. Harris in this vital endeavor, and I am grateful to all the members of this Council and its subcommittees for their outstanding achievement in bringing forth these valuable recommendations.”

The Council’s report presents a four-pronged action plan to address prevention of opioid misuse, intervention within the law enforcement and justice systems, treatment of those with opioid use disorders, and community response that engages the people of Alabama in finding solutions at a local level.

Some of the major findings are summarized below:


  • Improve and modernize the Alabama Prescription Drug Monitoring Program so that it will be more user-friendly, and more prescribers will participate and be better informed; the Governor is requested to support a legislative appropriation of $1.1 million to the Alabama Department of Public Health for this;
  • Strengthen prescription data and research capabilities and create a unique identifier for each individual patient;
  • Promote efforts to educate current and future prescribers, better implement current guidelines, adopt guidelines specific to opioid prescribing and impose mandatory opioid prescribing education;
  • Create a website and messaging campaign to reduce the stigma of opioid addiction; and implement an outreach program to teach young people the dangers and to avoid opioids;
  • Create a website and social media campaign to motivate opioid abusers to seek help and to effectively connect them and family members with ways to get help; and
  • Create a partnership for the Alabama Department of Mental Health to provide training about addiction to law enforcement agencies and the judiciary.


  • Advocate legislation in the 2018 session to specifically prohibit trafficking in fentanyl and carfentanil, which is particularly important because vastly smaller amounts of these than other opioids can be deadly; for example, a lethal dose of fentanyl is 1,000 times less than that of heroin, and the threshold amounts for the crimes of trafficking in fentanyl and carfentanil would better be measured in micrograms; and
  • As overdoses are 50 times greater for those leaving incarceration or other enforced abstinence, establish a process for the Department of Mental Health to reduce the stigma of medication-assisted treatment, and begin a pilot program by the Department of Corrections in partnership with the Board of Pardons and Paroles to use naloxone, counseling and life skills to help released inmates remain drug free.


  • Promote adequate funding for treatment services and recovery support;
  • Establish collaboration between the Department of Mental Health and recovery support providers to increase access;
  • Support creating two addiction medicine fellowships to train Alabama physicians to recognize and treat substance abuse;
  • Expand access and target effective treatment and prevention programs to areas where there is greater need; and
  • Improve education of professionals through continuing education for licensing and expand postsecondary and graduate curriculums.


  • Increase access to naloxone, and maintain a list of participating pharmacies;
  • Prioritize naloxone to law enforcement and for distribution in areas of greatest need;
  • Provide naloxone training for first-responders;
  • Encourage prescribing naloxone for high-risk patients;
  • Have a Community Anti-Drug Coalitions of America program in each judicial circuit and work toward having them at municipal levels;
  • Engage employers, businesses, higher education and private-sector in a network to get resources into communities;
  • Encourage having a Stepping Up Initiative in each county to work with the criminal justice system regarding incarceration of those with mental health problems; and
  • Develop ways to provide service to veterans regarding opioid issues.

A copy of the Council’s report is available for download here.

Posted in: Opioid

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Possible Government Shutdown with CHIP in the Balance?

Possible Government Shutdown with CHIP in the Balance?

Friday, Jan. 19: Government shutdowns are rare, with the last shutdown in 2013 that lasted 17 days. Even though the U.S. House passed legislation that would fund CHIP for six more years, the Senate may not approve the measure. In fact, Congress is facing the possibility of another government shutdown, which could leave health care for more than 9 million children caught in the middle of the fray.

Late Thursday evening the House passed legislation 230-197 to keep the government open for business through Feb. 16. The measure now faces a steep battle with Senate lawmakers as time ticks down to midnight to avoid a full shutdown. It’s been widely reported that conservatives in the House Freedom Caucus largely backed the measure even after being locked in debate with the White House and GOP leaders over concerns of military funding and immigration reform. The legislation also includes a measure to renew the Children’s Health Insurance Program for another six years.

Now with the legislation in the Senate it faces steep opposition by Democrats who appear intent on securing concessions that would, among other things, protect from deportation young immigrants brought to the country illegally as children, increase domestic spending, aid Puerto Rico and bolster the government’s response to the opioid epidemic. Senate Democrats have publicly decried the GOP does not have the votes necessary to pass the legislation.

According to the Georgetown University Center for Children and Families, there are now 11 states in danger of running out of CHIP money by the end of February…a number that will double by the end of March. Complicating matters even more, the Congressional Budget Office has stated that extending CHIP funding for 10 years would save the federal government $6 billion whereas initial estimates were that renewing CHIP funding would cost $8.2 billion.

