02 Part 2640 Public Comments Oct 06 - Oct 11 - Redacted

Frances Carrillo
From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

Sent: Friday, October 06, 2017 2:33 PM
To: Frances Carrillo
Subject: FW: Regarding new pain rules

From: Miss Magnolia
To: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE; Beth Embry
Subject: Regarding new pain rules
 Dear MSBL
 after careful consideration of the proposed new rules:
 These rules will disproportionately affect patients with legitimate chronic pain. Legitimate chronic pain
patients do not abuse or misuse and it is not appropriate or in their best interest to criminalize them and
take away their ability to have quality of life due to the addicts that do abuse.
 There are few pain management specialists in rural areas. There are legitimate patients with arthritis
pain that I send to rheumatology that states they do not prescribe pain medications for arthitis, they in
turn send them to Pain Management who state that they do not prescribe pain medications for arthritis,
the patients come back to me and I would have to tell them that they can not have chronic arthritis pain
relief due to Mississippi laws, this is infringement on their rights as patients to have adequate care for
their pain. Stating that all of them can be treated by NSAIDS is not the answer as most can not Tolerate
NSAIDS and a large number of them are on anti-coagulants and legitimately can not take NSAIDS. The
board would leave them with little to no way of getting adequate pain relief and decrease their quality of
life. This in turn may increase our number of elderly suicides.
 We are concerned about the Opioid and Benzo withdrawal from patients who are appropriately taking
medications if their medication is abruptly stopped by their family physician. This would create undue
burden and cost on our already fragile healthcare system.
 100 hours of interactive live CME required for pain management certification puts a considerable time
and financial burden on a family doctor with a full-time practice.
 Family physicians are already overladen with regulations and these rules would take away even more
time from our patients.
 Because the MSBML does not regulate Advanced Practice Registered Nurses (APRN), I am concerned
patients with chronic pain or even recurrent acute pain will self-select APRNs to manage their chronic
pain due to physician access issues. This would further affect physicians' willingness to collaborate with
APRNs and potentially lead to quality of care issues. APRN's are being less scrutinized and I fear that
they are prescribing to a lot of the people that are addicted or abusers. Futhermore, due to thier
collaboraters getting sanctioned when they are not following guidelines when the collaboraters can not
spend every second of the day monitoring the APN's, Most of us have decided to not collaborate with
them.
1
 We are concerned the amount of opioid overdose deaths due to heroin will continue to increase because
of these regulations. In January of 2014 the state of Florida enacted similar rules and there was a
diproportionate amount of deaths from heroin in the ensuing months, If patients are not able to control
their pain with the type of controls that are being enacted, it will not stop overdoses but increase
overdoses by people looking to control their pain with street drugs and not knowing how or how much
to take. Again, legitimate chronic pain patients do not abuse or misuse and it is not appropriate to
criminalize them and take away their ability to have quality of life due to the addicts that do abuse.
 For patients stable on a pain regimen for a number of years, it would be a challenge to get them
comfortable on another medication. If a medication that does not interact with their polypharmacy that
most of them are on can be found, which would take time if any substitute could actually be
found. Stating that all of them can be treated by NSAIDS is not the answer as most can not Tolerate
NSAIDS and a large number of them are on anti-coagulants and legitimately can not take NSAID,
Limiting what they would be able to use, by restricting what can be prescribed, again would infringe on
their rights for Pain relief and quality of life.
Kim Mitchell‐Silver, M.D., FM
2
Frances Carrillo
From: RHONDA FREEMAN

Sent: Friday, October 06, 2017 11:04 AM
Subject: FW: Opioid Use

From: (Lois Jones)
Sent: Friday, October 06, 2017 10:58 AM
To: RHONDA FREEMAN
Subject: Opioid Use

Here we go again! Some abusers causing problems for those who sincerely need the medications. Which means, it will
be harder for them to get the meds they actually need. I have a brother with Psoriatic arthritis & sister who has
titanium rods in her spine due to degenerative arthritis. How much more difficult will obtaining their meds become? It’s
such a shame that those who actually need these meds should have to be subjected to such harassment.
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4
Frances Carrillo

Sent: Monday, October 09, 2017 9:39 PM
Subject: FW: New narcotic regulations
Categories: Regulation

From: Ben Kitchens
To: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE
Cc:
Subject: New narcotic regulations
Patients who are homebound, in nursing homes, hospitals or assisted care facilities should probably be placed
in the same category as cancer patients and eliminated from the regulations as they could not be expected to
fully comply.

Ben E. Kitchens M.D.
1
Frances Carrillo

Subject: FW: Opioids
-----Original Message-----
From: richard bates
Sent: Saturday, October 07, 2017 12:56 AM
Subject: Opioids
Make it illegal for any physician to prescribe opioids except an er doc or pain specialist. This would reduce the
amount of paperwork and protect the public from over prescribing doctors.
Sent from my iPhone
2
Frances Carrillo

Subject: FW: Opioid rules
From: Neil R Wanee
Sent: Saturday, October 07, 2017 7:04 PM
Subject: Opioid rules
I think that the rules proposed are somewhat excessive. Using the PMP at each visit for Long term patients is
excessive. Please consider at the first 4 visits and then twice yearly. Same for POS drug testing. Also, the
rule about benzos with opiates is going to be a problem for the many long term patients who have been
managed and are stable on their regimen. How about making the rule that no one on opiates may be given a
benzodiazepine and vice versa. This would not penalize all the patients currently prescribed both who have
been on them for years. While benzos are certainly not optimal for first line treatment for anxiety disorders,
their are some people who legitimately respond to nothing else. Pain and anxiety unfortunately are not
mutually exclusive disease states.
I also would suggest that doctors get education on using Suboxone and have this included in the 5 hrs of
biannual required opioid CME.
Sent from my iPad
3
Frances Carrillo

