APA and AMA issues press releases expressing concerns with ACA replacement bill
As the Trump Administration and Republican Congressional leaders unveiled their Affordable Care Act "repeal and replace" package in early March, the two premier organizations representing physicians acted swiftly in providing comments as to provisions affecting healthcare delivery in the future if the package is enacted.
Below are the press releases sent out by each organization. The APA also drafted a provision spreadsheet detailing the current provisions and provisions within the proposed Act. To obtain a copy of the spreadsheet, contact our office.
APA Concerned About Proposed ACA Replacement Bill
For Information Contact:
Glenn O'Neal, 703-907-8640
Erin Connors, 703-907-8562
ARLINGTON, Va. March 7, 2017 – The American Psychiatric Association (APA) is deeply concerned that the proposed ACA replacement released last night will negatively impact care for people with mental illness and substance use disorders. The APA urges continued support and expanded access to quality, evidence-based mental health and substance use services.
Mental illness is prevalent in the United States. According to the National Institute of Mental Health, more than 68 million Americans experienced a psychiatric or substance use disorder in the past year. Depression alone has an annual negative economic impact of $210.5 billion.
It is unknown how many people will lose coverage under this proposal, but discussions on implementing significant reforms to the current Affordable Care Act and Medicaid raise the possibility that a large number of people with mental illness or substance abuse disorders will lose some or all of their coverage.
"While a number of details about the potential impact of the proposed ACA replacement remain unknown, our current understanding of the proposal raises many concerns for people with mental illness," said APA President Maria A. Oquendo, M.D., Ph.D. "Particularly concerning are proposed changes to the Medicaid expansion program. Nearly one-third of people receiving coverage through Medicaid expansion have mental health or substance use disorders."
As efforts are made to reform the health system, services for people with mental health and substance use disorders – and their families – must be maintained. We cannot bring down the cost of health care without fully addressing mental health and substance use disorders issues. The American Psychiatric Association offers the following recommendations:
- Maintain the current level of coverage for mental health and substance use disorders in health insurance plans.
- Maintain safeguards in private insurance by specifically prohibiting the following:
- Denying coverage based upon a pre-existing condition;
- Establishing lifetime and annual dollar limits on essential health benefits; and
- Discrimination based upon health status, including a history of mental illness or substance abuse.
- Any efforts to restructure Medicaid must ensure sufficient funding for mental health and substance use issues and not shift the cost to states in a way that forces them to tighten eligibility requirements, provider reimbursement, or benefits.
- Ensure full implementation and enforcement of the bipartisan Mental Health Parity and Addiction Equity Act, which calls on insurers to offer coverage for mental health care on par with coverage for any other ailment.
The APA notes that the replacement bill, the American Health Care Act, keeps some positive provisions of the Affordable Care Act intact, such as the provision that allows for preexisting conditions and allowing young adults to stay on their parents' plan until age 26.
"As Congress considers reforms to health insurance coverage it is critical to maintain the significant progress made over the past three years, through bipartisan efforts, to improve access to mental health care," said APA CEO and Medical Director Saul Levin, M.D., M.P.A. "APA is committed to working with members of both parties in Congress to help ensure adequate access to quality mental health care for all those in need."
FOR IMMEDIATE RELEASE March 8, 2017
AMA says American Health Care Act is Critically Flawed; Points to Reductions in Insurance Coverage, Potential Harm to Vulnerable Patient Populations
CHICAGO – In a letter to congressional leaders, the American Medical Association (AMA) today outlined provisions of the American Health Care Act that would have an adverse impact on patients and the health of the nation. Largely due to the decline in health insurance coverage the bill would likely cause, the AMA is unable to support the AHCA as drafted.
"The AMA supported health system reform legislation in 2010 because it was a significant improvement on the status quo at the time; and although it was imperfect, we continue to embrace its primary goal – making high-quality, affordable health coverage accessible to all Americans," AMA President Andrew W. Gurman, M.D. said. "As drafted, the AHCA would result in millions of Americans losing coverage and benefits. By replacing income-based premium subsidies with age-based tax credits, the AHCA will also make coverage more expensive – if not out of reach – for poor and sick Americans. For these reasons, the AMA cannot support the AHCA as it is currently written."
In January, the AMA released its health system reform objectives – primary among them that people who currently have insurance should not become uninsured – and were shared at the time with Members of Congress.
