Octob er 11, 2017

'-U,"~~ 's
........'-U, ... ...
of Mississippi

Members of the Mississippi Board of Medical

M edical Licensure:

On behalf of the surgical

surgica l leadership of the Batson Ch ildren's Hospita l, we thank you for your efforts
in trying to curtai
curtaill our curre
current
nt epidemic of opioid abuse
abu se in the State of Mississippi. We res pect the
work t~at you are doing; hO''Iever,
hO''Ie\ler, it has come to ou'
oU' attention that there
the re will be so me spillover of
the new requirements for the use of narcotics
narcotics in the acute management of postoperative pain. It
would make sense that our pediatric patients present a low risk for opioid addiction, and certainly
not when treating within the narrow window of acute pain suffered in the initia initiall postoperative
period . The necessity to run reports on our children is not on only
ly unnecessary from an abuse
standpoint,
standpo int, but produces a real and undue burden on busy surgica l practices.
practices. We would like to
suggest that consideration be made for a reasonable wi window
ndow of time after a surgical procedure to
prescribe narcotic pain medicine for the trea treattment
ment of acute pain before having to file prescription
monitoring program reports. We thank you for your consideration in thi s matter.

Sincerely,

Brian E. Kogon,
Kogon, MD
Chief of Pediatric N urosurgery Chief of iatric CV Surgery

C~k ee. 6td-

()L~
Christopher J. Blew~tt, MD las
la s Maposa, MD
Chief of Pediatric Surgery Chief of Pediatric A

~'/~//"'"D
~'/~//" L::,
Edwin P.
P. Harmon, MD J. Mark Reed, MD
Chief of Pediatric Urolog

~~.
Ch"'::;](:J:010gy
.1
una rawad,
~~.
rdwad, MD Michael WW.. 3hrad",·, MD
Chief of Pediatric Den/Comm Oral Hea lth Chief of Pediatric Orthopedic Surgery

~
Chief of PediatriC Ophthalmology

University of Mississippi
ofMiss iss ippj Medical Center
Pediat ric Urology
Pediatric
2500 North Sneer . Jackson,
Norrh Stare Street Jackso n, Miss 3~2 16
issippi 392
Mississippi 16
85S .984 .KIDS
Referrals: 8SS.984.K IDS • New Patient Appo intments: 888.815.2005
Appointmellts:
Pho ne: 60 1.8
Phol1e: 1.8115.
5. 1454 • Fax: 60 1.815.
1.8 15. 172 1 • ummchealch.com/childrens
ummchcalrh.com/childrens
Frances Carrillo

From: RHONDA FREEMAN

Sent: Monday, October 16, 2017 12:49 PM
To: Frances Carrillo
Subject: Fwd: Attached Image
Attachments: 2819_001.pdf; ATT00001.htm

Categories: Regulation



Rhonda

Beginforwardedmessage:

From:"EdwinP.Harmon"< >
Date:October16,2017at10:49:32AMCDT
To:"Rhonda@msbml.ms.gov"<Rhonda@msbml.ms.gov>
Subject:FW:AttachedImage

Theattachmentisalettersignedbyallofthesurgicaldivisionchiefsrepresentingtheirsurgeonsatthe
BatsonChildrensHospitalhereatUMMC.Weareallveryconcernedattheupcomingchangesasit
affectschildren.Pleaseseethattheboardgetsthisletter.

Thanksforyourassistance,
EdwinPHarmon,MD

EdwinP.Harmon,MD,FAAP
JamesEKeetonChairofPediatricUrology
Director,PediatricSurgeryCenter
Chief,PediatricUrology
ProfessorofUrology/Surgery
2500NorthStateStreet
Jackson,MS39216

From: 
Sent:Monday,October16,201710:29AM
To:EdwinP.Harmon >
Subject:AttachedImage


Individuals who have received this information in error or are not authorized to receive it must
promptly return or dispose of the information and notify the sender. Those individuals are hereby
notified that they are strictly prohibited from reviewing, forwarding, printing, copying,
distributing or using this information in any way.