Subject: FW: Feedback on Proposed Rules Regarding Scheduled Drugs

From: Dr Shane Scott
Sent: Sunday, October 08, 2017 12:54 PM
Subject: Feedback on Proposed Rules Regarding Scheduled Drugs
I am concerned regarding Section 1.10 H : "Benzodiazepines limited to 1 month supply”. This would also
include those use for insomnia (Restoril, Ambien, etc). I would ask that these be granted a 90 day supply with
no refills.
Our current clinic policy requires a provider visit every 90 days to assess the need for these
medications. Although they are designed for short term use, many patients find they are necessary for adequate
sleep.
1.7 K : Drug testing. Is it in the Board’s power to mandate these be covered/adequately reimbursed tests by
government and private insurances?
Thanks
MSS
4
Frances Carrillo

Subject: FW: your proposed pain medicine regulations
From: JAMES DENNEY
Sent: Monday, October 09, 2017 8:33 AM
Cc:
Subject: your proposed pain medicine regulations
Dear Sirs and Madams, As a physician in Picayune, I have a number of patients who have to take pain
medicines for chronic pain either due to the severity of their pain or sometimes due to the fact their kidneys
cannot tolerate nsaids and as you know, nsaids have cardiovascular risks which in some cases are not
acceptable. A fraction of these patients also have chronic anxiety which is not controlled with SSRIs and
NSRIs and Buspar alone. These patients are stable on the combination of narcotics and benzodiazepines and
while it is a high risk combination and they have been made aware of it and I am aware of it, I genuinely do not
believe these patients can function without both medicines. Your new rules would prevent me from being able
to continue to care for their needs. I realize I am advocating for probably less than 10 patients in my practice
but they are worth advocating for. It is unclear to me what I would do if forced to find a specialist for one
problem, whether it would be acceptable to keep treating the other problem.
I actually appreciate specific guidance on urine drug testing preferences for the MS DEA.
It would be nice to document MSPMP checked without having to print it and upload it into the patient's chart.
I understand there is a serious abuse or prescription drugs, but your regulations do make it hard for the
patients in whom their medications help them function better and they do not abuse their medicines.
Delora Denney, MD
5
Frances Carrillo

Subject: FW: point of service drug testing
From: JAMES DENNEY
Cc:
Subject: point of service drug testing
One additional comment is that point of service drug testing is not overly accurate so I have opted for send out
testing with confirmation ability. I understand the advantages of both, but when I tried doing both, it added cost
to the patient and did not seem to add benefit to my ability to discern who to give medicines to. I have had
occasions when tests have come back showing marijuana or other things that might have changed my care.
Delora denney, md
6
Frances Carrillo

Subject: Fwd: new opiate recommendations
Rhonda
Begin forwarded message:
From: chad hosemann >

Date: October 9, 2017 at 1:30:41 PM CDT
To: "rhonda@msbml.ms.gov" <rhonda@msbml.ms.gov>
Subject: new opiate recommendations
Reply-To: chad hosemann
To whom it may concern, my name is chad hosemann and i'm an orthopaedic surgeon at capital
orthopaedic in flowood. I am writing to request a full stop to the nonsense that is being proposed by the
board for schedule 2's. As I write this, my rather large clinical staff is working frantically to keep up with
scanning and filling in all of the redundant information into our brand new "streamlined" emr. They
certainly are already strapped for time and my overhead is stifling due to all the regulations put into place
on us already. We are barely making it out here in the "real world". You guys need to take a long hard
look at the redundancy and ridiculousness of the policies you have proposed and think about it's impact
on us little guys out here, the actual doctors....Having my nurse run a PMP on every patient every time
and scanning it into the chart is ludicrous. This information is readily available online, why do I need it in
my chart? Who exactly is going to do my point of service drug tests for me? I don't have a lab or any way
to quality control that???! If you prohibit a orthopaedic post op patients to 7 days narcotic, there are going
to be a lot of people riding around on the streets of Mississippi in slings and casts trying to get to my clinic
to get more narcotic in severe pain.There is so much wrong with that policy I cannot even go into it. If you
have ever had orthopedic surgery then you would understand. Many of my patients live 2 hours away.
This is a rural state with little medical care outside of the major cities. If they are in pain management
clinics then their pain management physician is expecting me to write their postoperative narcotic.
Therefore they will be getting on the road about every 5 days to try to get up here to get it as they will be
in continued pain that is quite severe for the first few weeks.This is obviously extremely dangerous.
We are so incredibly regulated at this point. Why don't you guys take a break from the regulations and let
us do our jobs that we went to school for a decade to do. I have been in practice for 6 years now as an
orthopedic surgeon. I probably right more narcotic than most doctors in Mississippi. I cannot recall 1 of my
postoperative patients that ended up with a significant narcotic problem. We get them off their pain
medication within 90 days If that does not work, we will get them to the appropriate pain management
clinic. Most people are off narcotic within just 4-6 weeks and we keep close tabs on it trust me.
Please take a step back and rethink this proposal. This is not the answer you are looking for...go back to
the drawing board, talk to real doctors on the front lines, and then come up with some realistic and
innovative policies.
Chad Hosemann, MD
7
Frances Carrillo

Subject: Fwd: Opioid Prescribing rules
Attachments: image001.jpg; image002.jpg; image003.png; image004.png

Rhonda

From: Jeff Bedford
Subject: Opioid Prescribing rules
Rhonda,

Good afternoon, I hope your day is going well. We are all very pleased that there are efforts being
made to help curb the current opioid epidemic.