The CBO adjustment stems from changes Congress has made to the Affordable Care Act making private health insurance more expensive and an increase in federal spending on subsidies for that coverage makes CHIP a better deal in comparison.

A government shutdown means more to medicine than health care for America’s children. It will affect the Centers for Disease Control and Prevention during one of the most dangerous flu seasons in recent history. The National Institutes of Health will be forced to stop enrolling patients in clinical trials. Drug approvals by the Food and Drug Administration will come to a complete stop.

The Medical Association is closely monitoring legislation pertaining to CHIP funding and will report any changes as they occur.

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New Research Shows Americans with Mental Illness use Opioids at Alarming Levels

New Research Shows Americans with Mental Illness use Opioids at Alarming Levels

More than half of all opioid medications distributed each year in the United States are prescribed to adults with mental illness — patients diagnosed with depression and anxiety — according to new research by Dartmouth-Hitchcock and the University of Michigan.

The study, published in the July issue of the Journal of the American Board of Family Medicine, is among the first to show the extent to which the population of Americans with mental illness use opioids.

In the setting of the U.S. opioid crisis, the authors warn this connection between mental illness and opioid prescribing is particularly concerning because mental illness is also a prominent risk factor for overdose and other adverse opioid-related outcomes.

“Adults with mental health disorders were more than twice as likely to receive an opioid prescription,” said Dr. Brian Sites, an anesthesiologist at Dartmouth-Hitchcock. This higher opioid use among those with mental illness persists across all key characteristics including cancer status and various levels of self-reported pain.

“Despite representing only 16 percent of the adult population, adults with mental health disorders receive more than half of all opioid prescriptions distributed each year in the United States,” said Matthew Davis of the University of Michigan, co-author of the study.

The study found among the 38.6 million Americans diagnosed with mental health disorders more than seven million (or 18 percent) are being prescribed opioids each year. In comparison, only 5 percent of adults without mental disorders are likely to use prescription opioids.

“Because of the vulnerable nature of patients with mental illness, such as their susceptibility for opioid dependency and abuse, this finding warrants urgent attention to determine if the risks associated with such prescribing are balanced with therapeutic benefits,” Sites warns. Sites noted because pain is a subjective phenomenon, “the presence of mental illness may influence the complex dynamic between patient, provider and health system that results in the decision to write an opioid prescription.”

Posted in: Opioid

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Alabama Physician Health Program Announces Reorganization

Alabama Physician Health Program Announces Reorganization

The Alabama Physician Health Program, the Medical Association’s confidential resource for physicians and other medical professionals with potentially impairing conditions or illnesses, recently announced a reorganization and new staff to better protect the health, safety and welfare of those it serves.

The APHP provides confidential consultation and support to physicians, physician’s assistants, residents and medical students facing concerns related to alcoholism, substance abuse, physical illness and behavioral or mental health issues. It monitors an average of 280 physicians in Alabama at any given time. These physicians, whether self-referred or mandated, many initially may be hesitant to come forward for help, soon learn the APHP is their best advocate. Now, the APHP has even more staff and physicians available to assist when medical professionals need help.



Robert C. Hunt, D.Min, ASAM, LPC

Medical Director

Sandra L. Frazier, M.D., FASAM

Associate Medical Directors

James H. Alford, M.D.

Daniel M. Avery, Jr., M.D., FACOG, FACS

Jill Billions, M.D., ABAM, FASAM

APHP Case Manager

Fay McDonnell

APHP Program Coordinator

Caro Louise Jehle

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Centreville Physician Receives National Recognition

Centreville Physician Receives National Recognition

john waitsCentreville physician John Waits was the only Alabama physician to be recognized by the National Organization of State Offices of Rural Health’s 2017 Community Stars Program. Dr. Waits was one of 31 honorees during the 2017 National Rural Health Day working tirelessly to improve, protect and advance health and wellness in our rural communities.

Dr. Waits is Chief Executive Officer and faculty physician at Cahaba Medical Care in Centreville and was nominated as a 2017 Community Star by Charles Lail of the Alabama Department of Public Health. Below is an excerpt of the information from the awards program:

“From the time we opened in 2004, we decided to never turn away a patient due to an inability to pay. We’ve held to our promise even when unemployment in the area went from 3 percent to 15 percent, and more patients found themselves without insurance.” The words of Dr. John Waits speak to the heart of why he is most deserving of recognition of an outstanding 2017 Community Star!

