State Member Board Briefs

PCA SEEKS TO BETTER DEFINE ITS MISSION

During the past six months, the Patient Care Assessment Division (PCA) has been taking time to reflect on its role in the arena of patient safety and quality in the Commonwealth. What does PCA need to be? Not just a collector of reports, but a distributor of information. Not a narrow analyzer of unique reports, but a consensus builder of best practices for categories of errors, a claxon to avoid pitfalls. There are other organizations similarly involved in quality and patient safety initiatives that have worked hard to improve the quality of care for patients in the Commonwealth, such as the Department of Public Health, Joint Commission, Betsy Lehman Center, Massachusetts Coalition for Prevention of Medical Errors, Leapfrog and the Institute for Healthcare Improvement.

So why do we need PCA? For two very important and powerful reasons: (1) PCA can ensure physician involvement in patient safety and quality programs; and (2) reports made to PCA are provided statutory confidential protections. PCA is able to oversee, but not compromise, the peer review processes in health care facilities. So how does PCA fulfill its mission? Our challenge is to achieve results using persuasive, collaborative, attractive strategies; to thread the needle between over-assertiveness, which worsens relationships, and too little, which limits achievement. Some health care facilities argue that PCA has been neither efficient nor effective in improving patient safety, that the reports received from PCA only serve as a substrate for argument about who is right, the institution or the PCA reviewer. Many others acknowledge that PCA has been effective in identifying quality and patient safety systems that were functioning in name only, not truly the fabric of the institution. For those health care facilities, the authority of PCA was the impetus for the cultural change that was needed to make quality and patient safety the top priority at the governing board level.

Where does PCA begin? Keeping the “big picture” in mind is essential. All of us, as patients or potential patients, know that having a renowned physician doesn't assure that we will receive the best care. Successful health care must include everyone, from housekeeping to house officers. Our first step is the expansion of the PCA Committee. We now have a more diverse, multidisciplinary committee that includes health care quality experts and a patient advocate. We look forward to the new PCA Committee members being our “ambassadors” for change. As Verizon says, “it's the network.”

Generating more reports is not the answer. It is about better reports. The Department of Public Health collects and investigates “Serious Reportable Events” (SREs) as defined by the National Quality Forum. Some SREs are also reported to PCA under the PCA regulations requiring the reporting of certain unexpected serious patient outcomes. SREs are only a small subset of the reports received by PCA. In fact, last year only 25 percent of the unexpected events reported to PCA met SRE reporting criteria. It is through the review of those “non- SRE” reports that we have been able to understand how institutions identify quality problems, determine causes of the problems and implement solutions. Our goal for 2009 is to find the best way to use the information we receive in reports to PCA to make patients safer in the Commonwealth. We look forward to working with the newly expanded PCA Committee, the other organizations involved in patient safety and quality, and most importantly with the individual health care facilities to meet this challenge.

By improving the efficiency and expediency in its methods for overseeing patient care in hospitals, PCA will be able to focus more on how it can assure quality patient care in the office setting. As with the institutions, it is only with collaboration and consensus building that this work can be done. These efforts are ongoing. PCA is working closely with the Massachusetts Medical Society and physicians leaders in the state on strategies for improving credentialing practices, statewide. We look forward to making great strides in this initiative in 2009.

SOUTHCOAST HOSPITALS GROUP REDUCES INSULIN ASSOCIATED ERRORS

The following Southcoast Hospitals Group actions to reduce errors with insulin products have resulted in a 45 percent reduction in insulin-associated medication errors. These initiatives were developed through the combined efforts of Southcoast's medical staff, and nursing and pharmacy services:

1. Prior to administering a dose of insulin, a second nurse is required by policy to perform a second check, verifying the dose and the type of insulin against the medication administration record.

2. Insulin is designated as a high alert medication requiring special procedures such as the second nurse verification, as well as unique storage and dispensing.