We (statewide physicians) recently went through something very similar with BCBS of MS in relation to
opioid prescriptions. The post‐operative patients were given a slightly different set of rules than pain
management and general practice. The information my physicians have brought me I do not see any
details relating to post‐operative patients. Where do these patients fall under this new set of rules?

Thanks,

The link ed image cannot be display ed.
The file may hav e been mov ed, renamed,
or deleted . Verify that the link points to
the correct file and location.
JEFF BEDFORD
Chief Executive Officer

The link ed image cannot be display ed. The file may hav e been mov ed, renamed, or deleted. Verify that the link points to the correct file and location.
290 E. Layfair Dr Suite A, Flowood MS 39232

Phone: 601-987-8200
Web: capitalorthosports.com

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8
Frances Carrillo

Subject: Fwd: Consideration of Pediatric Post Surgical Pain Management

Rhonda

From: "J. Mark Reed"
Date: October 9, 2017 at 8:06:46 AM CDT
Subject: Consideration of Pediatric Post Surgical Pain Management
October 9, 2017

To Members of the Mississippi Board of Medical Licensure:

Thank you for your efforts in trying to curtail our current epidemic of opioid abuse in the State of
Mississippi. Certainly, some of your proposed changes are well thought out and will be effective.
However, in reading the new requirements, I fail to see reasonable considerations for surgical
practices, particularly those that involve surgery on pediatric patients. Surgical pain is typically
acute and would fall under your current proposal to mandate a prescription monitoring program
report. As a pediatric otolaryngologist, I preform some of the most common (and painful)
procedures done in this country. I was therefore concerned to see the requirement for the
necessity to run a prescription monitoring program report at each encounter when prescribing
opioids. As you would expect, the removal of tonsils is an exceedingly painful surgery and
frequently requires opioids to control the pain in postoperative pediatric patients. The necessity
to run a report on a four or five year-old child is not only unnecessary from an abuse perspective,
but produces a real and undue burden on a busy surgical practice. Obviously, there are many
other specialties who perform surgery on pediatric patients and would be affected by the new
proposals. The purpose of a new bureaucratic requirement should meet its intended goal in
virtually every case, however, to introduce a new burden when it fails to serve its intended
purpose is nothing more than a complete waste of very valuable time and effort. Please consider
any new requirements to be tailored for their intended purpose- the cessation of abuse- not to
penalize those who appropriately prescribe or receive necessary pain medications for post-
surgical acute pain.

Thank you in advance for your consideration of modifications to the current proposals especially
in light of pediatric practices and acute post-operative pain. Consideration of age modifications
would be very appropriate and thoughtful.

Sincerely,
9

J. Mark Reed, MD, FAAP, FACS
Chief, Division of Pediatric Otolaryngology
University of Mississippi Medical Center
Batson Children’s Hospital

Individuals who have received this information in error or are not authorized to receive it must
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10
Frances Carrillo

Subject: Fwd: "Opposed" to Current Proposal for Prescribing Regulation
Follow Up Flag: Follow up

Flag Status: Flagged
Rhonda
From: "Jason Murphy, M.D."

To: <rhonda@msbml.ms.gov>
Cc:
Subject: "Opposed" to Current Proposal for Prescribing Regulation

Reply-To: "Jason Murphy, M.D."
Dear Drs. Miles, Brunson, Rea, Crawford, Easterling, Lippincott, Mayo, McClendon, and
Owens:
I am writing this e-mail to the Mississippi State Board of Medical Licensure as I stand in
'STRONG' opposition to the currently written proposed changes to prescribing regulations by the
Mississippi Board of Medical Licensure. The regulations as they are written do not reflect a
reasonable understanding of the day to day operations of surgical practices in the state of
MS. The burdens that will be imposed on the physicians and their staff are unreasonable and not
acceptable to an efficiently functioning surgical practice. I do stand in strong support of
regulating opioid prescribing, but the current proposed regulations are only functional for 'in
clinic' operations. Again, the duties being asked of the surgeons are not reasonable when they
are treating patients in an outpatient surgical setting. I would be happy to discuss this further
with any of the Board members. Please feel free to contact me at you convenience via my cell
phone, 601-572-0400.
Sincerely,
Jason
Jason G. Murphy, M.D., F.A.C.S.

