Maine Drug Law PL488: A Multitude of Problems…Part 3

Maine Drug Law PL488: A Multitude of Problems…Part 3

HIPAA is a privacy law enacted, passed by Congress and signed by President Clinton in 1996. A state (Maine) cannot implement law at will to supersede federal because federal laws takes priority over state laws due to the supremacy clause of our Constitution.

Under the Privacy Law there are Covered Entities and Business Entities; however neither list includes veterinarians. The American Medical Association’s web page has this description of HIPAA on it today. Note, this description is on the website of the American Medical Association, which represents human medicine,  not the American Veterinarian Association (AVMA) which represents that of animals. Plus neither veterinarians nor their designated staff are  bound by HIPAA regulations. How can pet owners who agree to have their personal prescriptions reviewed  by someone from a veterinary practice be assured that whatever is seen will remain confidential? They can’t. Whereas in human medicine any HIPAA violations are dealt with appropriately. I think this places an extra burden on a practice, especially a small one. Plus I believe they are as uncomfortable viewing a humans prescriptions as we are knowing the law requires them to.

That gives rise to the question, how can Maine residents be sure their personal data is safe? On March 22, 2017 it was announced that a hacker had breached the Maine Department of Labor’s Job Link, a job matching service. While the service was outsourced to a Kansas company in July 2016, it was reported that the Maine DOL’s computer system is antiquated therefore indirectly played a part in the breach. Officials say the hacker was able to view names, social security numbers, and birth dates of site users. Since July, over 12,000 Maine residents have utilized the site and to date the number of users affected is unknown. So how do we know if the Maine PMP is secure? It’s disturbing alone that a veterinary practice staff member is required to look at consenting humans drug records and that a 5 year window of prescription activity is accessible on the PMP. Now we must also wonder about the security of the electronic system.

 

Screen Shot 2017-04-06 at 2.05.15 PM

Screen Shot 2017-04-06 at 2.08.24 PM
Email sent by Maine DOL on March 24

 

Secondly the state is mandating that veterinarians operate outside their scope of practice since pharmacology is often vastly different between the species. They are expected to make a judgement call when reviewing the owner’s (or anyone picking up the animal) prescription drugs on the PMP database and determining if prescribing a controlled drug for the animal would enable the owner to “potentially” exceed the mandated daily limit of 100 MME. This alone is requiring a doctor trained in animal physiology to understand human physiology. Would you expect your dentist to prescribe medications for your cat’s seizures? Or expect your veterinarian to know how much Vicodin you need following major orthopedic surgery? What if a veterinarian makes the wrong judgement call simply based on the numbers? A pet could be denied much-needed medication. Do legislators really have the power to make such laws where one’s medical privacy is violated and their pet possibly left in pain or distress?The inclusion of veterinarians in this hasty bill is not the answer to the opiate epidemic. Perhaps stricter sentencing should be considered. Recently in my Maine community, during the same court session, a drug trafficker was given a suspended sentence and allowed to freely  exit the building whereas someone who embezzled money was sentenced to jail hence escorted out by deputies. The drug he trafficked was Suboxone which is both addictive and has the potential to be fatal  if combined with certain other drugs. While I’m certainly not defending someone who embezzled money, as a nurse who worked in a large city teaching hospital, I’ve never heard of someone dying because of it. The stark contrast in sentencing was disturbing and reinforced my belief that including veterinarians in PL 488 is not going to stem the opiate epidemic; appropriate sentencing is.

As a Maine resident  who refuses to allow my HIPAA rights to be violated, and as an animal owner who does not want my pet to suffer, I  reached out to my elected officials and Augusta, the state capitol, multiple times since February 2017 in an attempt to express my concern. My communications have been completely ignored with the exception of Senator Thomas Saviello who was initially  helpful but once I began asking more focused questions regarding PL 488, he no longer responds. This is certainly not the reaction I expected from my elected officials nor is it one I’ve experienced while living in other states.

Next ~ Who else is adversely affected by Maine’s PL488?

Maine’s New Drug Law: Veterinary Visits Get Complicated….Part 2

Maine’s New Drug Law: Veterinary Visits Get Complicated….Part 2

Why are the legislators in Maine including veterinarians in a bill that is geared towards stemming the opiate epidemic?