Dr. Waits is a practicing, board-certified Family Medicine/Obstetrician and leader in the field of innovative, rural health care. He serves as CEO of Cahaba Medical Care and is the Director of the Cahaba Family Medicine Residency Program. He also created Alabama’s only Teaching Health Center, which has a dually accredited family residency program within Cahaba Medical Care. He currently serves as the co-founder and CEO of Cahaba Medical Care Foundation, a Federally Qualified Health Center in rural Bibb County, Alabama.

Dr. Waits is particularly interested in healthcare policy as it relates to women and children (maternal and infant care), the rural poor, health care access, and the care of the uninsured and underinsured. Under his leadership, CMC’s mission to treat people in underserved communities regardless of insurance or financial status is steadfast. He believes that it is critically important to offer patients the highest quality care the team can provide, while also providing the most extensive scope of services possible.

Dr. Waits and the care CMC provides extend beyond the walls of their practice locations. CMC is very active in community service, giving weekend backpack meals to children in three of Bibb County’s schools, with plans underway to expand the program into neighboring Jefferson County. CMC is a ‘no restrictions’ community service organization in that they also provide support to a local food bank and a clothes closet for all those in need, patient or not.

Another notable area of his reach and community benefit results – CMC has expanded into mental health and nutrition, offering counselors and dietitians to community members in need. He and his loyal, equally dedicated team are motivated by the idea of investing in communities, working and partnering with others to try to make people healthier and places better.

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Metro Areas Increasingly Dominated by Single Insurance Companies

Metro Areas Increasingly Dominated by Single Insurance Companies

In an analysis of competition in health insurance markets across the U.S., a study conducted by the American Medical Association found that in 169 of 389 metropolitan areas (43 percent), a single health insurer had at least a 50 percent share of the market. This represents an eight percent increase in such markets over just two years. The finding comes from the newly released 2017 edition of the AMA’s Competition in Health Insurance: A Comprehensive Study of U.S. Markets, which examines market concentration in 2016.

High market concentration tends to lower competition among commercial health insurers. These markets become ripe for the exercise of health insurer market power, which harms patients by raising premiums above competitive levels.

The AMA study presents the most comprehensive data on the degree of competition in health insurance markets across the country, and is intended to help researchers, policymakers and regulators identify markets where consolidation among health insurers may cause anti-competitive harm to patients and the physicians who care for them.

“After years of largely unchallenged consolidation in the health insurance industry, a few recent attempts to consolidate have received closer scrutiny than in the past, including the proposed mergers of Anthem and Cigna, as well as Aetna and Humana,” said AMA President David O. Barbe, M.D. “Previous versions of the AMA study played a key role in efforts to block the proposed mega-mergers by helping federal and state antitrust regulators identify markets where those mergers would cause anti-competitive harm.”

The 2017 edition of AMA’s Competition in Health Insurance: A Comprehensive Study of U.S. Markets offers the largest and most complete picture of competition in health insurance markets for 389 metropolitan areas, as well as all 50 states and the District of Columbia. The study is based on 2016 data on commercial enrollment in fully and self-insured health maintenance organization (HMO), preferred provider organization (PPO), point-of-service (POS), public health exchange and consumer-driven health plans (CDHP).

In addition to assessing competition in the commercial health insurance market at large, the study also separately examines competition for the main plan types, including HMO, PPO, POS, and the exchanges.

The prospect of future consolidation in the health insurance industry should be viewed in the context of the lack of competition that already exists in most health insurance markets. According to the AMA’s latest study:

  • A significant absence of health insurer competition was found in 69 percent of metropolitan areas. These markets are rated “highly concentrated” based on federal guidelines used to assess the degree of competition in a market.
  • In 43 percent (169) of metropolitan areas, a single health insurer had at least a 50 percent share of the commercial health insurance market, compared to 40 percent (156) in 2014.
  • Anthem has a bigger geographic footprint than any other health insurance company in the United States. Anthem was the largest health insurer by market share in 82 of 389 metropolitan areas examined by the AMA. Health Care Service Corp. was second with a market share lead in 42 metropolitan areas, followed by UnitedHealth Group with a market share lead in 26 metropolitan areas.
  • The 10 states with the least competitive commercial health insurance markets were: 1. Alabama, 2. Delaware, 3. Hawaii, 4. South Carolina, 5. Louisiana, 6. Michigan, 7. Kentucky, 8. Vermont, 9. Alaska, and 10. Illinois.
  • The commercial health insurance market in 27 states became more concentrated between 2014 and 2016.
  • The 10 states that experienced the largest increase in market concentration between 2014 and 2016 were: 1. Kentucky, 2. Alaska, 3. South Carolina, 4. Mississippi, 5. South Dakota, 6.Oklahoma, 7. Vermont, 8. Arkansas, 9. Nevada and 10. New Mexico.