General Surgeon
11
Surgical Clinic Associates, P.A.
501 Marshall St., Suite 500
Jackson, MS 39202
12
Frances Carrillo

Subject: Fwd: Opioid Prescribing Proposal
Attachments: Letter to MSBML.docx; ATT00001.htm
Rhonda
From: corey jackson >

To: "Rhonda@msbml.ms.gov" <Rhonda@msbml.ms.gov>
Subject: Re: Opioid Prescribing Proposal
Reply-To: corey jackson
Please see attachment.
Thank you,
Corey Jackson
13
MSBML:
Upon review of recent proposed change to prescribing practices, I feel it is my obligation to not only
request a formal hearing but also advocate for my patients first and my colleagues second. I am
concerned that this proposal will bring about serious and unintentional consequences that lie far
beyond its purposed impact. Shedding focus upon my profession of psychiatry, our patients currently
have enough barriers to care in Mississippi without placing another before them. And I may be wrong,
but I feel that some of the proposals will simply result in that very thing without yielding the benefits we
all desire.
I am personally unfamiliar with a single event of benzodiazepine overdose coming to clinical attention
which resulted in death. Most cases of fatal overdose were the result of combining benzodiazepines
with other substances like opioids, the intended focus of the Governor’s task force. Let us keep our
eyes upon the prize. History is fraught with those in leadership positions who lost sight of the mission
and went astray. Let us not be placed in that category with this proposal.
Our patients wait long enough to be seen for intake evaluations, and even longer to see a prescribing
provider. Unintended as it may be, this proposal will likely make that wait even longer. Those waiting
may not even require medications covered by the proposal; however, they will likely be made to wait
nonetheless. I speak of individuals who may be recently discharged from an inpatient service following
their first psychotic break, or a new mother recently diagnosed with post‐partum depression that simply
needs to be seen as a referral to a psychiatrist from her PCP. She will be made to wait while struggling
with a treatable disease during the first weeks of her newborn’s life. Let us keep our eyes upon the
prize.
Let us now turn attention to the provider just starting up his or her practice. This proposal now places
yet another extremely time‐consuming regulatory step in their operational logistics. The results of this
additional step, which may not yet be so apparent, could be devastating to business and force providers
across the state to seek other employment options. Again, let us keep our eyes upon the prize.
I am personally unfamiliar with a single psychiatric provider in my community who does not hold
dearest to the oath, “primum non nocere.” We are a personable and well‐rounded group of individuals
with competency in our craft and a solemn heartfelt duty to both our patients and their loved ones. We
check the PMP when clinically indicated, not when forced. We do not dispense or prescribe medications
when they are not indicated. We do not prescribe at all when it is not the answer. We are practitioners
of medicine. Let us keep our eyes upon the prize.
Respectfully,
Jon Corey Jackson, M.D.
Diplomate, American Board of Psychiatry and Neurology
Secretary, Mississippi Psychiatric Association
Delegate, Central Mississippi Medical Society, MSMA

Frances Carrillo

Subject: Fwd: Opioid prescribing
Rhonda
From: Lisa Leek >

To:
Subject: Opioid prescribing
These proposed rules would put a HUGE and unnecessary burden on emergency physicians who
routinely treat acutely painful conditions. I find it hard to believe that I would be required to
consult the PMP for every patient with a broken bone or severely painful abscess.
As an emergency physician I am fully aware of our drug seeking population. These patients are
usually easily identified by their repeat visits. I think that these proposed rules are going way
overboard. They will add burden to our already very busy emergency department. I went to
medical school to help people, not to be subjected to endless rules and unnecessary regulations.
Please don't forget that most physicians have a very clear understanding of our opioid problem
and are already very judicious in their prescribing habits.
Please reconsider these rules. While they are well meaning they are not at all well written.
Lisa Loughman Leek, M.D.
Sent from my iPhone
14
Frances Carrillo

Subject: Fwd: New opioid prescribing rules
Rhonda
From: Brett Lampton

Subject: New opioid prescribing rules
After speaking with a couple of MSBL members, I was given the impression that these new
rules do not apply to inpatient facilities(i.e...hospitals, acute inpatient rehabs, swing beds, SNF
and LTC)where pts are continuously in a supervised environment. I would like to see some
wordage added to confirm this point.
------Brett Lampton MD
Sent from my iPhone
15
Frances Carrillo

Subject: Fwd: New opioid prescribing rules
Rhonda
From: Brett Lampton

Subject: New opioid prescribing rules
After speaking with a couple of MSBL members, I was given the impression that these new
rules do not apply to inpatient facilities(i.e...hospitals, acute inpatient rehabs, swing beds, SNF
and LTC)where pts are continuously in a supervised environment. I would like to see some
wordage added to confirm this point.
------Brett Lampton MD
Sent from my iPhone
16
Frances Carrillo

Subject: Fwd: Proposed changes to policy on Opiates and Benzodiazepines
Rhonda
From: andrew bishop

Subject: Proposed changes to policy on Opiates and Benzodiazepines
Please accept this as a request for a full hearing on this issue. I wish to make this request ahead
of the deadline. I will shortly forward to you the specific issues that are of concern.
Thank you for this consideration.
Andrew Bishop, MD FAPA
Medical License #009943
Sent from my iPad
17
Frances Carrillo

Subject: Fwd: Opioid rules
Rhonda
From: John White >

Subject: Opioid rules
Gentlemen:
There are enough regulations governing the knowledge and prescribing of medications.
These rather draconian rulings will further complicate and obfuscate the already difficulties of
delivering good treatment to patients.
Thank you,
John J. White, M.D.
18
Frances Carrillo