The nation has an opioid abuse problem and it’s naive to think some animals owners have never diverted their pet’s medication or sought drugs for the animal when it’s really for them. To vet shop however requires more than doctor shopping. When doctor shopping one much be a very good actor. If you have a history of chronic pain even better. Veterinarian shopping requires a prop; your animal. It means establishing a profile for your pet at numerous veterinary practices. It means paying multiple veterinary bills to get drugs which A. aren’t really the type an addict wants and B. could be obtained cheaper on the street or through friends.

It’s not uncommon for veterinarians to prescribe painkillers to animals that suffer from chronic pain or that have undergone surgery. In some cases, these painkillers can be opioid based. But what our legislators  fail to take into consideration is the dosing difference between humans and animals; the dosing difference between felines and canines. And unlike a human who can “act” the part of a person in pain and verbalize their symptoms, animals can’t. Because they cannot communicate, non-verbal cues are the best way to determine the severity of a pet’s pain regardless of what the owner says. The veterinarian listens to the owner describe what Pup or Kitty are doing but then does a physical assessment of the animal. The last two decades have seen a huge change in the way veterinary medicine addresses  pain in an animal. Whereas the previous line of thinking was Animals don’t feel pain” or “Keep them quiet and it will speed their healing because they won’t move around much”. Thankfully the veterinary profession has embraced the idea of pain management for both large and small animals and several pain scales are currently in use. Colorado State University Veterinary Medical Center uses this scale to evaluate acute pain in kittens and this one to evaluate acute canine pain.

A November 2015  publication from JAMA  gives an excellent overview of how pain is assessed and evaluated in animals whether it’s acute as in surgical or chronic like osteoarthritis. And if one is fortunate to live in a progressive area, there are even pain management clinics for animals like the one at Cummings Hospital which is part of The Veterinary School of Medicine at Tufts University in Massachusetts. More than ever, veterinarians are aware of pain in animals whether it be a broken leg, advanced arthritis or cancer. This excellent article, The Hurt Unlocker, by Genevieve Rajewski, Editor for Tufts Veterinary School, gives a great overview of pain in animals and how it’s best managed.

PL 488 requires the following parameters for veterinarians:

  • All veterinarians who prescribe opiates or benzodiazepines must register as data requesters with the PMP
  • All veterinarians must check the records of the individual seeking care for the animal, and if appropriate the owner, prior to prescribing opiates or benzodiazepines. A valid state or federal photo ID should be checked, and a birthdate and full name must be acquired in order to check the PMP of an individual. This would also apply to anyone you had drop off or pick up Fido.
  • All written prescriptions must include a DEA number.
  • All prescriptions intended for use by an animal must indicate such use on the prescription.
  • Diagnosis and exemption codes are not required on veterinary prescriptions.
  • As of July 1, 2017, veterinarians with the capability to prescribe electronically will be required to do so. In April 2017 a waiver is expected to be released that will allow veterinarians without the capability to apply to be exempt.
  • The Aggregate Morphine Milligram Equivalent for the person who either owns the animal or is transporting.  The 100 MME/daily limit would  include the anticipated new prescription.
  • The number of prescribers currently prescribing controlled substances to the individual.
  • The number of pharmacies currently filling prescriptions for controlled substances for the individual.
  • Veterinarians will be required to complete three hours of CE (continuing education) related to the prescription of opioids by December 31, 2017, and subsequently every two years. **

