AMA Delegates Debate Privacy of Substance Use Tx Records

Comments address patient privacy, treatment needs

This article was first published on Sunday, June 9, 2019 in MedPage Today.

By Joyce Frieden, News Editor, MedPage Today.

CHICAGO -- The struggle between maintaining patient privacy and ensuring the best possible treatment of patients was evident Sunday as American Medical Association (AMA) House of Delegates members debated whether patients' drug addiction treatment records should be made more easily available.

"Why would you make an exemption for this very important, critical piece of information for a physician making a decision regarding patient care?" said Robert Wailes, MD, of Rancho Santa Fe, California, a delegate from the American Academy of Pain Medicine. "As a pain physician, I desperately need to know if a patient is on a controlled substance like methadone or buprenorphine."

"Opioid use disorder is a significant concern among women," said Marilyn Heine, MD, of Langhorne, Pennsylvania, on behalf of the AMA women physicians section."When HIPAA [the Health Insurance Portability and Accountability Act] violations are escalating and penalties [for violation] are being cut, it's even more urgent that we ensure vulnerable patients' privacy will be protected. At a time when substance use disorder patients face stigma, rampant discrimination, and potential loss of custody, housing, and employment that threatens their recovery if confidentiality is breached, we must champion their rights."

The comments came during a House of Delegates reference committee meeting; the committee was discussing several resolutions and a board report addressing whether opioid use disorder treatment records should be made accessible to both healthcare providers and law enforcement officers via databases such as a state Prescription Drug Monitoring Program (PDMP).

One resolution, introduced by a host of delegations including the American Psychiatric Association, the American Society of Addiction Medicine, and delegations from Colorado, Vermont, Washington, and Wisconsin, would require the AMA to support aligning federal regulations with HIPAA for the purposes of treatment, payment, and healthcare operations, but opposing use of substance disorder records in criminal proceedings; it would also have the AMA "support the sharing of substance use disorder patient records as required by the HIPAA Privacy Rule."

Another resolution would have the AMA "study whether the confidentiality protections of 42 CFR Part 2 outweigh the potential benefits of coordinating care with HIPAA privacy protections in the treatment of substance related disorders." The 42 CFR Part 2 regulation prohibits unauthorized disclosure of patient records except in certain circumstances.

The Board of Trustees also weighed in on the issue with a report on a resolution from the 2018 AMA meeting that would have had the AMA seek changes to require that opioid treatment programs to report to PDMPs.

"The AMA has significant privacy concerns about law enforcement and other non-healthcare entities using a PDMP because of the personal health information (PHI) contained within a PDMP," the report said. "PHI may include a patient's controlled substance prescription history, which can potentially cause someone to learn a patient is being treated for gender dysphoria, a substance use disorder, mental illness, HIV/AIDS, or other medical condition that has historically been subject to stigmatization."

"The AMA believes that an appropriate balance between law enforcement access and a patient's right to privacy occurs when law enforcement obtains a court-issued warrant or other judicially authorized access. That occurs, however, in fewer than 20 states." The report recommended that the resolution not be adopted.

Some delegates took a more moderate approach."I speak with great trepidation to voice opposition to the board report," said Lee Snook, MD, of Sacramento, California, a delegate from the American Society of Interventional Pain Physicians, who was speaking for himself.

"This horse has left the barn ... We are required to use [the PDMP] or some type of electronic prescription monitoring ... and compelled to do biological fluid analysis on our patients for whom we're prescribing controlled substances ... It's important that this should be referred back to the board for consideration in view of the inherent conflict it's creating, because as practitioners we'll have to explain why the substance is present and not in your [PDMP]."

Peter Kaufman, MD, of Bethesda, Maryland, a delegate from the American Gastroenterological Association who was speaking for himself, called the subject "a very thorny issue ... You'd definitely want to know what drugs the patient is on at any time, but on the other hand, you don't want people with a substance abuse problem to have any inhibition ... to get substance abuse treatment ... I challenge you to come up with a good solution for that," he said to the reference committee.

Another reference committee got a visit from Surgeon General Jerome Adams, MD, who came to speak in favor of giving Medicare beneficiaries better access to dental care. The surgeon general was speaking in response to a report from the AMA's Council on Medical Service, which recommended that the association "support continued opportunities to work with the ADA [American Dental Association] and other interested national organizations to improve access to dental care for Medicare beneficiaries."

The report also urged that the AMA "support initiatives to expand health services research on the effectiveness of expanded dental coverage in improving health and preventing disease in the Medicare population" as well as supporting research on the optimal dental benefit plan design. Adams noted that one of his predecessors, former Surgeon General David Satcher, MD, put out a report 20 years ago highlighting the importance of insurance coverage for oral health services.

"I'll be putting out a Surgeon General's report -- a 20-year update -- next year highlighting these issues ... I'm not in a position to advocate one way or the other [on the report] but I want to applaud the council and the House [of Delegates] for taking on this important issue because the science tells us when people are covered for critical oral health services, they're healthier, communities are healthier ... and our country is safer. One of the number one reasons people are sent home from deployment in the military is because of oral health issues."

"The Office of the Surgeon General supports oral health and supports measures to increase coverage for oral health," he added.