Competition in Health Insurance: A Comprehensive Study of U.S. Markets is free to AMA members. The study is also available to non-members. To order a copy, visit the online AMA Store, or call (800) 621-8335 and mention item number OP427117.

Editor’s Note: Credentialed members of the media can obtain a free copy of the AMA’s newest study on competition in the nation’s health insurance industry by contacting AMA Media & Editorial at: (312) 464-4430.

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Trump: Opioid Epidemic “Worst Drug Crisis” in U.S. History

Trump: Opioid Epidemic “Worst Drug Crisis” in U.S. History

President Trump called the opioid epidemic the “worst drug crisis” to strike the U.S. in its history while declaring a public health emergency – not a national emergency as promised earlier in the summer. According to the Centers for Disease Control and Prevention, more than 140 American die every day from an opioid overdose, which made President Trump’s announcement one of the most anticipated of the last few months yet not quite what health care advocates were expecting.

“Nobody has seen anything like this going on now. As Americans, we cannot allow this to continue,” Trump said at a White House ceremony. “It is time to liberate our communities from this scourge of drug addiction. … We can be the generation that ends the opioid epidemic. We can do it.”

There’s a legal distinction between a public health emergency, which the secretary of Health and Human Services can declare under the Public Health Services Act, and a presidential emergency under the Stafford Act or the National Emergencies Act. The President’s Opioid Commission recommended in July for a declaration of national emergency in order for the president to have more power to waive privacy laws and Medicaid regulations.

However, declaring a public health emergency, which can only last for 90 days and be renewed a number of times, demonstrates the complexity of an opioid crisis that continues to grow through an ever-evolving cycle of addiction, from prescription pain pills to illegal heroin to the lethality of fentanyl.

What the public health emergency won’t do is free up much federal funding. Acting Health and Human Services Secretary Eric Hargan will be given more room to loosen certain regulations that he otherwise would not be able to.

The declaration will expand access to telemedicine to better help those with an addiction in remote areas receive medications; allow for the shifting of resources within HIV/AIDS programs to help people eligible for those programs receive substance use disorder treatments; and more. It could spur a fight for funding in Congress, as Senate Democrats have introduced a bill to put $45 billion toward the epidemic. Many Republicans also back much more funding to combat the epidemic.

The opioid action is the first public health emergency with a nationwide scope since a year-long emergency to prepare for the H1N1 influenza virus in 2009 and 2010.

Posted in: Opioid

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Pres. Trump’s Executive Order Creates Confusion

Pres. Trump’s Executive Order Creates Confusion

Earlier this week, President Trump signed an executive order that could be a first step in dismantling the Affordable Care Act. About 20 health organizations have so far spoken out against the executive order arguing the action could weaken patient protections and destabilize the individual market.

President Trump’s executive order signed on Thursday, Oct. 12, does not implement any policies, but it does request federal agencies such as the Department of Health and Human Services and the Department of Labor to develop regulations to expand the use of association health plans, which allow small businesses to join forces to purchase health coverage together, as well as to expand the definition of short-term insurance, which typically offers less coverage and comes with higher out-of-pocket costs.

The order issues three primary directives to federal agencies:

  • Consider ways to expand access to association health plans, potentially allowing employers to purchase insurance across state lines.
  • Consider expanding coverage through short-term health insurance plans, which are not subject to the Affordable Care Act’s regulations such as minimum coverage requirements.
  • Consider changes to health reimbursement arrangements (HRAs) — employer-funded accounts that reimburse workers for healthcare expenses — to allow employers to make better use of them.

During a press conference, President Trump said expanding use of association health plans would increase competition and allow more small businesses to have the same purchasing options as larger employers. He said he also plans to eliminate the three-month limit on short-term health insurance plans.

“The Medical Association is in the process of reviewing the President’s Executive Order and is consulting with industry experts to get a full understanding of the downstream effects the order will have on patient care. There is some concern that the order could erode important patient protections, which would be a serious issue however the true impact is unclear at this point,” Executive Director Mark Jackson said.

The executive order does not make policy changes itself, any new rules will go through a notice and comment period that could take months.