The Maine Veterinary Medical Association has even “helped” veterinarians by preparing a presentation  plus consent form for the humans to sign which gives the veterinarian or his designate permission to access the person’s drug records. What exactly does that mean? If narcotics are being prescribed, the human bringing the animal in or picking the animal up must consent to having their drug records accessed by someone in the veterinary practice. Let’s think about this for a minute. Your dog has surgery and because of the postoperative pain the veterinarian wants to prescribe tramadol, a Schedule III narcotic as of 2014. Because of work hours you ask your neighbor to pick Fido up. Imagine their shock when they have to fill out the consent form, show their driver’s licence or other form of photo ID and wait while their drug profile is accessed and evaluated by a veterinarian, highly trained and skilled in animal medicine. And if the veterinarian calculating the human dosage determines your neighbor is at the top of the 100 MMEs daily allotment and the tramadol for your dog would exceed that amount, legally they can’t prescribe it. Also, a veterinarian had no way of knowing why a person is on the controlled drugs; only that they are. Based on numbers found in a database, a highly skilled veterinarian is being ordered by the State of Maine to practice veterinary medicine but use human protocols. In short, they are being mandated to practice outside their scope which is a violation. To ask a veterinarian who as I outlined in my previous post has extensive knowledge of animal physiology to prescribe pain medication for an animal based on how much of the daily allotment a human already has prescribed for them by a medical doctor is absolutely ludicrous.

Then there is palliative care for an animal with an end stage disease that is painful. The State has not set any exemptions for veterinarians but has for human doctors.

Prescribers are exempt from the limits on opioid medication prescribing established in this rule if:

  1. Pain associated with active and aftercare cancer treatment. Providers must document in the medical record that the pain experienced by the individual is directly related to the individual’s cancer or cancer treatment. An exemption for aftercare cancer treatment may be claimed up to six months post remission

  2. Palliative care in conjunction with a serious illness;

As someone who had a beloved dog diagnosed with canine lymphoma in October 2015, I would have been beyond furious if her oncologist couldn’t prescribe opiates for her as she neared the end ~ simply because my husband or I were at the top of the daily allotment. 

Addiction is an epidemic that can no longer be ignored. However the welfare of innocent animals should not be impacted, veterinarians mandated to operate at best, on the fringe of their scope of practice, nor our guarantee of privacy under HIPAA violated because neither veterinarians nor their staff are bound by HIPPA regulations.

Yet the State of Maine is doing all of these things.

IMG_2608 (1)

Veterinary Visits In Maine Just Got Complicated…

Veterinary Visits In Maine Just Got Complicated…

Like nearly every state, Maine is dealing with an opiate and heroin epidemic. In 2015, Maine experienced 272 overdose related fatalities. In January 2017 one of Maine’s media outlets, WMTW, did an outstanding feature entitled Goodnight moon, goodnight mum,’ ‘Chronicle’ investigates Maine’s heroin epidemic. Anchor David Charns did a phenomenal job detailing the pain and heartache of addiction through a series of interviews and videos including one with Oxford County Sheriff’s Office Sgt. Matthew Baker Sergeant  who, moments after arriving home from work in February 2015, discovered his 23-year-old daughter Ronni near death in the upstairs bathroom. Despite CPR from her father and several doses of Narcan by paramedics, she died, leaving behind an 11 month old daughter Claire. Ronni’s daughter, now 2, lives with her grandparents and is the source behind the name of the WMTW article:

When Claire asks for her mother, she and her grandfather look up, past that second-floor bathroom, to the sky. “I’ve always told her that that full moon is mum,” Baker said. “We go outside, and she says, ‘Goodnight moon and goodnight mum.'”

In an effort to combat the Maine opiate epidemic, the Maine Legislature enacted Public Law 488 which became effective January 1, 2017. PL488 affects nearly all facets of healthcare except in this law, veterinarians are included. I didn’t have all the exact data on PL488 so reached out to my State Senator, Thomas Saviello. I must tell you, he is the only government official to respond during the two weeks I called and emailed various agencies, elected officials  including the State House. Sad indictment against them but a huge kudos for Senator Saviello. 

What I do know about PL488 and it’s impact on veterinarians is such. If an owner takes their pet to be seen and the veterinarian feels it necessary to prescribe a narcotic or benzodiazepine for your pet, they must first do a check on the owner with DHHS to determine if the owner is on a controlled substance. As I previously mentioned I still need to clarify the parameters but the fact that a veterinarian or perhaps his staff has the power to access a person’s prescriptions is a huge HIPAA violation. But I digress. Let’s use a hypothetical situation. Owner has an anxiety disorder for which he takes Valium on a daily
basis. He also has a severe back issue (long-term) so is on hydrocodone for pain control. His cat is hit by a car and taken to the vet where she undergoes successful emergency surgery but because her injuries are severe, the vet prescribes a pain medication; hydrocodone. Would the fact that the owner is on hydrocodone prohibit the vet from prescribing it for the cat’s postoperative pain? If so, would he be allowed to prescribe a different pain medication such as tramadol which also falls in the opiate category? Is
he is prohibited from prescribing any narcotic because the owner is on two (2)?  Or is it only if the owner is on the same drug? If his prescriptive powers are limited
because the owner is on a controlled substance, what criteria is used to determine if the animal can or cannot get a prescription?