   1. U-500 insulin is only stored within the pharmacy. All doses of U-500 insulin are individually prepared, labeled and dispensed by the pharmacy.

   2. Insulin vials approved for storage in patient care areas are color-coded. Each type of insulin is assigned a color and is stored within a color code bin and labeled with the same color label. This ensures that the insulins are stored separately to avoid confusion and possible error in selecting the wrong product.

3. A physician's preprinted sliding scale insulin order sheet was created to eliminate illegible orders and eliminate the practice of abbreviating units with “u”.

   1. The order sheet provides four different intensity levels of sliding scales to address different patient populations and conditions. It has been readily adopted by the medical staff and has eliminated errors with poorly written orders, confusion between the various insulin types, as well as the incorrect interpretation of the abbreviation of units for an additional zero. The order sheet also lists a four-step algorithm for the treatment of hypoglycemia.

4. In conjunction with the sliding scale order sheet, a corresponding page on the Nursing medication administration record (MAR) for the documentation of all administered sliding scale insulin doses was developed and implemented.

   1. This computer-generated document is produced after review by a pharmacist. The insulin MAR page is specific to the scale ordered eliminating handwritten transcription of the orders. The sliding scale is presented as a two-column table including the glucose level and the amount of insulin to be administered. This eliminates the potential of incorrectly transcribing the order and legibility concerns on the MAR.

   2. The MAR sheet prompts the nurse for appropriate documentation by providing a specific location for the patient's glucose level value, the initials of the nurse administering the dose, as well as that of the nurse performing the required second check.

   3. The MAR sliding scale page contains immediate steps to be taken by the nurse for hypoglycemia and hyperglycemia.

5. For non-sliding scale insulin doses a computer generated MAR page is printed from the pharmacy. This page documents administered insulin doses with specific locations and prompts for glucose levels and nurse initials. This page also contains a table of the various insulin products classified by the onset of action, as well as the brand and generic names. This helps to avoid confusion and reduce the potential of administering the wrong insulin type.

6. Insulin products with the potential for name confusion or mix-up were added to the Hospital's Look-alike/Sound-alike (LASA) list.

   1. Designation as a LASA medication prompts the pharmacist to verify the appropriateness of the order during order review and computer entry. The pharmacist must respond to this computer prompt that such actions have been taken before completing the order.

   2. The LASA designation also generates specific warnings on the labels placed on the insulin vials, as well as similar warnings on the MAR, alerting the nurse to avoid potential confusion with this insulin type.

7. For the long acting insulin products, the pharmacist includes a specific administration time onto the MAR to reduce errors associated with missed doses.

8. SHG has worked to increase nursing and medical staff education and awareness regarding the errors with insulin.

   1. Data regarding the prevalence of insulin errors and the source of the errors is routinely reviewed and discussed at various forums and committees.

   2. A colorful poster entitled “Pause to avoid a medication error” lists insulin as the medication most frequently associated with errors. The poster has endearing animal paw prints across it, playing off the association of Paws and Pause for medication awareness. The posters are located throughout the hospital in all areas where medications are stored as well as at physician lounges and entrances.

Reprinted from the December 2008 online version of First Do No Harm published by the Massachusetts Board of Registration in Medicine

CHANGES IN COLLABORATIVE PRACTICE STATUTE

During the 2008 legislative session the Missouri General Assembly passed Senate Bill 724, which included amendments to the board's collaborative practice act, Section 334.104 RSMo. In addition to allowing advanced practice nurses the authority to administer, dispense or prescribe controlled substances listed in Schedules III, IV and V, the legislation also amended the information that must be contained in a collaborative practice arrangement. Following is a copy of Section 334.104 RSMo. as amended. We would encourage you to specifically review Section 334.104.3 for the information that must be contained in a written collaborative practice arrangement as of August 28, 2008. A complete copy of Senate Bill 724 can be found at www.moga.mo.gov under the icon Truly Agreed/Finally Passed.