In today's letter to congressional leaders, the AMA outlined several provisions within the AHCA where the legislation falls short of the objectives articulated by the AMA. These provisions include:
- The AMA has long supported advanceable, refundable tax credits as a preferred method for assisting individuals in obtaining private health coverage. It is important, however, that available credits be sufficient for quality coverage. The AMA is concerned that by relating credits to age – rather than inversely related to income – the AHCA will result in greater numbers of uninsured Americans.
- The AMA is concerned with the proposed rollback of Medicaid expansions, which have been highly successful in providing coverage for lower income individuals. The AMA is also concerned that changes to Medicaid could limit states' ability to respond to changes in demand for services, including mental health and substance abuse treatment as a result of the ongoing crisis of opioid abuse and addiction.
- The AMA cannot support provisions of the legislation that repeal the Prevention and Public Health Fund or that eliminate the ability of patients to receive their care from qualified providers of their choice.
- The AMA does not support provisions targeting, in this specific case, affiliates of the Planned Parenthood Federation of America. Provider choice is an important element of a reformed health care system, and the AMA cannot support the precedent of restricting access to otherwise qualified providers of care for covered services.
"As you consider this legislation over the coming days and weeks, we hope that you will keep upmost in your mind the potentially life altering impact your decisions will have on millions of Americans who may see their public, individual or even employer-provided health care coverage changed or eliminated," the AMA said in its letter. "We encourage you to ensure that low and moderate income Americans will be able to secure affordable and adequate coverage and that Medicaid, CHIP, and other safety net programs are maintained and adequately funded. And critically, we urge you to do all that is possible to ensure that those who are currently covered do not become uninsured."
AMA Media & Editorial
Governor holds press conference to tighten medication rules to fight opioid crisis
Governor Wolf held a press conference this past week highlighting the accomplishments of his Administration on fighting the opioid and heroin overdose crisis and next steps.
The focus of his reforms is within the Medicaid realm. One of the most significant changes involves revising a current policy allowing non-participating providers that see Medicaid patients as cash clients but prescribe medications for substance use treatment with prescriptions submitted to independent and chain pharmacies under the Medicaid payment structure. Effective April 1st, all ordering, prescribing or referring providers must be enrolled in the Medicaid program. The administration believes that "…this will prevent current cash providers who are not enrolled in the Medicaid program from having their prescriptions filled at the pharmacy." When researching this requirement, we have been told that this is a requirement of the Affordable Care Act that was never enforced in the commonwealth, so it is highly unlikely that this change can be overturned. That being said, please let me now if you have any comments/concerns moving forward.
Other changes include working with the PA Department of Drug and Alcohol Programs (DDAP) to eliminate policies allowing Medicaid enrollee cash payments to providers for treatment, auditing/ceasing relationships with providers prescribing substance use medications in an office setting without an in-person appointment, and referring "high volume" providers to DHS' Bureau of Program Integrity for further action.
A copy of the press release is below for your convenience.
The Society continues to hold a crucial role in the state's substance use initiatives. Dr. Certa and I serve on the Pennsylvania Medical Society's Task Force on Opioids. We are working on providing comments and have been invited to meeting with Attorney General Josh Shapiro soon to discuss next steps. Lois Hagarty, our outside lobbyist, and I continue to meet with members of the Wolf Administration and Representative Matt Baker (chair of the House Health Committee and sponsor of one of the involuntary commitment bills of concern) this coming Tuesday (weather-permitting) to discuss our position on involuntary commitment for substance use and the expansion of Medication Assisted Treatment. As per Council action, we have been directed to draft a position paper on the use of involuntary commitment for substance use (which includes clinical considerations and alternatives). This document should be available soon for Society and member use in grassroots lobbying. Please contact the PaPS office with additional questions or for more information.
for Immediate Release
March 6, 2017
Pennsylvania Tightens Medication Rules to Help Combat Opioid Crisis
Harrisburg, PA – Today, Governor Tom Wolf announced several additional steps the commonwealth is taking to help combat the opioid addiction crisis. These steps will help tighten the rules under which medication such as buprenorphine can be prescribed under the Medicaid program.