17
 Frances Carrillo

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

Sent: Thursday, October 12, 2017 2:44 PM
To: Frances Carrillo
Subject: FW: Concerns with changes in prescribing rules

Categories: Regulation

 
 
From: Sarah Jones ]
Sent: Thursday, October 12, 2017 12:47 PM
To: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE;
Subject: Concerns with changes in prescribing rules

To whom it may concern:

I have sincere concerns about the proposed prescribing rules changes listed below:
1. Each licensee must run a Prescription Monitoring Program (PMP) report at each encounter when prescribing opioids for 
acute/chronic pain. (pg 25)
2. Licensees must keep PMP reports in the patient's file and available for inspection. (pg 25)
3. Licensees are prohibited from prescribing more than a 7‐day supply of opioids for acute pain. (pg 36)
4. Licensees may not prescribe Benzodiazepines and opioids concurrently, with limited exception for an acute injury, and for a 
maximum of 7 days. (pg 37)
5. Licensees are bound by new guidelines for prescribing any controlled substance (pg 25, at the top "those licenses who 
practice is not pain management... all patients who are prescribed, administered, dispensed controlled substances”)
6. Prescriptions may not be written outside of a valid licensee‐patient relationship (pg 41, Rule 1.11, first paragraph and 
section “A”)                                                 

Items 5 and 6 are of most concern for the application of everyday pediatric and complex care practice and will have
unintended and prohibitive consequences.

I am concerned about the gross generalization to all controlled substances for general practitioners to follow the same
guidelines as opiates. We manage ADHD with stimulants which are controlled substances. We do this with great care and
maintain HEDIS rules of visits and assessments. If a Rx is lost, we do not given extra. The regulations would require a
PMP report at every visit and imply that any acute changes in meds can only be written for 7 days. This causes billing
issues (insurance paying for medications in a 30 day period), major office time concerns, and begets the question, when it
is considered a chronic medication and when can write 30 day supplies?

In complex care, we at times write medications or refill other specialists medication that are also in the UMMC practice out
of acute necessity that are benzodiazepines and similar controlled medications for seizure and/or pain management from
spasticity. We also rarely write Ambien and other sleep aids for our older complex children, for which sleep is a common
concern and they have failed other management. These medications would be difficult to order and obtain for the patients
with limited supplies and increased paperwork from the office. We can see with out EHR when these medications were
last written and outside pharmacies report medications to our EHR. In addition, sometimes there are acute to acute on
chronic changes that need increased dosages of medications for the complex children that would be limited to 7 days by
the new rules. Again, it begets the question, when would it become "chronic"?

I feel we are very responsible with controlled substances of these natures and uses as noted above.
3
We do not often write other controlled substances like Percocet or Lortab for general pain. I completely support the
regulation of pain medications in acute use. I refer chronic or concerning pain patients to pain management. If I am
concerned about their pain medication requests or needs, I pull a PMR report. If sleep aids are required for a longer
period of time, I refer them to sleep medicine for sleep studies and assessment.

The stipulation that physicians are not allowed to write ANY prescriptions for people that are not in a “physician‐patient” 
relationship with them (e.g. clinic staff who have picked up strep or pink eye from a patient, etc) is concerningly broad. I
completely support not writing pain medications or similar controlled medications outside of the appropriate relationship,
but helping office staff after a general history, assessment and physical with an antibiotic prescription or eye drops for pink
eye, for instance, is quite benign and helpful to the staff and office practice. It carries risks that the physician must bear
since it is not documented formally, but that should be the discretion of the physician and not banned in totality by the
governing board. I do not feel the MBML should limit physicians ability to practice general medicine if one is duly licensed
to practice medicine.

I appreciate your consideration.

Sincerely,
Sarah Jones, MD

University of Mississippi Medical Center

Department of Pediatrics
Ambulatory Medicine
Complex Care and Primary Care

4
Frances Carrillo

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

Sent: Thursday, October 12, 2017 2:43 PM
To: Frances Carrillo
Subject: FW: Proposed changes to prescribing rules

Categories: Regulation

 
 
 
From: Tanya Fitts [mailto ]
Sent: Thursday, October 12, 2017 10:31 AM
To: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE
Subject: Proposed changes to prescribing rules

Members of Mississippi State Board of Medicine,

I have read and reviewed the changes outlined from Part 2640. I understand the sense of urgency to change
prescribing behaviors in the wake of the opioid crisis present throughout the United States. However, these rule
changes greatly impact my practice as a pediatrician. To date this year, this clinic has had 345 visits for ADHD,
which comes to about 15% of our charges. Most pediatric practices routinely treat ADHD patients as the
incidence of this condition is about 5-10% of school aged children. Living in a college town, I understand that
the stimulants that are the mainstay of ADHD have a street value and could be diverted. I have even terminated
patients from my practice for that diversion.