1. A physician may enter into collaborative practice arrangements with registered professional nurses. Collaborative practice arrangements shall be in the form of written agreements, jointly agreed-upon protocols, or standing orders for the delivery of health care services. Collaborative practice arrangements, which shall be in writing, may delegate to a registered professional nurse the authority to administer or dispense drugs and provide treatment as long as the delivery of such health care services is within the scope of practice of the registered professional nurse and is consistent with that nurse's skill, training and competence.

2. Collaborative practice arrangements, which shall be in writing, may delegate to a registered professional nurse the authority to administer, dispense or prescribe drugs and provide treatment if the registered professional nurse is an advanced practice nurse as defined in subdivision (2) of section 335.016, RSMo. Collaborative practice arrangements may delegate to an advanced practice registered nurse, as defined in section 335.016, RSMo, the authority to administer, dispense, or prescribe controlled substances listed in Schedules III, IV, and V of section 195.017, RSMo; except that, the collaborative practice arrangement shall not delegate the authority to administer any controlled substances listed in schedules III, IV, and V of section 195.017, RSMo, for the purpose of inducing sedation or general anesthesia for therapeutic, diagnostic, or surgical procedures. Schedule III narcotic controlled substance prescriptions shall be limited to a one hundred twenty hour supply without refill. Such collaborative practice arrangements shall be in the form of written agreements, jointly agreed-upon protocols or standing orders for the delivery of health care services.

3. The written collaborative practice arrangement shall contain at least the following provisions: (1) Complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the advanced practice registered nurse; (2) A list of all other offices or locations besides those listed in subdivision (1) of this subsection where the collaborating physician authorized the advanced practice registered nurse to prescribe; (3) A requirement that there shall be posted at every office where the advanced practice registered nurse is authorized to prescribe, in collaboration with a physician, a prominently displayed disclosure statement informing patients that they may be seen by an advanced practice registered nurse and have the right to see the collaborating physician; (4) All specialty or board certifications of the collaborating physician and all certifications of the advanced practice registered nurse; (5) The manner of collaboration between the collaborating physician and the advanced practice registered nurse, including how the collaborating physician and the advanced practice registered nurse will: (a) Engage in collaborative practice consistent with each professional's skill, training, education, and competence; (b) Maintain geographic proximity; and (c) Provide coverage during absence, incapacity, infirmity, or emergency by the collaborating physician; (6) A description of the advanced practice registered nurse's controlled substance prescriptive authority in collaboration with the physician, including a list of the controlled substances the physician authorizes the nurse to prescribe and documentation that it is consistent with each professional's education, knowledge, skill, and competence; (7) A list of all other written practice agreements of the collaborating physician and the advanced practice registered nurse; (8) The duration of the written practice agreement between the collaborating physician and the advanced practice registered nurse; and (9) A description of the time and manner of the collaborating physician's review of the advanced practice registered nurse's prescribing practices. The description shall include provisions that the advanced practice registered nurse shall submit documentation of the advanced practice registered nurse's scribing practices to the collaborating physician within 14 days. The documentation shall include, but not be limited to, a random sample review by the collaborating physician of at least twenty percent of the charts and medications prescribed.

4. The state board of registration for the healing arts pursuant to section 334.125 and the board of nursing pursuant to section 335.036, RSMo, may jointly promulgate rules regulating the use of collaborative practice arrangements. Such rules shall be limited to specifying geographic areas to be covered, the methods of treatment that may be covered by collaborative practice arrangements and the requirements for review of services provided pursuant to collaborative practice arrangements including delegating authority to prescribe controlled substances. Any rules relating to dispensing or distribution of medications or devices by prescription or prescription drug orders under this section shall be subject to the approval of the state board of pharmacy. Any rules relating to dispensing or distribution of controlled substances by prescription or prescription drug orders under this section shall be subject to the approval of the department of health and senior services and the state board of pharmacy. In order to take effect, such rules shall be approved by a majority vote of a quorum of each board. Neither the state board of registration for the healing arts nor the board of nursing may separately promulgate rules relating to collaborative practice arrangements. Such jointly promulgated rules shall be consistent with guidelines for federally funded clinics. The rulemaking authority granted in this subsection shall not extend to collaborative practice arrangements of hospital employees providing in-patient care within hospitals as defined pursuant to chapter 197, RSMo.