In a decision that coincided with the executive order, the White House has confirmed that it will stop federal payments for cost-sharing reductions to health insurers. These payments help insurers pay out-of-pocket costs for low-income individuals purchasing coverage through the exchanges. If stopped, premiums could dramatically rise and cause insurance companies to leave the exchanges and challenge the decision in court. There’s confusion as to when the payments, which could total about $9 billion this year, would end.

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The Medical Association Supports Replacement of ACA with Workable Health Care System

The Medical Association Supports Replacement of ACA with Workable Health Care System

The Medical Association released its 2017 Legislative Agendas earlier this year, which were developed with guidance from the House of Delegates and great contribution from our physician members who participated in the 2017 Legislative Agenda Survey. The Medical Association has continued to express support for the repeal of the Affordable Care Act and its replacement with an adequate system to protect not only physicians but their patients as well.

The U.S. Senate is engaged in deliberations on legislation to repeal and replace the Affordable Care Act. So far these debates have one thing in common – they fail to meet the basic requirements of a solid health care plan, which does not further damage an already weakened Medicaid program or make it more difficult for low and moderate-income Americans to obtain affordable health insurance.

As from the beginning, Medical Association continues to support the repeal of the Affordable Care Act and replacement with a system that:

  • Includes meaningful tort reforms that maintain existing state protections
  • Preserves employer-based health insurance
  • Protects coverage for patients with pre-existing conditions
  • Protects coverage for dependents under age 26
  • With proper oversight, allows the sale of health insurance across state lines
  • Allows for deducting individual health insurance expenses on tax returns
  • Increases allowed contributions to health savings accounts
  • Ensures access for vulnerable populations
  • Ensures universal, catastrophic coverage
  • Does not increase uncompensated care
  • Does not require adherence with insurance requirements until insurance reimbursement begins
  • Reduces administrative and regulatory burdens

The disproportionate funding model dictated by the ACA has left most states, including Alabama, sorely underfunded. Medicaid is a critical component of our health care system, covering the young and elderly. Medicaid covers more than half of Alabama births and 47 percent of our children, as well as 60 percent of Alabama’s nursing home residents. Without full funding, the Medicaid program will collapse, leaving these individuals without coverage. While uncompensated care is delivered every day in all 67 counties of this state, without Medicaid, charity care needs could skyrocket, crippling the health care delivery system and potentially placing the burden on those with private health insurance through higher premiums and co-pays.

Now’s the time to fix our broken health care system to ensure access to care for our citizens and the ability for physicians to practice medicine without overwhelming federal burdens guiding the way. The Medical Association continues to work with our Congressional Delegation during these negotiations and urges them to work together toward the passage of a viable health care solution for our residents.

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Opioids in Alabama: Where Do We Go From Here?

Opioids in Alabama: Where Do We Go From Here?

The numbers are staggering. In 2015 alone opioid-related overdoses accounted for more than 33,000 deaths — nearly as many as traffic fatalities. Today more than 2.5 million adults in the U.S. are struggling with addiction to opioid drugs, including prescription opioids and heroin.

According to the Centers for Disease Control and Prevention:

  • About 91 Americans die every day from an opioid overdose (that includes prescription opioids and heroin)
  • Drug overdose deaths and opioid-involved deaths continue to increase in the United States
  • The majority of drug overdose deaths — more than six out of 10 — involve an opioid
  • Since 1999, the number of overdose deaths involving opioids — including prescription opioids and heroin) quadrupled
  • From 2000 to 2015 more than half a million people died from drug overdoses
  • In 2014, almost 2 million Americans abused or were dependent on prescription opioids
  • Many people receiving prescription opioids long term in primary care settings struggle with addiction, ranging from 3 to 26 percent in a review by the CDC
  • Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids

How did we get here?

In 2015, among 52,404 drug overdose deaths, 33,091 were from opioids that physicians prescribe such as hydrocodone. Studies suggest most of these involve diversion of legally prescribed pills, but some people died of the pills prescribed to them. Increasingly, as officials from the CDC recently testified before Congress, it is illicit drugs such as heroin and fentanyl that account for a rising tide of deaths.

Tracing America’s opioid epidemic goes back some experts say to the Roaring Twenties – a time when flappers danced to hot jazz, bootleggers sold black market alcohol in speakeasies run by mobsters, and morphine was handily prescribed for anxiety and depression.