Sent: Wednesday, October 11, 2017 7:56 AM
Subject: FW: Proposed rules

From: Elizabeth Farrar
Sent: Tuesday, October 10, 2017 9:38 AM
Cc: beth@msafp.org
Subject: Proposed rules
Hello. I am a family physician in Meridian, MS. Your proposed rules for prescribing narcotics are EXTREMELY
burdensome. Do you realize how much time it takes to sign into the PMP system, look up a patient, get their file in a
printable format, print the report and then scan it into the patient's EMR chart? I believe doctors have a pretty good idea
of which patients try to abuse/override the system and we routinely look into their PMP file anyway---without your
mandate---and there is no need to print it out if the patient is compliant and not doctor/pharmacy shopping. Most of my
narcotic patients are older adults with poor kidney function who cannot take NSAIDs and whose lives would be miserable
as they suffer from pain, thus increasing their depression and inactivity and therefore morbidity and mortality. I also worry
about withdrawal from narcotics and benzos because if your proposals are adopted and medications are stopped, patients
who have been on them for years would definitely withdraw and with benzos, this could lead to seizures!
So I am begging you, as a representative of my colleagues and for my chronic pain patients, to not punish us by passing
these prescribing laws. I propose you go "back to the table" and rethink how burdensome these will be for physicians who
are already strapped by governmental regulations like meaningful use. Mississippi is already an underserved
state...imagine how difficult it will be to attract physicians here with such demanding restraints on prescribing. I think the
focus should be on patient education, perhaps through media outlets, and I'm already seeing PSA commercials about it
on TV. This is working as my patients are increasingly asking me about weaning off their medications and engaging me
in conversations about it.
Thank you for your consideration in this matter.
Sincerely,
Elizabeth Vereen Farrar MD
1
Frances Carrillo

Subject: FW: Comments on proposed rule changes
Attachments: Letter to MSBOML re opioid rule changes 2017.docx

From: Kirk Kinard, DO
Sent: Tuesday, October 10, 2017 11:38 PM
Cc:
'
Subject: Comments on proposed rule changes

Please see attached word document. This is a revision of a previous version circulated today with some notable
changes.

Kirk L. Kinard, DO
Medical Director
Willow Pain and Wellness, LLC
2215 Jefferson Davis Drive
Oxford, MS 38655

F: (866) 658‐0083

2
To Whom It May Concern, 10/10/17
After recent conversations with many colleagues, it is apparent that those of us currently
practicing to the standard of care already established by our professional societies, and the
more recent CDC guidelines, are likely to be unaffected by the greater portion of the rule
changes proposed to the MSBOML by the Governor’s task force. Most are reasonable and will
result in positive change. However, there are a few that could prove cumbersome and
potentially counterproductive for the very licensees to which the regulations direct chronic pain
patients for more appropriate care. Specifically, the language regarding the stipulation that a
physician see all new chronic pain patients.
Typically, the Board is highly receptive to constructive and respectful suggestions in these
cases. The following opinions are expressly my own, but very much in line with those gleaned
from recent conversations with other Board-Certified Pain Specialists, referred to as “we” and
“us” throughout. For all intents and purposes, this might also include any licensee in a practice
with a track record of responsible prescribing and utilization of a sound “process” to determine
one’s fitness for any particular chronic pain treatment modality, including opioid therapy.
Below are some excerpts from section 2640 (numerals) which have proposed language
changes and need more clarification and/or revision. I underlined only a portion of the change
for emphasis and listed them in descending order of personal urgency. My comments follow
each quote, with a kind recommendation in bold print.
I. “The initial visit for each patient in a pain management practice must include an in
person evaluation and plan of care by a registered pain management physician.”
If not modified, this would destroy the essence and functionality of collaborative
NP/PA agreements for legitimate pain practices. I personally screen all referrals
and prefer to see as many new patients as physically possible. However, with
the number of patients being funneled our way through via the consequences of
the current regulations, we “specialists would have even less time to perform the
interventions necessary to limit the daily oral analgesic requirement, specifically,
opioid analgesics.
The decision of whether to continue or initiate opioid therapy in a safe manner is

best facilitated by objective protocols which remove emotion and subjectivity from
the exercise. Most of “us” utilize such protocols for every patient and they are
enforced by the entire staff, including the non-physician providers. Once a
medical indication for opioids is determined (fully in the purview of a licensed
APRN/PA by review of old records, treatment history, diagnostics/imaging,
physical examination, etc.), the risk stratification and appropriateness for these
drugs is determined as much by the objective “process” (i.e. review of the PMP,
urine toxicology, pill counts, screening questionnaires), as by the subjective
interview. Obviously, the interview is extremely important, but it is simply not
practical for a physician to complete every one of them if the “specialty” practices
are expected to accommodate the increased patient volume going forward.
Furthermore, this rule change would severely restrict access of new patients to
secondary clinic sites currently operating under collaborative arrangements. The
physician simply cannot be in two places at one time, but the “process” can.
Other places in part 2640 use “licensee” instead of “physician” and substitution of
“licensee” would then include registered APRNs and PAs within practices
directed by a registered pain management physician. This or an outright
exception for registered pain practices directed by a Board-Certified Pain
Specialist would be a welcomed compromise.
II. “When prescribing opioids for either chronic or acute pain, it is considered a
contraindication to prescribe opioids concurrently with Benzodiazepines and/or
Soma. However, opioids and benzodiazepines may be prescribed concurrently on a
very short term basis, and in accordance with section H of this rule, when an acute
injury requiring opioids occurs. The need for such concurrent prescribing must be
documented appropriately in the chart. Patients who are currently on an established
regimen of concomitant opioids and benzodiazepines may be allotted a reasonable
period of time to withdraw from one or both substances.”
I rarely prescribe benzodiazepines or SOMA. If so, only a short-term supply to