5. The state board of registration for the healing arts shall not deny, revoke, suspend or otherwise take disciplinary action against a physician for health care services delegated to a registered professional nurse provided the provisions of this section and the rules promulgated there under are satisfied. Upon the written request of a physician subject to a disciplinary action imposed as a result of an agreement between a physician and a registered professional nurse or registered physician assistant, whether written or not, prior to August 28, 1993, all records of such disciplinary licensure action and all records pertaining to the filing, investigation or review of an alleged violation of this chapter incurred as a result of such an agreement shall be removed from the records of the state board of registration for the healing arts and the division of professional registration and shall not be disclosed to any public or private entity seeking such information from the board or the division. The state board of registration for the healing arts shall take action to correct reports of alleged violations and disciplinary actions as described in this section that have been submitted to the National Practitioner Data Bank. In subsequent applications or representations relating to his medical practice, a physician completing forms or documents shall not be required to report any actions of the state board of registration for the healing arts for which the records are subject to removal under this section.

6. Within 30 days of any change and on each renewal, the state board of registration for the healing arts shall require every physician to identify whether the physician is engaged in any collaborative practice agreement, including collaborative practice agreements delegating the authority to prescribe controlled substances, or physician assistant agreement and also report to the board the name of each licensed professional with whom the physician has entered into such agreement. The board may make this information available to the public. The board shall track the reported information and may routinely conduct random reviews of such agreements to ensure that agreements are carried out for compliance under this chapter.

7. Notwithstanding any law to the contrary, a certified registered nurse anesthetist as defined in subdivision (8) of section 335.016, RSMo, shall be permitted to provide anesthesia services without a collaborative practice arrangement provided that he or she is under the supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if needed. Nothing in this subsection shall be construed to prohibit or prevent a certified registered nurse anesthetist as defined in subdivision (8) of section 335.016, RSMo, from entering into a collaborative practice arrangement under this section, except that the collaborative practice arrangement may not delegate the authority to prescribe any controlled substances listed in Schedules III, IV, and V of section 195.017, RSMo.

8. A collaborating physician shall not enter into a collaborative practice arrangement with more than three full-time equivalent advanced practice registered nurses. This limitation shall not apply to collaborative arrangements of hospital employees providing inpatient care service in hospitals as defined in chapter 197, RSMo, or population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008.

9. It is the responsibility of the collaborating physician to determine and document the completion of at least a one-month period of time during which the advanced practice registered nurse shall practice with the collaborating physician continuously present before practicing in a setting where the collaborating physician is not continuously present. This limitation shall not apply to collaborative arrangements of providers of population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008.

10. No agreement made under this section shall supersede current hospital licensing regulations governing hospital medication orders under protocols or standing orders for the purpose of delivering inpatient or emergency care within a hospital as defined in section 197.020, RSMo, if the hospital's medical staff and pharmaceutical therapeutics committee have approved such protocols or standing orders.

11. No contract or other agreement shall require a physician to act as a collaborating physician for an advanced practice registered nurse against the physician's will. A physician shall have the right to refuse to act as a collaborating physician, without penalty, for a particular advanced practice registered nurse. No contract or other agreement shall limit the collaborating physician's ultimate authority over any protocols or standing orders or in the delegation of the physician's authority to any advanced practice registered nurse, but this requirement shall not authorize a physician in implementing such protocols, standing orders, or delegation to violate applicable standards for safe medical practice established by hospital's medical staff.

12. No contract or other agreement shall require any advanced practice registered nurse to serve as a collaborating advanced practice registered nurse for any collaborating physician against the advanced practice registered nurse's will. An advanced practice registered nurse shall have the right to refuse to collaborate, without penalty, with a particular physician.

