Iowa Board of Medicine adds CDC guideline on opioid prescribing to list of resources for chronic pain treatment

Press Release (Hat tip: Dr. Menadue):

The Iowa Board of Medicine is encouraging physicians to consider a new federal guideline aimed to reduce the risk of addiction when treating chronic pain patients with controlled substances.

The Board recently adopted a new administrative rule to update a list of recommended resources for physicians who treat chronic pain. The list now includes the new Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain.

CDC developed and published the guideline in March to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care.

The CDC said that improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse, or overdose from these drugs.

Clinical practices addressed in the CDC guideline include:

  • Determining when to initiate or continue opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care
  • Opioid selection, dosage, duration, follow-up, and discontinuation
  • Assessing risk and addressing harms of opioid use

The CDC has produced three brochures (attached) to highlight the message in the non-binding standards:

  • Pocketguide summary of the CDC guideline
  • A checklist for providers who prescribes opioids for chronic pain
  • Non-opioid treatments for chronic pain

In the latter brochure, the CDC emphasizes that opioids are not the first-line therapy for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Evidence suggests that nonopioid treatments, including nonopioid medications and nonpharmacological therapies, can provide relief to those suffering from chronic pain, and are safer.

The federal guideline complements the Iowa Board’s administrative rule on appropriate pain management. This rule, 653 IAC 13.2, reinforces that physicians should not fear board action for treating pain with controlled substances as long as the physicians’ prescribing is consistent with appropriate pain management practices.

The Board’s rule encourages physicians to closely monitor patients who are prescribed opioids, including reviewing their controlled substance prescription history, considering the use of pain management agreements, and considering utilizing drug testing to ensure that the patient is receiving appropriate therapeutic levels of prescribed medications.

The Board strongly recommends that physicians consult the following resources regarding the proper treatment of chronic pain:

  • American Academy of Hospice and Palliative Medicine
  • American Academy of Pain Medicine
  • American Pain Society
  • DEA Policy Statement: Dispensing Controlled Substances for the Treatment of Pain.
  • Interagency Guideline on Prescribing Opioids for Pain (Developed by the Washington State Agency Medical Directors’ Group)
  • Responsible Opioid Prescribing: A Physician’s Guide. (By Scott Fishman, M.D.)
  • World Health Organization: Pain Relief Ladder. Cancer pain relief and palliative care. Technical report series 804
  • CDC Guideline for Prescribing Opioids for Chronic Pain

For the past five years, the Board has required primary care physicians to complete training on chronic pain management as a part o

ERs after Obamacare: More patients, fewer on-call specialists

Press Release:

The average monthly emergency department visit increased by 5.7 percent in Illinois after the implementation of the Affordable Care Act (ACA), although the population remained essentially flat. In Massachusetts, while visits to emergency departments climbed steadily between 2005 and 2014, availability of on-call specialists (surgeons, psychiatrists and other specialists) declined “significantly.” The results of two state-specific studies were published online last Thursday inAnnals of Emergency Medicine (“Increased Emergency Department Use in Illinois After Implementation of the Affordable Care Act” and “Decline in Consultant Availability in Massachusetts Emergency Departments: 2005 to 2014”).

“Emergency departments continue to be squeezed by pressures inside and outside the hospital,” said Scott Dresden, MD, MS, of Northwestern University Feinberg School of Medicine in Chicago, Ill., the lead author of the Illinois paper. “A large post-ACA increase in Medicaid visits and a modest increase in privately insured visits outpaced a large reduction in emergency department visits by uninsured patients. We still don’t know if these results represent longer-term changes in health services use or a temporary spike in emergency department use due to pent up demand.”

Annual emergency department visit volume in Illinois increased from 2.9 million in 2011 to 3.2 million in 2015, an 8.1 percent increase over the period. Comparing the pre-ACA period (2011 to 2013) to the post-ACA period (2014 to 2015), the average monthly emergency department visit volume increased by 5.7 percent. Hospitalizations were essentially unchanged, as was the size of Illinois’ population.

In Massachusetts, from 2005 to 2015 emergency departments reported that visits increased on average from 32,025 to 42,000. During the same period, there was a significant drop in availability of specialists in surgery, neurology, obstetrics-gynecology, orthopedics, pediatrics, plastic surgery and psychiatry. Availability of general surgeons declined from 98 percent to 83 percent while 24/7 psychiatry availability declined from 56 percent to 33 percent. Availability of orthopedic surgeons, pediatricians and plastic surgeons also declined significantly.

“During the studied period, the burden of increasing patient volume was clear,” said Jason Sanders, MD, PhD, of the Department of Emergency Medicine at Massachusetts General Hospital in Boston. “The proportion of emergency departments reporting any patients primarily cared for in the hallway climbed from 70 percent to 89 percent. That is obviously far from ideal and is indicative of an increasingly taxed emergency medical care system.”


Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians, the national medical society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. For more information, visit

Mylan to launch generic EpiPen at half the price of original

From Reuters:

Mylan NV said it would launch the first generic version of its allergy auto-injector EpiPen for $300, half the price of the branded product, the drugmaker’s second step in less than a week to counter the backlash over the product’s steep price.

The company reduced the out-of-pocket costs of EpiPen for some patients on Thursday, but kept the list price at about $600, a move that U.S. lawmakers and Presidential candidate Hillary Clinton said was not enough. EpiPen cost about $100 in 2008.

Mylan said on Monday it expected to launch the generic product “in several weeks,” an unusual move considering the branded bestseller is still patent protected and major rival treatments have failed to get regulatory clearances.

Pain management in ER may significantly impact patient satisfaction

From Fierce Healthcare (hat tip: Dr. Menadue):

Emergency room patients in particular have high expectations for pain management, according to an article in The New York Times, and when those expectations aren’t met, hospital patient satisfaction scores can suffer. In the wake of widespread opioid addiction, health providers are cutting back on prescriptions for such pain medications, despite patient demand. The ED is a particular target for such cutbacks, as many emergency room patients arrive in acute pain.

Patients expect their pain to be treated fully, according to the article, and think prescriptions for medications like opioids are a logical quick fix. And doctors like S. Michael Keller, medical director of the ED at Marion General Hospital in Indiana, says patients react negatively when doctors deny them the painkillers. “I’ve been swung at, spit on; I’ve been yelled at, all because I haven’t given a patient what they came in demanding,” Keller told the newspaper.

Teaching Medical Teamwork Right From The Start

From NPR:

“I think they come in with some preconceived or stereotyped notions of what a doctor [or] a social worker is,” says Scott Wilkes, an assistant dean at Case Western’s school of social work. Breaking down those stereotypes by giving students from various disciplines a place to hear other perspectives and different types of knowledge, in their earliest training days, could make a difference, proponents of the new joint-campus say.

Getting everyone on the same page when that happens is critical to preventing medical mistakes, says Dr. Patricia Thomas, an internist and vice dean overseeing medical education at the Case Western Reserve medical school.

In studying the problem, she says, “the root of many of our errors had to do with the fact that our professions were not working effectively together for patient care.

The Ways That Technology Has Changed the Definition of Death

From Vox:

In the 19th century, the moment one stopped breathing was the final indication of death, and a mirror held to the mouth, unfogged, was the indication that the soul had exited the body. Currently the measurement of death is a much more complicated one that involves a more industrialized and less religious view of the body: when mechanical and electrical activity ceases (the brain stops signaling, the heart stops beating and breath stops), one is pronounced dead.

But as we increasingly peer into the body with more powerful tools, these markers of death might not really indicate a final end.


Iowa Board of Medicine Establishes Minimum Supervision of Physician Assistants

From the Iowa Medical Society (hat tip: Dr. Menadue):

The Iowa Board of Medicine (IBM) recently announced adoption of a new administrative rule which establishes minimum standards for appropriate physician supervision of physician assistants (PA). IMS developed a brief summary to help physicians navigate and comply with the new rules.

In 2015, the Iowa Board of Physician Assistants (IBPA) noticed a proposed rule to eliminate the requirement for physicians and remote-site PAs to meet in-person at least once every two weeks. Physician organizations, including IMS, objected to elimination of the requirement, and through the process discovered that Iowa was the only state in the nation that did not grant its board of medicine clear authority to regulate physician supervision of PAs.

In response, the legislature enacted a bill requiring the IBM and the IBPA to work together to promulgate joint supervision rules. A subcommittee consisting of members from both boards met several times over the course of months and eventually agreed to a set of rules. Included in the rules was a requirement that physicians meet with PAs at least two times a year, that if the PA works primarily at a remote site clinic both meetings take place there, and that the two meetings be documented. This rule was intended to replace the requirement that physicians meet with remote site clinics in person every two weeks. After that set of rules was approved by the subcommittee, both licensing boards then needed to adopt the rules.

The IBM voted to formally adopt the rules last winter; they are now in effect and binding on Iowa physicians. However, the IBPA voted several times against adopting the rules. Because the IBPA did not adopt the rules, the process for rescinding the requirement that physicians meet with PAs in person every two weeks has stalled. Unfortunately, this means that physicians are currently bound by both rules: to meet with remote-site clinic PAs in person every two weeks as well as to meet with all PAs two times each year and document those visits.

The directive from the legislature required both the IBM and the IBPA to adopt joint rules. There is no precedent for a situation where a licensing board has not complied with a legislative directive, so it is unclear how the legislature and the Administrative Rules Review Committee will proceed.

IMS will continue to monitor the progress of the rules and keep members updated. In the meantime, if you have any questions about PA supervision, please contact Kate Strickler at



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