Letter to Mark Sullivan, President of the New Hampshire Board of Medicine - Make Changes to Opiate Prescribing Practices

Letter

Dear Mr. Sullivan:

New Hampshire is facing a growing opioid crisis, stemming in part from the overuse, misuse, and abuse of addictive prescription opioids. I know that the Board of Medicine has been working to address this issue, in particular through its efforts to increase Narcan availability and to support the establishment and use of the prescription monitoring program. I greatly appreciate those efforts, but those efforts alone are not enough. To strengthen our ongoing efforts to combat the heroin and opioid crisis, the Board should appoint one of your members to work with the Governor's Office and the Department of Justice to develop and adopt stronger, more explicit and more up-to-date rules on the prescribing of opioids.

As you are aware, with support from the Charitable Foundation, I appointed a Senior Director of Substance Misuse and Behavioral Health, Jack Wozmak. As a part of his efforts, Mr. Wozmak, along with Attorney General Joseph Foster, has highlighted concerns regarding the current Board rules related to the prescribing of opioids.

Licensees of the Board are currently required to follow Board Rule Med 501.02 (i) when prescribing opioids for pain control. Board Rule Med 501.02 (i) appears outdated and inconsistent with our current understanding of the addictive propensity of opioids. In particular, I believe that the rule's reliance on merely incorporating the guidelines outlined in the Chou, Fanciullo, et al, "Clinical Guidelines for the Use of Opioid Therapy in Chronic Noncancer Pain", The Journal of Pain is no longer appropriate or sufficient based on current information.[1]

Presently, the guidelines adopted by the Board are framed as mere recommendations, some of which are identified in the guidelines themselves as "weak". The Board appears to recognize the loose nature of these guidelines in that in a letter to physicians on its website, the Board proclaims that "[t]he guidelines are not rigid rules." The letter on the Board's website goes on to state the following: "While the Board will likely not take disciplinary action against a physician for failing to adhere to the provisions of this protocol, "significant deviation' from the guidelines will likely result in investigation and/or sanction."

A fundamental role of the Board during this crisis should be to monitor and discipline licensees who do not follow basic protocols regarding the prescribing of opioids. The Board can only do so with mandatory protocols that all practitioners must follow. With more explicit protocols in place, the abuse and misuse of opiates can be reduced and patients' needs still be met. In addition, such protocols will more easily permit effective administrative prosecutions of licensees who engage in inappropriate prescribing practices.

As part of the needed revision of Med 501.02 (i), the Board should adopt improved protocols that ensure that no more than a three day supply of opiates is prescribed in an emergency room setting and that require a mandatory referral to a pain management specialist for anyone who is prescribed opiates beyond a 90-day period. Further, I urge the Board to consider requiring the use of patient pain contracts to assure the patients fully understand and comply with their physician's recommendations, mandatory office visits for opiate prescription renewals, and other similar safeguards adopted by medical boards in other states to limit the risk of patients overusing, misusing, abusing, and becoming addicted to, prescription opioids.

Finally, I also ask that the Board adopt a rule requiring every practitioner licensed by the Board complete four hours of continuing education every two years in the area of pain management and opioid prescribing.

Attorney General Joseph Foster and the Department of Justice stand ready to work quickly with the Board to help you update your rules to help us all begin to stem the tide of opioid addiction. I would appreciate if, by September 4, 2015, you would select a member of the Board who can work directly with members of my staff and the Department of Justice with the goal of new proposed rules to present to the Board at its meeting on October 7, 2015.

It is my hope that the Board and the practitioners in this state will promptly make the necessary changes to opiate prescribing practices and thereby contribute to a focused and effective response to this public health crisis. My office stands ready to assist you in these efforts.

With every good wish,

Margaret Wood Hassan
Governor

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