Reprinted from vol. 23 issue 2 online version of Healing Art News, published by the Missouri Board of Registration for the Healing Arts.

CHIEF MEDICAL OFFICER LIMITS BSDC LICENSE IN RESPONSE TO INVESTIGATION

Joann Schaefer, M.D., Nebraska's chief medical officer, recently issued an order limiting the license for the Beatrice State Developmental Center (BSDC). The order prevents the facility from caring for medically fragile residents.

In limiting the license of BSDC, Dr. Schaefer ordered that “medically fragile” residents be transported to a Lincoln or Omaha hospital by 5 p.m. Feb. 6. The order will affect an estimated 35 to 40 residents.

“It is my medical opinion BSDC can no longer care for individuals with complex medical needs,” Dr. Schaefer said. “Because of this, I am ordering additional nursing staff to be at the facility around the clock and the removal of any resident deemed medically fragile in order to ensure their safety.”

The orders are the result of an investigation conducted by the Nebraska Department of Health and Human Services (DHHS) Regulation and Licensure Unit. In addition, the Centers for Medicaid and Medicare Services issued an immediate jeopardy for the facility based on the findings of state investigators. The immediate jeopardy cites a failure to provide adequate care to a resident in need of emergency assistance.

Gov. Dave Heineman was informed of the orders over the weekend and directed a team of DHHS and BSDC leaders to coordinate the removal of all medically fragile residents. Officials are notifying families and guardians of the relocation order and making arrangements for safe transportation to private hospitals in the coming days.

Gov. Heineman said, “In Dr. Schaefer's medical opinion and according to state statute, these medically fragile residents may be in imminent danger of death or serious physical harm. This is a very serious situation and I am in full and complete support of her actions.”

State Statute 71–446 gives the chief medical officer the authority to temporarily suspend or limit the license of Nebraska health care facilities and order the removal of at-risk individuals.

The order does not impact care being provided to other BSDC residents. The facility will continue to provide residential care and treatment for individuals with developmental disabilities.

Medically fragile individuals are those with developmental disabilities and additional complications such as seizure disorders, diabetes or other medical conditions requiring intensive monitoring and care, and/or the response to a complication emergency. Medically fragile residents make up less than 20 percent of the current BSDC population.

Hospitals expected to receive BSDC residents include Bryan/LGH and St. Elizabeth hospitals in Lincoln, as well as Creighton University Medical Center, The Nebraska Medical Center and Alegent Health Systems.

Reprinted from the Nebraska Department of Health and Human Services website.

MALPRACTICE REPORTING AND RULES WIN UNANIMOUS APPROVAL. OPPONENTS FORCE RECONSIDERATION BY NC GENERAL ASSEMBLY

Rules developed by the North Carolina Medical Board to govern the public reporting of medical malpractice payments won unanimous approval. The rules were approved by the Rules Review Commission, which oversees changes to the North Carolina Administrative Code.

The rules, passed in July by the medical board, apply to all licensed North Carolina physicians and physician assistants. They call for posting online all malpractice judgments, awards, payments and settlements greater than $25,000 occurring on or after Oct. 1, 2007.

Typically rules take effect the first day of the month immediately following approval by the state Rules Review Commission—Sept. 1 in this case. However, the commission received a sufficient number of letters objecting to the board's rules to require that the General Assembly have an opportunity to review the rules. The legislature does not reconvene for the 2009 long session until Jan. 28. The earliest the board's rules could take effect is March 2009.

The board hopes to unveil expanded practitioner profiles, including malpractice information, later this year.

DRUG OVERDOSE PREVENTION

The board is concerned about the three-fold rise in overdose deaths over the past decade in the State of North Carolina as a result of both prescription and non-prescription drugs. The board has reviewed, and is encouraged by, the efforts of Project Lazarus, a pilot program in Wilkes County that is attempting to reduce the number of drug overdoses by making the drug naloxone* and an educational program on its use available to those persons at risk of suffering a drug overdose.