The following proposed change will put an undue burden of documentation of my practice:

Those licensees whose practice is not a pain management practice as defined previously shallmust actively
utilize the MPMP upon initial contact with new patients and at least every three (3) months thereafter on any
and all patients who are prescribed, administered, or dispensed controlled substances. Reports generated on
such patients should span the length of time from the previous review of the MPMP so that adequate
information is obtained to determine patient compliance with treatment. Documentation, such as a copy of the
report itself and/or reflection in the chart dictation and/or notes, must be kept within the patient’s record and
made available for inspection upon request. In addition, licensees required to register under this section
shallmust also utilize the MPMP to generate a global report to review their entire practice as a whole at least
yearly. Documentation of the global report must be kept in a separate file to be available for inspection upon
request.

Rural pediatricians have the burden for providing most mental health services for our children in
Mississippi. Our nearest child psychiatrist in private practice is in Tupelo. Communicare provides services, but
has limited resources and couldn’t take on all of the ADHD care provided by the 7 excellent pediatricians in
Oxford. The above requirements for documentation will present a hassle factor that may keep children in our
rural areas from getting the care they need.

5
Please have a public hearing on these proposed changes.

Also, I am a physician first and a licensee second. I do not like the change of language throughout the
document.

Tanya Fitts, MD, FAAP

Lafayette Pediatric Clinic

1300 Access Rd, Suite 400
Oxford, MS 38655

6
Frances Carrillo

From: RHONDA FREEMAN

Sent: Thursday, October 12, 2017 2:41 PM
To: Frances Carrillo
Subject: FW: changes

Categories: Regulation

 
 
 
From: Vibha Vig [ ]
Sent: Thursday, October 12, 2017 1:04 PM
To: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE
Subject: changes

Dear Sirs,
I am writing to you in concern regarding the proposed rule changes for prescribing controlled substances. As I
am aware of the epidemic of Opioids in our state and how each one of us must practice responsible medicine, I
am worried how these changes might affect the ADHD patients that I follow in my practice. There are several
that are on Stimulants and come in once a month for their Rx refills. How will the prescribing pattern and
documentation change in the future with regards to these medicines?

Vibha Vig, MD Pediatrics

Sunshine Children's Clinics: Canton, Carthage and Yazoo City
PO Box 626, Canton, MS 39046
601-855-5287
www.sunshinechildrensclinic.com

8
Frances Carrillo

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

Sent: Thursday, October 12, 2017 7:47 AM
To: Frances Carrillo
Subject: FW: Adm. Cod Part 2640

Follow Up Flag: Follow up

Flag Status: Flagged

Categories: Regulation

-----Original Message-----
From: My Phone
Sent: Wednesday, October 11, 2017 9:56 PM
To: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE
Subject: Adm. Cod Part 2640

Dear Sirs,

As a friend of someone who suffered opioid addiction and a witness to the reality of narcotic-related deaths in
our country, I am all for the State Board getting aggressive in the fight against the illegal and imprudent use of
such drugs in the medical community. As a pediatrician in this state, however, I am extremely concerned
about the proposed changes to Administrative Code Part 2640 and how they might affect my practice and
patient care.

General pediatricians rarely have to deal with chronic pain and long-term opioid use. What we DO often
prescribe is behavior-modifying medications. These controlled substances already have a number of safety
standards built in: meds cannot be prescribed over the phone, there can be no refills and only 30 day supplies
can be given (in addition to up to two post-dated prescriptions). There are many limitations such as those
found on the various preferred drug lists we deal with and, not infrequently, medications require prior approval.

What we do not want to see with these new changes is anything that makes care of our patients more difficult
or cumbersome. These patients with ADHD and related conditions need long term, daily medications and
have to follow-up with their physicians frequently. Please take into consideration these physician/patient
relationships when proposing prescribing changes.

Sincerely,

Mike Artigues, M.D.

McComb Children’s Clinic
McComb, MS

19