"Success in the fight against opioid crisis requires that we address the issue from all angles," said Governor Wolf. "Not only must we make sure that quality treatment options are available from Pennsylvanians suffering from an opioid use disorder, we must also make sure that we are doing everything we can to make sure treatment is appropriate and that we keep unscrupulous individuals from taking advantage of those who are fighting the disease of addiction."
In order to help make sure that medication is used appropriately, the Department of Human Services (DHS) will take the following actions for Medicaid providers:
· Require all ordering, prescribing or referring providers who are identified on claims be enrolled in the Medicaid program. This will prevent current cash providers who are not enrolled in the Medicaid program from having their prescriptions filled at the pharmacy;
· Work with the Department of Drug and Alcohol Programs (DDAP) to cease allowing providers to accept cash payments from Medicaid recipients;
· Audit and potentially un-enroll providers who prescribe medication such as buprenorphine without an office visit;
· Encourage Medicaid Managed Care Organizations (MCOs) to terminate poor providers that do not meet certain quality metrics;
· Implement standardized prior authorization guidelines similar to those most recently implemented for the Medicaid Fee-For-Service Program; and
· Refer high-volume providers with poor quality records to DHS Bureau of Program Integrity for review and action.
"We are tightening the medication rules to ensure that the Medicaid providers writing these prescriptions are thoroughly treating the individual, coordinating care, and getting folks the counseling services they need while going through this treatment," said DHS Secretary Ted Dallas. "Our physical health, behavioral health, and pharmaceutical providers need to work together to provide the best care possible."
"If you, or someone you love, is receiving treatment from an Medicaid-enrolled provider, you should not pay out of pocket for that treatment. We ask that you refer the provider to DHS' tip line at 1-844-DHS-TIPS," said Governor Wolf.
In addition to the latest actions, the commonwealth has:
· Strengthening the Prescription Drug Monitoring Program (PDMP) so that doctors are required and able to check the system each time they prescribe opioids;
· Developed nine new prescribing guidelines to help doctors who provide opioid prescriptions to their patients;
· Created the warm handoff clinical pathway to facilitate referrals from the emergency department to substance abuse treatment;
· Established a new law limiting the amount of opioids that can be prescribed to a minor to seven days; and
· Designated 45 Centers of Excellence, central hubs that provide navigators to assist those with opioid use disorders with behavioral and physical health care, along with medication-assisted treatment, as needed.
New investments in battling the opioid epidemic in the 2017-2018 budget include:
· $10 million to expand access to naloxone for first responders through competitive grant funds will be awarded through the Pennsylvania Commission on Crime and Delinquency (PCCD).
· $3.4 million to expand specialty drug courts in PCCD to expand treatment strategies to divert offenders into more meaningful treatment and recovery.
· $26.5 million in federal Cures Act funds beginning in 2017-18 that will be used to expand access to treatment services, particularly for individuals who are uninsured or underinsured.
Continued investments in battling the opioid epidemic in the 2017-2018 budget include:
· $20.4 to continue the 45 Centers of Excellence throughout Pennsylvania which will help coordinate holistic treatment for people suffering from substance use disorder.
· $45 million to continue to fund services to address heroin and opioid addition through the Single County Authorities.
· Over $3 million for PDMP, which allows medical practitioners to see what their patients are being prescribed, and to make sure that, what they are prescribing is not at odds with that person's health. It will also allow a medical practitioner help a person get into treatment if they believe they have identified a patient suffering from a substance use disorder.
If an individual needs treatment for substance use disorder, and they are on Medicaid, they should call their MCO to determine a provider that is in their network. If the person is in the fee-for-service program, they can call DHS at 800-692-7462 for assistance in locating a provider.
For more information, visit www.pa.gov.
Do you prescribe opioids to minors? The mandatory state form is now ready!
ACT 125 Form (pdf)
In the December issue of News and Notes, members were informed of the enactment of Act 125 of 2016. The Act creating opioid prescribing limits for minors. Specifically, prescribers are unable to prescribe opioids to a minor for more than seven days unless a parent/guardian signs a form authorizing the prescription OR for no more than 72 hours if an authorized adult signs the form on behalf of a minor when a parent/guardian is not present. Under the law, an "authorized adult" is defined as "an adult who has a valid health care proxy to consent to the minor's medical treatment."