prevent acute withdrawal as a taper or bridge to follow-up with a behaviorist or
incorporate a suitable alternative. I also require documentation as to medical
necessity for their use from the prescribing provider if I intend to prescribe
opioids long-term. If they cannot provide documentation and/or it continues to
show up on drug screens, opioids are discontinued politely as a part of the
treatment plan.
“We” fully understand the potential consequences of concomitant use of these

drug classes, referring only to benzodiazepines and opioids. However, we also
appreciate the ever-present dynamic of psychiatric illness as both a progenitor
and consequence of chronic pain. Making a patient choose between disease
states, when there is no known or perceivable threat of abuse, misuse, or
diversion (as determined by our “process”), will cause needless disruption and
some major health crises. Attempting to limit the supply of the abusers in such a
fashion will increase street demand/production of the drugs, and many
responsible patients who benefit medically from such therapy (and have a
protective tolerance to the respiratory depressant effect) will likely gravitate to the
street as a refuge to avoid major physiologic withdrawal or simply achieve the
intended stabilizing effect of the former medication. This threatens to convert
many with uncomplicated dependence on either drug to destructive and
dangerous addictive behavior in a time when rehabilitative resources are
severely lacking.
Responsible prescribing of benzodiazepines should get its equal share of press

today. An exception for patients who have a documented medical
indication for the drug by the prescribing licensee would be a place for
meaningful compromise. It would then place the onus on the appropriate
party, the prescriber of the benzodiazepine, and relieve the pain practitioner of
the responsibility of discontinuing a medically indicated therapy based on a
technicality alone.
III. “Licensees must avoid dosages greater than or equal to 90 mg of morphine
equivalence per day and must provide significant justification for exceeding the 90
mg ceiling stated herein. If the licensee determines that a patient requires greater
than 100 mg of morphine equivalence per day, the licensee must refer the patient to
a pain specialist for further treatment.”
Does this imply that “we” are authorized to exceed 100mg and what “justification”
are “we” then obligated to provide? Again, I am aware of the higher incidence of
complications at doses higher than 100mg. In fact, I presented the very graph
showing such data at one of the Board-sponsored drug summits this year.
Nevertheless, those complications occur mostly in prescription drug abusers
whom are unlikely to avoid detection in practices with sound protocols directed
by Board Certified Pain Specialists. I would welcome any language that then
allowed such practices the freedom to maintain compliant patients on
proven, therapeutic opioid regimens without a morphine equivalence
restriction.
IV. “The use of Methadone to treat chronic and/or acute non-cancer pain is prohibited.”
I also have very few patients for which I prescribe methadone, as with fentanyl,
mainly due to the stigma and medico-legal scrutiny, not for lack of efficacy or
cost.
The pharmacokinetics of methadone must be well understood, but it has

improved efficacy in some primarily neuropathic pain states and is a very cost-
effective option for select patients. This is an ideal place to consider
protection of registered pain practices directed by Board Certified Pain
Specialists and preserve this option for indicated patients whom have
failed to respond to better first-line choices.

Thank you for attention and consideration.
Respectfully,
Kirk L. Kinard, DO
Frances Carrillo


From: Gordon Lyons
To: Kirk Kinard, DO; THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE; RHONDA FREEMAN
Cc:
Subject: Re: Comments on proposed rule changes
Kirk (and Rhonda),
I have not communicated with you before now, but as I am intimately familiar with the updated State of MS
Workers' Compensation Guidelines section on Pain Management in my role as an intermittent second-level
reviewer, I have included part of the updated "Guidelines for the Prescription of Opiates" forwarded to me by
Connie Mills, Director of Cost Containment for the Commission. If the group has time to read and print-off the
section, it will provide an excellent reference source. I can also forward the updated Guidelines via email in the
next few days, in between clinic patients and procedures.
Here is my/WC response (partial) to issue #1 as outlined by the MSBML, and I encourage you to forward my
email to the appropriate inboxes. I have added the italics and underlining. Elsewhere in the "Guidelines" it
mentions "Appropriate and Approved Clinicians", and fails to specifically isolate/identify "Physician" as the
sole qualified clinician. As the vast majority, if not all, "Of US" have been cognizant of and following "Best
Medical Practices" regarding opioid evaluation/prescribing/monitoring/use of Pain Psychologists and
Addictionologists for some time now, I again suggest that "US" (bad grammar) and the MSBML review the
updated Workers' Compensation Guidelines for the Prescription of Opiates". This is all the time I have for now,
and hope this has helped. I recommend using existing Guidelines as a Template, as the team that developed the
Workers' Compensation Guidelines for the Prescription of Opiates deserve our deepest thanks and gratitude,
and perhaps a blend of the two would be more clinically relevant and avoid any unnecessary and onerous
barriers, while maintaining safety for our patient populations.
Sincerely,
Gordon Lyons
II. Scope
3
These guidelines do not focus broadly on pain management, but rather focus on the use of opioids
to manage non-cancer related pain. They apply to all clinicians who prescribe opioids, including
nurse practitioners, physician assistants, podiatrists and dentists.
Clinicians should follow the guidelines. However, failure to follow a guideline will not warrant a
denial of service, with the following exceptions: Section V.C.; VII. B. 9.; E. 2. and 3. and F. 1. and
2.
A. Gordon Lyons M.D.
Fellowship Trained/ABMS Board-Certified
Interventional Pain Medicine and
Anesthesiology
St. Dominic's Pain Management Center