Whilst I understand the opiate epidemic our country is tackling, how can a veterinarian or
anyone for that matter be absolutely certain that a person who is taking several controlled drugs is abusing or trafficking? Plus the thought that an innocent animal might have to suffer needlessly because his owner is on a controlled substance is not only abhorrent but
inhumane.  I want to know if it’s possible for the check to be done during non-business hours when DHHS is closed. Does the veterinarian’s office have to speak directly to a DHHS employee or is the information accessible online? And if it is accessible online, how can we, the human patient, be assured it’s secure? If the drug check on the owner can’t be done when DHHS is closed, then what happens to the animal who is in pain?  Any pet owner knows that many accidents happen at night, weekends or holidays when government agencies like DHHS are closed; what then?  Going back to HIPAA, who has authority within the veterinary practice to request the DHHS information? Can a receptionist do it? A vet tech? Or only the veterinarian? Finally, I do not understand how PL488, a state law, can override HIPAA, a federal law enacted in 1996 by Congress and signed into effect by then President Bill Clinton. Under HIPAA an individual’s medical and other health information including prescriptions, is private and protected. The Privacy Law sets limits on who can look at and receive our health information such as covered entities and their business associates. As a nurse and former Union representative I am extremely familiar with HIPAA. In light of PL488 however I reviewed it once again and no where did I find where veterinarians, veterinary technicians, or veterinary employees of any type are entitled to our records in any form. Additionally, PL488 is in essence requiring veterinarians to understand human medication dosages compared to animals which often differ greatly.hipaa_violations_by_type_-_pie_chart

I chose a veterinary team for my German Shepherd based on their reputations and expertise in animal physiology, not human. I value all members of her team despite being in different practices because of their knowledge. Having said that, I expect they keep current with the newest modalities of treatment for my dog. They work long hours yet now the State of Maine expects them to undertake additional training in order to understand and monitor the Prescription Monitoring Program (PMP)?  A program historically used only for humans?

This is ludicrous. There has to be a middle ground, a way the government, human healthcare providers and law enforcement can work together in an effort to reduce the rampant drug abuse without violating a persons rights or including veterinarians where there is potential for an animal to suffer because “something” raises a red flag when in reality it could be legitimate.

Once I have all the specifics, I’ll revisit this in a future post.

funny-dog-pictures-your-dog-has-a-tummyache

I Am Beyond Blessed

I Am Beyond Blessed

This is definitely my shortest post ever. I want to shout from the rooftop although in the Western Mountains of Maine there are only trees.

I HAVE WON! My four-year battle with a Whistleblower case is over! I honestly think the ultra prestigious law firm that represented the nursing facility was testing me because they were adamant about taking it to trial. We had jury selection the end of last week. The corporate climbing female lawyer told me how she was looking forward to having me on the witness stand. My response?  “No dear. Actually the pleasure will be all mine”. I bluff quite well I’ve discovered because I was actually quaking in my Danskos. The most important component is I refused to sign a confidentiality agreement. Non-negotiable. To agree to keep quiet was never a bargaining chip on the table. Because by doing so, what would that say about my ethical obligation to a patient? The very situation that started this legal battle?  That I cared more about money than morals and respect. That was how I viewed it.

So even though technically I’ve won, I feel more as if a victory albeit it small has been achieved for patients who for whatever reason, don’t realize they have the right to speak up, speak out and be treated with respect. My only regret is that my dear friend is no longer here to share this with; he too lost his job merely because he was at the top of the pay scale. His 22 year old replacement was paid half the weekly salary. How sad…

“…Because Faith is merely the road that leads us to the Greater Love…”