Exceptions to the seven-day limit are when the prescription is for the management of pain associated with cancer, for use in palliative/hospice care, for management of chronic pain not associated with cancer, and when a prescriber (in their medical judgment) believes that the use of medication for longer than a week will stabilize a minor's acute medical condition. Documentation must be accompanied for the exception to the seven-day rule when establishing stabilization of a minor's acute condition. Treating a minor for a medical emergency or when complying with the law would jeopardize the minor's health or safety is also an appropriate reason for deviating from the provisions of Act 125. The Act takes effect as soon as the Bureau of Professional and Occupational Affairs can finalize the standardized prescription form.
The consent form was finalized in early February and published in the Pennsylvania Bulletin. The form is available now online at http://www.pabulletin.com/secure/data/vol47/47-5/191.html. A PDF copy of the form is attached for your review here.
As stated within the legislation, the form requires information on the prescription (name of medication, quantity, initial dosing details, refill amount) and requires the prescriber to formally ensure that the minor patient and their parent/guardian/authorized adult has been informed of the following: 1) risks of addiction/overdose related to opioid medication; 2) increased risk of addiction to controlled substances for individuals with behavioral health needs; 3) the dangers of taking any opioid in conjunction with use of benzodiazepines, alcohol or other central nervous system depressants; and 4) other information in the patient counseling information section of the federal regulation 21 CFR 201.57 (c) (18).
Copies of the certification form(s) must be kept in the patient record. NOTE: Per state law, the PA Prescription Drug Monitoring Program must be checked prior to prescribing any opioid or benzodiazepine REGARDLESS OF THE AGE OF THE PATIENT. If you have any additional questions or need more information, contact Deb Shoemaker, Executive Director, via phone (800.422.2900)
Mental Health Parity resources from the APA:
The Consumer Portal:
Consumer Guide to Disclosure Rights
APA Expresses Concerns About Executive Order on Temporary Immigrant Travel Ban
On January 27, President Donald J.Trump signed an executive order placing a temporary ban on immigrants from seven countries - Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen. Read the following message sent on behalf of Saul Levin, MD, CEO and Medical Director of the American Psychiatric Association, that shares APA's concerns about the ban.
President Obama Signs 21st Century Cures Act: Crucial Mental Health and Substance Use Provisions Enacted
In mid-December, President Barack Obama signed House Resolution 34 (the 21st Century Cures Act) into law. This Act contains long-overdue mental health and substance use reform initiatives. During the bill signing, President Obama expressed his longstanding support for House Resolution 34. Although the Act contains provisions related to pharmaceutical oversight and other crucial healthcare funding and research initiatives, key provisions from the Helping Families in Mental Health Crisis Act (House Resolution 2646- Congressman Tim Murphy), the Mental Health Reform Act of 2016 (Senate Bill 2680- Senator Chris Murphy), the Mental Health and Safe Communities Act (Senate Bill 2002- Senator John Coryn), and the Comprehensive Justice and Mental Health Act (Senate Bill 993- Senator John Coryn) were included in the final version. APA supported all of these bills and held a critical role over the past few legislative sessions in ensuring that provisions benefiting the profession and our consumers were including prior to its enactment.
Governor Wolf held a press conference expressing his support for the Act this past week. Prior to its passage in the Senate, the governor sent a letter of support to Senators Casey and Toomey.
The APA has created a comprehensive summary of the Act identifying key mental health reform and other mental health-related provisions contained in the legislation. The summary is divided into three parts:
•provisions that directly benefit the practice of psychiatry and the treatment of individuals with serious mental illness;
•provisions that improve both access to and delivery of evidence-based mental health and substance use disorder treatment services, and;
•other notable mental health-related provisions.
As provisions of the Act are enacted, the APA will provide updates. Thanks to those APA members who provided crucial grassroots lobbying support throughout the legislative process. Detailed Summary
DEA Changes Registration : Important Notice
Through a notice on its website, the Drug Enforcement Administration (DEA) recently announced significant changes to its registration renewal process. Effective January 1, 2017, the DEA is eliminating the informal grace period which the agency has previously allowed for registrants to renew their registrations. Only one renewal notice will be sent to each registrant's "mail to" address approximately 65 days prior to the expiration date; no other reminders to renew the DEA registration will be provided. The notice also advises that online capability to renew a DEA registration after the expiration date will no longer be available, and that failure to file a renewal application by midnight EST of the expiration date will result in the "retirement" of the registrant's DEA number. The original DEA registration will not be reinstated. In addition, paper renewal applications will not be accepted the day after the expiration date. If DEA has not received the paper renewal application by the day of the expiration date, mailed in renewal applications will be returned and the registrant will have to apply for a new DEA registration.