“Opioids have been around for a very long time. Even back in the 1920s if you had depression or anxiety and you went to the doctor, you were likely to be prescribed a morphine-like medication,” said Daniel Doleys, PhD, clinical psychologist, director and owner of The Doleys Clinic in Birmingham. “Narcotics and opioid compounds do tend to stabilize different psychiatric problems, so oftentimes when we are prescribing these to patients, we think we are treating pain, but we may inadvertently be treating these underlying problems. The significance being that the patient may not show much improvement in pain or functioning, resulting in a lowering of the dose. This, however, can lead to re-emergence of the psychiatric symptoms and a plea from the patient and family to restore the medicine to its previous level. The potential impact of opioids on psychiatric symptoms, such as anxiety, depression, bipolar disorder, PTSD, and how this relates to the prescribing and overuse of opioids has not gotten much attention.”

According to Dr. Doleys, the altruistic nature of medicine itself could be one of the primary factors involved in today’s opioid crisis. Physicians are trained in the healing arts and simply want to heal their patients.

“You cannot cure suffering, and that’s part of the problem. You have a lot of well-intended clinicians who feel their job is to cure suffering. But, you cannot cure all suffering,” Dr. Doleys explained. “A certain amount of suffering is not necessarily a bad thing. It motivates us; it drives us. In our attempt to try to cure suffering, we have become co-dependent with the patient and taken their problem and made it our problem. So, we’ve communicated with the patient that I have something here that I’m going to give you. We will start with two of these pills a day. It may or may not be enough, but we’ll see. The message to the patient may be, if two isn’t enough, we can increase the dose. The often unrecognized position assumed by the well-meaning doctor is that I’m committed to saving this patient from suffering, and if this patient is still suffering, then I need to keep going until I find a cure.”

More emphasis needs to be placed on clarifying expectations, goals and patient responsibilities as it relates to their treatment. All too often patients are allowed to become ‘passive recipients rather than active participants’ in their treatment, according to Dr. Doleys.

What is so special about opioids?

In 1986, pain specialists Russell K. Portenoy and Kathleen M. Foley published “Chronic Use of Opioid Analgesics in Non-Malignant Pain: Report of 38 Cases” in the journal Pain.

“We conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse,” the authors wrote.

Dr. Doleys said of the study that with 67 percent of patients reporting a fairly good outcome with little adverse effects, although at doses much smaller than we typically see today. The study became “the lightbulb” that began a trend for opioids, which were originally prescribed only for malignant pain, to be used with other types of chronic pain.

“Questions soon began about how our bodies have these receptors which we already know will react to specific medications. We have these medications, but we are not helping people who are suffering and dying with pain,” Dr. Doleys said. “There was an increased awareness of people in pain from other sources rather than cancer, and the concerns began to grow about the under-treatment of pain, and some concerns were valid and almost criminal.”

In the 1980s, physicians began facing mounting pressures from not only their patients who were suffering from chronic pain issues, but also from advocacy groups and the federal government over the under-treatment of pain as a serious medical issue. By this time, there were about 100 million Americans reportedly suffering from chronic pain-related issues, according to the Institute of Medicine. With advertisements blasting away on television further advocating for the treatment of pain and applying even more pressure to the medical community to aggressively treat chronic pain, physicians were caught in the middle.

Pharmaceutical companies saw an opportunity and began producing more and more opioid medications, touting these new medications to physicians and federal regulatory boards as being safer than other painkillers on the market at that time. Unfortunately, this was not the case. When the dust settled and some of these companies were brought to court over their false advertising claims, millions of patients were addicted to their products.

Where the pendulum of prescribing opioids once swung toward over-treating chronic pain issues is now swinging back in a new direction, new issues are being uncovered – specifically addiction.

How opioids kickstarted the national conversation of addiction

“There is one positive outcome of the opioid epidemic. It has raised the awareness and acknowledgment that addiction is a disease. A national conversation has been initiated as a result of the severity, morbidity and mortality associated with opioid misuse and addiction,” explained addiction medicine specialist James Harrow, M.D., PhD. “We have been reluctant to acknowledge that addiction is a chronic, primary brain disease as opposed to what many people still believe is a voluntary process and that sufferers can just stop. That’s not the way it works. It is a biopsychosocial-spiritual disease that is chronic, relapsing and potentially lethal.”

According to Dr. Harrow, addiction is no different than other chronic diseases such as diabetes, asthma or hypertension. Addiction is preventable and when a patient has the illness, it is treatable with resultant long-term abstinence and remission. Those who are affected will be at risk of relapse to their drug of choice or other substances including alcohol for their lifetime. One of the problems we encounter is that addiction medicine is not taught in medical school.

