Michigan’s New Opioid Laws: Saving grace or administrative nightmare?

New Michigan rules are on the way for those who prescribe prescription painkillers and other controlled substances. The requirements – like checking an online database of controlled substances dispensed in Michigan, and prescribing for acute pain no more than seven-day supply of opioids in a seven-day period – are among a host of provisions in new laws that proponents hope will help prevent addiction and detect it earlier. Public Acts 246-255 will impact physicians and other prescribers as well as pharmacies, adult and minor patients, schools and others.

“A lot of what this package does is focus on prevention, and education and awareness,” said Kim Gaedeke, acting deputy director of the Michigan Department of Licensing and Regulatory Affairs.

But opinions differ over some aspects in the new laws, including the clinical utility of requiring physicians and other prescribers to check the Michigan Automated Prescription System (MAPS) before prescribing anything more than a three-day supply of controlled substances like oxycodone, morphine, sleeping medications and cough syrup.

Another concern: That the seven-day limit on prescribing opioids to treat acute pain restricts physicians’ flexibility to do what’s appropriate for patient care.

The Michigan State Medical Society (MSMS) is among the stakeholders that will be watching the new laws’ outcomes on doctors, patients and the opioid epidemic.

“Michigan’s opioid epidemic has taken far too many lives and shattered far too many communities. The Michigan State Medical Society and its member physicians are taking an active role to reverse the trends,” said Kevin McFatridge, the society’s senior director of marketing and public relations.

“MSMS will be watching how the latest signed legislation will affect the physicians and their practices. Some may stop prescribing opioids; some may be more thoughtful in their prescribing,” he said. “Reversing the trends is what’s important here and MSMS will make sure the results are lining up with that intent.”

Beginning June 1, MAPS registration and advance patient checks will be required prior to prescribing what are known as schedule two through five controlled substances – federal classifications that reflect a drugs’ potential for abuse and likelihood of causing dependence.

Scott Monteith, a Traverse City-based practicing psychiatrist with Northern Lakes Community Mental Health and president of the Michigan Psychiatric Society, said that MAPS is a good tool but requiring checks in every circumstance has the potential to impact a physician’s work flow, depending on their practice and prescribing levels.

“Mandating that they check every single time before they write a prescription is counterproductive, micromanagement, taking away precious resources from people who are already working at 110 percent of capacity,” he said.

Monteith is on the MSMS’ committee on state legislation and regulations and has served on the Michigan Controlled Substances Advisory Commission, a predecessor to the current Michigan Prescription Drug and Opioid Abuse Commission.

Monteith said the legislation is “going to increase a lot of administrative demands … and I don’t think it’s going to give us the tools we need to address the opioid crisis.”

He said solutions to the opioid epidemic at the state level need to include: Additional training for medical professionals on pain management and substance abuse disorder treatment; increased access to treatment; addressing barriers to medication-assisted treatment that reduces patient desire for opioids; and improving integration of substance abuse disorder management and pain management by mental health and physical health providers.

Of Michigan’s approximately 60,000 prescribers, about 30 percent as of mid-January were registered and using the MAPS system.

The state announced last June that it was making funds available through August 2019 to integrate MAPS into the electronic health records and pharmacy dispensation systems of hospital health systems, physician groups and pharmacies that apply.

Gaedeke said integrating MAPS adds it into the clinical work flow. She said using MAPS prior to prescribing gives the practitioner “some valuable insights about the patient that they are seeing,” including identifying substance abuse problems and whether the patient has been going to multiple doctors to get narcotics, a practice called “doctor shopping.”

Beyond the MAPS provisions, the new laws contain patient education and consent requirements about the use and dangers of opioids. Prior to prescribing an opioid, a prescriber or other health professional must provide information to a patient that includes the danger of opioid addiction and how to properly dispose of expired, unused or unwanted controlled substances. The patient must sign a form verifying they received the information.

For minor patients, discussion with the minor and their parent, guardian or authorized adult must include the risks of addiction and overdose associated with the controlled substance. Signed consent forms are also required. Gaedeke said her department is collaborating with the Michigan Department of Health and Human Services to develop a form that could cover all needed consents, with a goal of making the process as simple as possible for providers while ensuring that communication occurs between practitioner and patient.

The laws also spell out that prescribing a controlled substance requires a “bona fide prescriber-patient relationship.” That’s defined as a treatment or counseling relationship in which the prescriber has reviewed the patient’s records and fully assessed medical history and condition in person or via telehealth, and has created and maintained records of the patient’s condition in accordance with medically accepted standards.

A controlled-substance prescriber must provide follow up care to the patient to monitor the drug’s efficacy in treating the patient. And if the prescriber can’t provide follow-up care, they must refer the patient for those services to the patient’s primary care provider or to another licensed prescriber who is geographically accessible.

For schools, there will be student education considerations. Under the new laws, the Michigan Department of Education, based on recommendations to be developed by the Prescription Drug and Opioid Abuse Commission, must make available a grade- and age-appropriate model program of instruction on prescription opioid drug abuse for school districts and public school academies. That instruction program must also be part of model state academic standards for health education.

Pharmacists could also see impact from the new laws. In certain instances, one measure will allow pharmacists to partially fill prescriptions for schedule two controlled substances like oxycodone even if the patient requests a smaller quantity than prescribed. A partial fill provides a new option for patients and could lessen the potential for pills to be diverted to others for whom they were not prescribed, said Larry Wagenknecht, CEO of the Michigan Pharmacists Association.

“We think the partial fill may decrease the number of opioids that are in people’s medicine cabinets, or toiletry bags,” he said. Wagenknecht was on the state’s Prescription Drug and Opioid Abuse Task Force chaired by Lt. Gov. Brian Calley and is on the Prescription Drug and Opioid Abuse Commission.

Wagenknecht said the seven-day supply limit on opioids “will go a long way to minimizing the potential for people to become addicted.”

He added that the MAPS checks that will be required of prescribers are a good idea, reducing inappropriate opioid use.

“We were supportive of it because right now, the standard of practice in pharmacy is that [pharmacists] do a MAPS report on a patient that’s new that’s come in,” he said. “Many times we become frustrated that this patient has seen five doctors in the last month, has been to eight different pharmacies,” which could potentially trigger pharmacist inquiry to the prescriber.

“I think that the result will be that people who are currently doctor shopping and pharmacy shopping will have more difficulty getting medications,” Wagenknecht said.

He said the legislative package is a step forward but many additional areas, like expanded access to treatment and educating health professionals on how to taper doses, still need attention. It’s important for the state to take a long-term approach to the problem and continue to put strategies in place, Wagenknecht said.

“This is a problem that affects every age, every economic group … and it’s a serious problem,” he said. “And we’ve all been touched in some way. It’s very pervasive. And we need something to get us to a better spot.”

Amy Lane is a freelance journalist and former reporter for Crain’s Detroit Business, where she covered business, state government, energy and utilities for nearly 25 years.