Both the American Medical Association and the American Psychiatric Association have expressed concerns to the DEA about these policy changes and the inconveniences this could cause both patients and providers. If you run into snags, contact the PaPS office at firstname.lastname@example.org or at 1.800.422.2900.
Wolf Administration Releases Warm Handoff Guidance to Emergency Room Doctors and Healthcare Professionals
Today, Governor Tom Wolf released guidance developed by the Department of Health and the Department of Drug and Alcohol programs in conjunction with the American College of Emergency Physicians to help emergency room doctors and healthcare professionals identify individuals with substance use disorder, including those who have been saved by naloxone, and get them into treatment – a process known as a warm handoff.
"Over the last few years, heroin and opioid overdoses have become the leading cause of accidental death in Pennsylvania, killing more individuals than motor vehicle accidents – 10 Pennsylvanians per day," said Governor Tom Wolf. "We must do everything we can to destigmatize the disease of addiction and get patients into treatment so they can begin the recovery process."
A warm-handoff is a process in which a person who is identified as having a substance use disorder is transferred from a hospital emergency room or other healthcare provider to a drug treatment provider.
"Ensuring overdose victims and other patients who seek help for opioid use disorders get into treatment is essential," said Physician General Rachel Levine. "One of the best ways to help people enter treatment is for them to be properly identified by doctors and other medical personnel when they arrive in an emergency room, and referred immediately to treatment."
"The Wolf Administration has been working with emergency room doctors to develop a 'clinical pathways' guide to help determine how to get a patient into treatment for substance use disorders," said Secretary Gary Tennis. "We believe this guidance is critical to getting those who suffer from the disease of addiction the help that they need."
Below are the steps physicians and healthcare professionals are advised to follow:
• Permission: Asking permission to talk about the issue shows respect for the patient's autonomy, which can help to minimize resistance. It keeps the conversation focused on the patient.
• Open-ended questions: Using open-ended questions can help the conversation move forward. Open-ended questions encourage patients to tell their story. Generally, try to avoid questions that can be answered with yes, no or other one-word answers. And listen when the patient responds.
• Listen reflectively: The provider should focus on listening to the patient, using reflective listening as a tool. Reflective tools such as repeating, rephrasing and paraphrasing keep the focus on the patient and reveal behavioral change opportunities. Listening with an attitude of respectful curiosity is easier when the patient is held up as expert and the physician recognizes him or herself to be more of a companion in the process of change.
• Affirmation: Affirmation allows the provider to work with the patients' strengths and acknowledge his/her efforts. Affirmation can build confidence. Affirmations must be sincere to be effective.
• Roll with ambivalence: As the patient talks, listen for information that could assist the patient in developing a plan to put them on course for less risky behavior. Listen for change talk, opportunities where the patient is willing and able to make changes. Talk of change often produces "but" or "if" statements indicating ambivalence. Ambivalence is not indecision but rather the equal desire for two opposing realities at the same time. Acknowledging the ambivalence can be the first step to finding a way out of it. The interviewer should use techniques to illicit "importance" and "confidence" statements from the patient. When you hear ambivalence, help the patient identify the ambivalence.
• Summarize plans: Summarizing, or restating what you have heard, can be helpful at transitions or near the end of the conversation. If the patient has used a change statement, make sure to include it in your summary.
Contact number for the single county authority and/or substance use disorder referral and warm handoff personal: http://www.pa.gov/collections/opioid-epidemic/#GetTreatment
Hailey: A Physician's Personal Journey With Treating Addiction Our president-elect, Gail Edelsohn, MD, MSPH, provided us with a copy of the November 15, 2016 JAMA 's A Piece of My Mind. The piece, entitled Hailey, was written by William B. Weeks, MD, PhD, MBA. This poignant article explores a physician's personal struggle with seeing his own sister lose her battle with substance use.
We felt it fitting to share this story with all of you for distribution as you deem appropriate. Our Society has also shared this article with our colleagues at the PA Medical Society.