The prevention of drug overdoses is consistent with the board's statutory mission to protect the people of North Carolina. The board therefore encourages its licensees to cooperate with programs like Project Lazarus in their efforts to make naloxone available to persons at risk of suffering opioid drug overdose.

* Naloxone is the antidote used in emergency medical settings to reverse respiratory depression due to opioid toxicity.

Reprinted from the North Carolina Medical Board website.

TECHMED TO THE RESCUE!

In January 2006, the Oregon Medical Board began a complete overhaul of its database systems to ensure that the board continues to complete licensing and renewal of licenses in a timely manner, investigates complaints that appear to be in violation of the Medical Practice Act, and monitors licensees under disciplinary action or probation.

The current system is more than 15 years old and is inadequate for case management activities. It also is unable to meet applicant, licensee and other customer expectations for services, such as online processing and payment for license renewals.

In April 2008, the board signed a contract with GL Suite (GLS), a company from Bend, to create a system that will meet the above expectations and more. Board staff has worked tirelessly with GLS to create a clear vision of what is needed to efficiently manage cases and process licenses and renewal applications, along with bringing more convenience to the process by adding additional online options.

The estimated completion date is March 2009. At that time, the board will have a unified system that will allow the licensing and investigations depertments to work in a more cohesive manner and provide more fluidity between all board departments, while increasing our customer service levels and providing more opportunities for convenience.

Reprinted from the online version of vol. 120 issue 1 of the Oregon Medical Board Report, published by the Oregon Medical Board.

TMB CONDUCTS TOWN HALL MEETINGS THROUGHOUT TEXAS

Over the course of 14 weeks this summer, the Texas Medical Board conducted 13 Town Hall meetings, visiting every region of the state. Almost 450 people came to the meetings, the vast majority of whom were physicians. Board members and staff listened to a lot of complaints, heard some good ideas and answered many, many questions about the board and its practices.

The board already has begun to act on some of the good suggestions that were offered this summer and at meetings earlier in the year:

• Administrative violations: The board heard numerous complaints regarding administrative complaints and the time required to resolve them. Many doctors suggested the board should devote far less attention to administrative violations and concentrate more of its resources toward prosecuting doctors who pose a threat to the public. The board agrees. Earlier this year the board instituted a “fast track” procedure for administrative violations. The procedure allows these minor violations to be processed and resolved quickly.

• Education: Many suggested the board should provide more education for the profession to help physicians avoid violations in the first place. The board agrees that both licensees and the public are much better served if a violation never occurs. To that end, the board included in its Legislative Appropriation Request to the 81st Texas Legislature a request for funding for an educational component. If the request is approved, the board will offer three levels of instruction. The first level would target medical students still in school. The second would be for doctors just completing their residencies, and the third would be for mid-career doctors.

• Complaint response time: A frequent complaint was the board does not allow a physician sufficient time to respond during the initial 30-day review period before a complaint is filed for investigation. Because the time-line is statutory, this will require a legislative fix. The board has been talking to key legislators about extending this initial review time to 45 days so the physician will have 28 days to provide an initial response. Currently, 41 percent of jurisdictional complaints are dismissed after this initial review. If more physicians can provide better responses at this initial stage, both the board and the licensees will benefit from saved resources.

It is clear from the comments the board received at the meetings that there is a lot of mistrust of the board, much of it related to misinformation. A possible source of misunderstanding is the confidentiality that surrounds individual cases. That said, the perception of the board can be exaggerated and inaccurate, like a caricature. The board recognizes that the physicians who face board orders make up a very small subset of the 59,000 physicians licensed in Texas. However, the board is charged with enforcing the laws surrounding the practice of medicine in this state and will do what is required to fulfill that charge. The board hopes increased communication and education will help everyone better understand the regulation of the medical profession in this state.