Dominican Plaza
970 Lakeland Drive Suite 45
Jackson, MS 39216
Office 601.200.4690
Office Fax 601.200.4698
From: Kirk Kinard, DO
To: mboard@msbml.ms.gov
Cc:

changes.
Kirk L. Kinard, DO
Medical Director
Oxford, MS 38655
4
F: (866) 658-0083
5
Frances Carrillo

Subject: FW: Comments Concerning New Opioid Prescribing Guidelines

From: Lori Marshall
To: RHONDA FREEMAN
Subject: Comments Concerning New Opioid Prescribing Guidelines
I agree with placing some restrictions on the prescribing of methadone. However, I do not feel that pain
fellowship trained physicians or board certified pain physicians should be unable to prescribe Methadone for
any type of chronic pain. This opioid causes less euphoria when compared to other long-acing opioids for the
treatment of chronic pain. Also, this medication is not expensive and reduced the financial healthcare burden
for patients. This medication is on formulary and is often required by many insurance companies as step
therapy prior to trying other mediations for chronic pain therapy. This medication can also be used as a sole
agent for the treatment of chronic pain without using any short-acting agents for breakthrough pain. It is also a
good option for pain control in patients who have had issues with substance abuse (alcohol, illicit drugs, etc...)
in the past who suffer from chronic pain caused from a variety of diagnoses. I do agree with NOT allowing
physicians who are NOT pain fellowship trained physicians or board certified pain physicians to prescribe
methadone for non-cancer, chronic pain. This medication can be used safely and effectively by practitioners
who are trained to manage and prescribe this medication. I have included some literature citations below for
your review concerning the safe and effective use of methadone for the treatment of chronic pain.
--
Lori Hill Marshall, M.D.
Premier Pain Care, P.C.
Methadone Treatment for Pain States

JAMES D. TOOMBS, M.D., and LEE A. KRAL, PHARM.D, University of Iowa Hospitals and Clinics, Iowa City, Iowa
Am Fam Physician. 2005 Apr 1;71(7):1353-1358.
Methadone is a synthetic opioid with potent analgesic effects. Although it is associated commonly with the treatment
of opioid addiction, it may be prescribed by licensed family physicians for analgesia. Methadone’s unique
pharmacokinetics and pharmacodynamics make it a valuable option in the management of cancer pain and other
chronic pain, including neuropathic pain states. It may be an appropriate replacement for opioids when side effects
have limited further dosage escalation. Metabolism of and response to methadone varies with each patient.
Transition to methadone and dosage titration should be completed slowly and with frequent monitoring. Conversion
6
should be based on the current daily oral morphine equivalent dosage. After starting methadone therapy or
increasing the dosage, systemic toxicity may not become apparent for several days. Some medications alter the
absorption or metabolism of methadone, and their concurrent use may require dosing adjustments. Methadone is
less expensive than other sustained-release opioid formulations.
https://www.practicalpainmanagement.com/treatments/pharmacological/opioids/methadone-pain-
management
Methadone for Pain Management

Over the past 20 years there has been renewed interest in using methadone as an
analgesic—raising concerns about its safety. This educational review discusses the
efficacy and safety of methadone when used in chronic pain management.
By Courtney Krueger, PharmD, BCPS
https://www.practicalpainmanagement.com/treatments/pharmacological/opioids/methadone-pain-
management
Methadone Safety: A Clinical Practice Guideline From the American

Pain Society and College on Problems of Drug Dependence, in
Collaboration With the Heart Rhythm Society
Roger Chou Correspondence information about the author Roger Chou Email the author Roger Chou
,
Ricardo A. Cruciani
,
David A. Fiellin
,
Peggy Compton
,
John T. Farrar
,
Mark C. Haigney
,
Charles Inturrisi
,
John R. Knight
,
Shirley Otis-Green
,
Steven M. Marcus
,
Davendra Mehta
,
Marjorie C. Meyer
,
Russell Portenoy
,
Seddon Savage
,
Eric Strain
,
Sharon Walsh
,
7
Lonnie Zeltzer
Methadone is used for the treatment of opioid addiction and for treatment of chronic pain. The safety of methadone has been called into
question by data indicating a large increase in the number of methadone-associated overdose deaths in recent years that has occurred
in parallel with a dramatic rise in the use of methadone for chronic pain. The American Pain Society and the College on Problems of
Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned an interdisciplinary expert panel to develop a clinical
practice guideline on safer prescribing of methadone for treatment of opioid addiction and chronic pain. As part of the guideline
development process, the American Pain Society commissioned a systematic review of various aspects related to safety of methadone.
After a review of the available evidence, the expert panel concluded that measures can be taken to promote safer use of methadone.
Specific recommendations include the need to educate and counsel patients on methadone safety, use of electrocardiography to
identify persons at greater risk for methadone-associated arrhythmia, use of alternative opioids in patients at high risk of complications
related to corrected electrocardiographic QTc interval prolongation, careful dose initiation and titration of methadone, and diligent
monitoring and follow-up. Although these guidelines are based on a systematic review, the panel identified numerous research gaps,
most recommendations were based on low-quality evidence, and no recommendations were based on high-quality evidence.
http://www.jpain.org/article/S1526-5900(14)00522-7/abstract
Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain
http://americanpainsociety.org/uploads/education/guidelines/chronic-opioid-therapy-cncp.pdf
American Pain Society's New Clinical Practice