Maintenance of Certification Survey Results
Maintenance of Certification is a topic of interest and concern to the psychiatrists we serve. The Pennsylvania Psychiatric Society conducted a survey of its membership in September to determine the MOC climate for use in determining our advocacy strategy as we move forward with the APA and other related stakeholders.
survey results. (pdf)
42 Young Physicians Among the Best Earn Physician 40 Under 40 Recognition
Released by the Pennsylvania Medical Society on 9/19/2016.
Forty-two physicians named to this year’s Physician 40 Under 40 by the Pennsylvania Medical Society were chosen by a committee of physicians after being nominated for outstanding contributions to the practice of medicine and the delivery of patient care, despite being early in their medical careers.
Combating Opioid Abuse in Pennsylvania ― PAMED Launches "Opioids for Pain: Be Smart. Be Safe. Be Sure." Initiative
The problem: Opioid abuse, misuse, and overdoses are increasing, both in Pennsylvania and nationally. Opioid overdoses accounted for nearly 2,500 deaths in Pennsylvania in 2014 – that's nearly 7 people a day – and indications are that those numbers are climbing.
The solution: A multi-pronged approach that includes physicians, patients, and health care organizations like the Pennsylvania Medical Society (PAMED) working collaboratively to address this growing epidemic.
PAMED recently launched its Opioids for Pain: Be Smart. Be Safe. Be Sure. initiative, which focuses on patient empowerment and physician education. This initiative consists of a five-step physician call to action and seven questions patients should ask when prescribed an opioid.
The Physician Call to Action ― All Pennsylvania physicians should take these five steps:
Know the prescribing guidelines. They are available on PAMED's website at
www.pamedsoc.org/OpioidResources. The first session in PAMED's online CME series focuses on the guidelines. In this session, analyze your prescribing practices against statewide guidelines and identify when and why to prescribe opioid medications. Get the CME at
Use Pennsylvania's prescription drug monitoring program (PDMP) once it's up and running (it's expected to be operational in August 2016). The fourth session in PAMED's online CME series will address common physician questions regarding governance, user access, and provider and dispenser reporting requirements. Watch PAMED's
Daily Dose email for when this session is available.
Refer patients who have a substance use disorder to treatment. Referral to treatment is covered in the third session in PAMED's online CME series. This session addresses substance use disorders; explores screening and assessment tools; reviews intervention strategies; and assesses best practices in referrals to specialists, rehabilitation services, and community resources. Get the CME at
Discuss alternatives to opioids with patients.
Ask patients to keep their pills safe, and properly dispose of a prescribed medication when they no longer need it. A list of drug take-back locations is available at
Patient Empowerment ― Patients should ask these seven questions when prescribed a pill for pain:
- Is this prescription an opioid?
- At what level of pain should I take this prescription?
- Do I have to take every pill in the prescription?
- Where can I safely dispose of remaining pills?
- What can I do to avoid addiction?
- What are possible warning signs of dependence or addiction?
- What can I do if I believe that I might have developed a dependence on this drug?
Resources for physicians, patients, and lawmakers are available at
"We need to make sure that we ― as physicians ― are doing everything we can to stop this wave of abuse, and empowering our patients to do the same," said PAMED Board Chair David Talenti, MD.
"If physicians don't suit up for the battle, who will?" he asks. "Education is a silver bullet."
In addition to the above-mentioned educational sessions, PAMED's online CME series also has a session on naloxone. This session addresses the use of naloxone as an opioid antidote, reviews regulatory requirements for prescribing naloxone to third-party first responders, and assesses naloxone prescribing options.
PAMED is collaborating with the Pennsylvania Department of Health and 11 other health care associations on this educational series.
"I think that we have to understand this is a public health crisis and we all have a role to play in terms of solving this," said PAMED member and Pennsylvania Physician General Rachel Levine, MD.
"This crisis hits everyone ― our mothers, fathers, brothers, sisters, sons, daughters, rural, urban, suburban," she said. "We have to get past the idea that this is someone else's problem. We have to get people into treatment and recovery. "Addiction is a medical illness. It is not a moral failing. We have to erase the stigma."
PAMED's educational series seeks to address the many layers and complexities of this crisis. Learn more and get CME credit by visiting
www.pamedsoc.org/OpioidsCME. Access additional resources such as prescribing guidelines in PAMED's Opioid Abuse Resource Center at