The board also heard that there is frustration in the medical community about the rapidly increasing number of complaints filed every year and the time it takes to resolve them. While a case is pending, a doctor must work under a cloud of suspicion, even in those cases in which the complaint eventually will be dismissed. And the process, the board readily admits, is taking too long. The number of complaints the board receives shot up a couple years ago and shows no signs of easing, resulting in a longer resolution time for all complaints. The board is complaint-driven. When complaints are received, the agency is compelled by law to investigate them. The increase has placed an added burden on the staff and has slowed the process. The board has asked the Texas Legislature for additional employees and appropriations to help break the logjam. Unnecessarily prolonged investigations are a disservice to both the public and to physicians being investigated and detract from the mission of public protection.

The goal for these meetings was to dispel misperceptions and ease frustrations by offering a candid discussion, answering questions and presenting ideas in an open, informal setting. The board also wanted to collect ideas about what the board could do to make adherence to the rules easier for physicians without compromising on its vital core mission, which is to protect the public. The board wanted to achieve a higher level of interaction between the regulator and the regulated.

On these counts, the meetings were successful. The board learned a lot from the doctors who attended the meetings, and participants left with a better appreciation of what the board seeks to do and the reasoning behind the methods used to accomplish it.

The board is still analyzing comments and suggestions collected at the Town Hall meetings, but board members and staff know there are other good ideas that were offered for consideration. The board will be reviewing these further, looking for those suggestions that will help ease the regulatory burden without sacrificing the board's mission.

To read the meeting notes from the Town Hall meetings, go to http://www.tmb.state.tx.us/townhall/meetings2008.php.

Reprinted from the Texas Medical Board website.

METHADONE: THE GOOD, THE BAD AND THE UGLY

Alvin H. Moss, M.D., FAAHPM, and Michael G. O'Neil, PharmD

West Virginia physicians need to know the ugly truth about the use of methadone for pain management. In West Virginia between 2001 and 2006, the number of unintentional drug overdoses associated with methadone resulting in death increased sixfold.

• (1) Between 1999 and 2004 the percentage change in unintentional poisoning mortality rate (most poisoning deaths are due to drug overdoses) was higher in West Virginia, 550 percent, than in any other state.

• (2) More patients dying of unintentional drug overdoses died from methadone overdose than any other medication. Clearly methadone should only be prescribed for those patients when other medications have not satisfactorily controlled their pain. For each patient prescribed a controlled substance, especially patients who are prescribed methadone, attention needs to be given to the possibility of drug abuse, diversion, and serious drug interactions.

The good is that methadone is increasingly being recognized as a useful alternative for the treatment of cancer pain and is effective in the treatment of both nociceptive and neuropathic pain. It blocks the N-methyl D-aspartate (NMDA) receptor channel complex in the dorsum of the spinal cord and is a mu, kappa and delta opioid receptor agonist. Methadone is also inexpensive, costing about one-tenth the amount of morphine. Because methadone has a long half-life, which increases the longer the medication is prescribed, methadone can be dosed at extended intervals (every eight to 12 hours) for the treatment of chronic pain and for end-of-life care. Because methadone is metabolized by the liver and there are no renally excreted active metabolites, methadone is one of the safer opioids analgesics to use in patients with chronic kidney disease.

Methadone's bad properties include that it has a long and variable half-life and that it has a large number of interactions with other medications. Conversion from other opioids to methadone can be challenging (there are several different approaches), and there is not a standard approach for converting from methadone to other opioids. Drug interactions with methadone may lead to an increase or decrease in methadone levels. Because of its long half life, if a physician over shoots on his or her initial dosing of methadone, patients may need to be treated with a naloxone continuous infusion until the patient wakes up from the central nervous system depressant effects of the methadone.

Physicians should not prescribe methadone for the treatment of chronic pain unless they are well versed in its pharmacokinetics, drug interactions and conversion from other opioids analgesics. Physicians who want to prescribe methadone in their practice should obtain continuing medical education on its use.