Guidelines Promote Safer Use of Methadone
and Highlight Research Gaps
Elabd, Sonia MA
Topics in Pain Management: December 2014 - Volume 30 - Issue 5 - p 9–12
doi: 10.1097/01.TPM.0000458784.89173.f7
http://journals.lww.com/topicsinpainmanagement/Citation/2014/12000/American_Pain_Society_s_Ne
w_Clinical_Practice.2.aspx
8
Frances Carrillo


From: Gordon Lyons
To: Kirk Kinard, DO; THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE; RHONDA FREEMAN
Cc:
Subject: Re: Comments on proposed rule changes
Kirk (and Rhonda),
I have not communicated with you before now, but as I am intimately familiar with the updated State of MS
Workers' Compensation Guidelines section on Pain Management in my role as an intermittent second-level
reviewer, I have included part of the updated "Guidelines for the Prescription of Opiates" forwarded to me by
Connie Mills, Director of Cost Containment for the Commission. If the group has time to read and print-off the
section, it will provide an excellent reference source. I can also forward the updated Guidelines via email in the
next few days, in between clinic patients and procedures.
Here is my/WC response (partial) to issue #1 as outlined by the MSBML, and I encourage you to forward my
email to the appropriate inboxes. I have added the italics and underlining. Elsewhere in the "Guidelines" it
mentions "Appropriate and Approved Clinicians", and fails to specifically isolate/identify "Physician" as the
sole qualified clinician. As the vast majority, if not all, "Of US" have been cognizant of and following "Best
Medical Practices" regarding opioid evaluation/prescribing/monitoring/use of Pain Psychologists and
Addictionologists for some time now, I again suggest that "US" (bad grammar) and the MSBML review the
updated Workers' Compensation Guidelines for the Prescription of Opiates". This is all the time I have for now,
and hope this has helped. I recommend using existing Guidelines as a Template, as the team that developed the
Workers' Compensation Guidelines for the Prescription of Opiates deserve our deepest thanks and gratitude,
and perhaps a blend of the two would be more clinically relevant and avoid any unnecessary and onerous
barriers, while maintaining safety for our patient populations.
Sincerely,
Gordon Lyons
II. Scope
9
These guidelines do not focus broadly on pain management, but rather focus on the use of opioids
to manage non-cancer related pain. They apply to all clinicians who prescribe opioids, including
nurse practitioners, physician assistants, podiatrists and dentists.
Clinicians should follow the guidelines. However, failure to follow a guideline will not warrant a
denial of service, with the following exceptions: Section V.C.; VII. B. 9.; E. 2. and 3. and F. 1. and
2.
A. Gordon Lyons M.D.
Fellowship Trained/ABMS Board-Certified
Interventional Pain Medicine and
Anesthesiology
St. Dominic's Pain Management Center

Dominican Plaza
970 Lakeland Drive Suite 45
Jackson, MS 39216
Office 601.200.4690
Office Fax 601.200.4698
From: Kirk Kinard, DO >
To: mboard@msbml.ms.gov
Cc:

changes.
Kirk L. Kinard, DO
Medical Director
Oxford, MS 38655
10
P: (662) 638-0462
F: (866) 658-0083
11
Frances Carrillo

Subject: Fwd: Opioid prescribing
Rhonda
From: Scott Kelly >

Subject: Opioid prescribing
What has been done to coordinate with the Nursing Board so FNP and MD follow the same
prescribing practices?
Sent from my iPad
12

02 Part 2640 Public Comments Oct 06 - Oct 11 - Redacted

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Frances Carrillo

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

 after careful consideration of the proposed new rules:

From: RHONDA FREEMAN

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

Sent from my iPhone

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

Sent from my iPad

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

From: RHONDA FREEMAN

Begin forwarded message:

From: chad hosemann >

From: RHONDA FREEMAN

290 E. Layfair Dr Suite A, Flowood MS 39232

From: RHONDA FREEMAN

From: RHONDA FREEMAN

Follow Up Flag: Follow up

Begin forwarded message:

From: "Jason Murphy, M.D."

Subject: "Opposed" to Current Proposal for Prescribing Regulation

Jason G. Murphy, M.D., F.A.C.S.

From: RHONDA FREEMAN

Begin forwarded message:

From: corey jackson >

Please see attachment.

From: RHONDA FREEMAN

Begin forwarded message:

From: Lisa Leek >

Subject: Opioid prescribing

Lisa Loughman Leek, M.D.

Sent from my iPhone

From: RHONDA FREEMAN

Begin forwarded message:

From: Brett Lampton

Sent from my iPhone

From: RHONDA FREEMAN

Begin forwarded message:

From: Brett Lampton

Sent from my iPhone

From: RHONDA FREEMAN

Begin forwarded message:

From: andrew bishop

Sent from my iPad

From: RHONDA FREEMAN

Begin forwarded message:

From: John White >

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

The decision of whether to continue or initiate opioid therapy in a safe manner is

I rarely prescribe benzodiazepines or SOMA. If so, only a short-term supply to

“We” fully understand the potential consequences of concomitant use of these

Responsible prescribing of benzodiazepines should get its equal share of press

The pharmacokinetics of methadone must be well understood, but it has

Thank you for attention and consideration.

From: THE MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE

Subject: Re: Comments on proposed rule changes

Kirk (and Rhonda),

St. Dominic's Pain Management Center

Willow Pain and Wellness, LLC

2215 Jefferson Davis Drive