“Medical education provides little to no training for what is probably the most prevalent disease in our nation today,” Dr. Harrow said. “The teaching of addiction is beginning to develop gradually within medical schools. However, if we do not educate medical students early in their training, then it is more difficult to assimilate the understanding of the disease when they enter practice.”

As with any other disease, physicians are not immune to the disease of addiction. Looking at the national population of physicians in the United States, roughly 900,000 doctors, the lifetime prevalence of addiction of practicing physicians is around 15 percent or about 135,000, Dr. Harrow said.

“Physicians may see themselves as superhuman, but that’s not the case. They may not be able to see themselves as being able to have these diseases, but they can and do,” Dr. Harrow said.

Because physicians face the same diseases as the patients, including addiction, that’s where the Alabama Physician Health Program steps in. APHP was created by the Alabama Legislature as a means for the Alabama Board of Medical Examiners and the Medical Association to address problems such as chemical dependence or abuse, mental illness, personality disorders, disruptive behaviors, sexual boundaries, etc. All information is privileged and confidential. The success rate of APHP for five years of monitoring is 85-90 percent with physicians successfully returning back to practice versus the long-term success rate of other programs of about 60 percent.

A clinical tool to aid in the war on opioid abuse

The Prescription Drug Monitoring Program is housed in the Alabama Department of Public Health and developed to detect diversion, abuse and misuse of prescription medications classified as controlled substances under the Alabama Uniform Controlled Substances Act. Under the Code of Alabama, 1975, § 20-2-210, et.seq, ADPH was authorized to establish, create and maintain a controlled substances prescription database program. This law requires anyone who dispenses Class II, III, IV and V controlled substances to report the dispensing of these drugs to the database.

Mandatory reporting began April 1, 2006. For those physicians who are eligible to use the PDMP, but are not yet registered, access is easy. Registering to access the PDMP database can be done by:

  • Go to
  • Click on PDMP Login found in the orange menu banner on the left
  • Click on Practitioner/Pharmacist
  • Click on Registration Site for New Account
  • Enter newacct for the User Name and welcome for the Password
  • Complete the registration form and click on Accept and Submit

You will receive two emails when your application is approved; one with your user name and a second with a temporary password. Each physician can designate two delegate users per office. These delegate users have their own usernames and passwords to access the PDMP system.

If you have trouble using the PDMP, help is at your fingertips. Assistance with passwords, connection issues, search and query issues, and most other PDMP problems is just a phone call away at (855) 925-4767 and follow the prompts or by email at

The Alabama PDMP anticipates switching to new software later this year. The new software is user-friendly and has additional features that will aid prescribers and dispensers in making the best clinical decisions for their patients. More information about training will be emailed to users in the coming months.

Where do we go from here?

It would seem there’s a story on the news every day about opioid abuse. A new statistic, a new arrest, a new death toll, yet no new solutions even though every state and every organization has a task force or study group working on the nation’s epidemic.

Stefan Kertesz, M.D., MSc, is associate professor at the University of Alabama-Birmingham School of Medicine and director of the Homeless Patient-Aligned Care Team at the Birmingham Veterans Affairs Medical Center. His 20-year career has combined research and clinical care focused on primary and addiction care of vulnerable populations with funding from the National Institute on Drug Abuse and the U.S. Department of Veterans Affairs. In 2016, he provided peer-reviewed and public media reviews of several facets of the opioid crisis, the rise of illicit fentanyl and heroin deaths, and how new policies affect patients with pain conditions. He may not have any new solutions, but his close study of the opioid epidemic has uncovered some interesting insights.

“We as doctors played a significant role in developing the opioid market, even though at this point we’re not the ones sustaining it,” Dr. Kertesz said.

In fact, one of Dr. Kertesz’s chief concerns stems from the revised CDC Guideline for Prescribing Opioids for Chronic Pain, issued in March 2016, which might have caused a “pendulum swing” from the status quo of prescribing of opioids for chronic pain to a stricter guideline for their use. The CDC Guideline provides recommendations for primary care physicians who are prescribing opioids for chronic pain outside cancer treatment, palliative care and end-of-life care. This pendulum swing toward an effort to curb prescribing habits might be putting more patients at risk than physicians might know.

“As physicians today execute a hard shift on opioids, I plead for caution,” Dr. Kertesz said. “Patients with chronic pain have reported enormous suffering, some committing suicide as they see their lives turned upside down by doctors pressured to reduce their medications. Opioid prescribing ran up even more because of the use of the pain score…a subjective single number. Now there is an emergence of academic physicians who have dedicated their work to fighting addiction, including some who even worked on the CDC Guideline. They see that clinical practice has sprung ahead of data, that it has begun to look like someone has shouted fire in a crowded theater, creating a social stampede. This does not reflect the cautious, patient-centered care urged by the CDC.”

Dr. Kertesz is not advocating a return to the old days of prescribing opioids. Far from it. He works in Jefferson County, one of Alabama’s hardest hit counties where deaths by heroin, fentanyl and other prescription medications are disturbingly high. In fact, he’s doing everything he can, short of shouting from the rooftops, to inform government officials and colleagues about changing the opioid epidemic. He’s written opinions and reports for STATNews, Pain News Network, Huffington Post, and Politico. He’s given interviews for state and national news agencies. He’s published numerous peer-reviewed papers and articles. And, earlier this year, he issued a briefing for Surgeon General Vivek Murthy. The message should be clear: We need a better message.

“Saying that opioids are just as addictive as heroin is fantasy, the same as solving opioid overdoses in doctors’ offices alone when most individuals with opioid addiction did not start out as pain patients,” Dr. Kertesz explained. “When Surgeon General Dr. Vivek Murthy made an under-appreciated declaration that we cannot allow the pendulum to swing to the other extreme here, where we deny people who need opioid medications those actual medications, as an addiction professional, I agree.”

How the Medical Association continues to be a leader in the fight against Alabama’s prescription drug abuse epidemic

In Alabama, our situation is equally staggering. According to the Alabama Department of Public Health, 762 Alabama residents died between 2010 and 2014 due to drug overdose, which included prescription drug overdose. In 2014 alone, there were 221 deaths due to drug overdoses.

“A group of us from the Medical Association met with some DEA officials and sheriffs who told us that Alabama was number one for hydrocodone until 2001,” said Association President Jerry Harrison. “We fell out of the top slot for a few years, but we got it back. We recognized that Alabama was in a very bad place, and we knew we had to take action.”

The Medical Association helped pass legislation in 2013 to reduce prescription drug abuse and diversion. That legislation resulted in Alabama having the largest decrease in the southeast and third-largest in the nation regarding the use of the most highly-addictive prescription drugs.

In 2016 the Medical Association launched a new public awareness campaign called Smart & Safe, which is the only prescription drug awareness program in Alabama spearheaded by physicians. Smart & Safe promotes safe prescription use, storage and disposal of medication by providing helpful tips, news and educational opportunities online at

Last year, the American Medical Association also partnered with the Medical Association to create a new clinical tool in the fight against prescription drug abuse. The collaboration produced Reversing the Opioid Epidemic in Alabama: A Health Care Professional’s Toolbox to Reverse the Opioid Epidemic, a downloadable document housed on the Smart & Safe website, contains handy reminders about Alabama law pertaining to prescribing opioids, tips for disposal of medication, statistics and useful links.

“When we started the prescribing lectures, we encouraged physicians to prescribe dangerous combinations less. We discussed the impact of the combination of pain medications and nerve medications because adding together one and one does not equal two…one and one can equal three or four in the damage or the potential damage they do to the patients. We have presented this course to almost 5000 prescribers now, and we’ve had an impact there,” Dr. Harrison said.

This year marks the ninth year of the Association’s Prescribing courses. By the end of the year, the Association will have completed 31 courses, and until 2013 Alabama was one of the only states offering an opioid prescribing education course when the FDA developed the blueprint for Risk Evaluation and Mitigation Strategies for producers of controlled substances.

“We have to as a medical profession realize what we were taught 18-20 years ago, that we were not adequately treating pain and to increase the dosage of the pain medicine until there is a side effect, is no longer adequate. When you wake up in the morning and the first thing you think about should not be to reach for your pain tablet before you have your breakfast because you have to get going. I often wonder just what’s causing your pain first thing in the morning?” Dr. Harrison questioned. “You have to question your patients and be honest with them: Is that your pain talking, or is that your opioid rebound pain? When you and your patients start to look at that from a different point of view, then you can work together to decrease the amount of opioids used. Life is not pain-free, and opioids are not a cure for pain. It’s like licking the red off your candy. You’re making it so that the pain medicine doesn’t work for you as well as it used to. The more you take now, the less it’s going to work for you in the future. We’re part of the problem. And, if we’re part of the problem, we should be part of the solution.”

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