New Opioid Law Limits Prescriptions for Acute Pain
A woman in her early 20s had abdominal surgery. Afterwards, she was prescribed opiates for pain, which led to addiction and a cycle of repeat infection and hospitalization. About 15 years later, she died from an opioid overdose.
Her story, and stories like hers, make the tragedy of this nation’s opioid epidemic real for families and their physicians, among them Dr. Haseeb Rahman, a physician advisor for BayCare at Winter Haven Hospital and Bartow Regional Medical Center.
“They basically end up taking opiates for the rest of their life,” he says, explaining the only medical intervention he’s aware of is methadone or suboxone with “medical treatment backing it up.”
A new Florida law limiting how opioids are prescribed for acute pain went into effect July 1, as part of the state’s attempts at curbing the epidemic. The law pumps $53 million into substance abuse treatment, other services, and Prescription Drug Monitoring Program upgrades.
“This is the law of the land and we’re doing everything we can to educate physicians to comply with the letter and the spirit of the law,” says Dr. John N. Katopodis, president of the Florida Medical Association.
The statute limits prescriptions of Schedule II opioids for acute pain to a three-day supply. There is an option for a seven-day supply if considered medically necessary. It excludes chronic pain caused by cancer, terminal illness, palliative care, and serious traumatic injuries. It also requires authorized physicians prescribing controlled substances to take a two-hour continuing education course and expands the PDMP, requiring the database to be checked for almost any controlled substance.
Additionally, pain management clinics must become certified by January 1, 2019, if they claim an exemption to registration requirements.
While the physician community was “100 percent” behind addressing the problem, the FMA regarded the law as excessively broad, says Jeff Scott, the FMA’s general counsel. “We felt that requiring checking the PDMP for every controlled substance went too far,” he explains.
Dr. Katopodis shares a similar sentiment. “The law is very broad and there may be some opportunities for some additional exceptions. That needs to be worked out in future legislative sessions,” he says. “The FMA fully supports efforts to end the tide of opioid addiction.”
The FMA also believed there should be an exemption on the opioid limit for surgeries. “Generally, when you have a big piece of legislation like this, they do a glitch bill the following year,” Scott says. “I would think there would be talk about doing a glitch bill.”
Opioid use climbed after heavy marketing for OxyContin, which was introduced in 1996. Purdue Frederick Company Inc. and three company executives pleaded guilty in 2007 to charges of misbranding it as less addictive than it really was, according to a February 2009 article in American Journal of Public Health, “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy.”
The rate of long-term opioid use is six percent, one year later, when the drug is taken for one day, according to the Centers for Disease Control report “Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015.” The rate climbs to 13.5 percent when an individual’s first use of the drug is for eight or more days and to 29.9 percent when use lasts for at least 31 days.
Dr. Rahman says the new law forces physicians to critically consider each patient’s needs. “The vast majority [of opioids] end up in the medicine cabinet,” he asserts, adding from there they can be used inappropriately.
Extra time spent checking the database and complying with the new legal requirements is “time well invested,” he says, because a large majority of those with opioid dependency problems are introduced to the drug legally.
Questions still remain about how the law will be implemented, acknowledges Dr. Katopodis. For example, does a doctor need to see his patient again to authorize a refill for an acute pain prescription? “My personal recommendation is that they have the face-to-face visit until we learn more from the respective boards,” he says, referring to the Florida Board of Medicine and Department of Health.
Physicians can learn more about the law at the FMA website, where Dr. Katopodis has an open letter to colleagues. “Our profession is uniquely positioned to proactively confront this grim reality,” he notes. “I am writing to share information about the current state of the opioid crisis and potential solutions. I also want to ask for your help and inform you of what the FMA is doing.”
He suggests reevaluating prescribing processes. “For now, what you can do is reassess your prescribing practices, review and, if needed, revise any institutional guidelines and clinical pathways,” he concludes.
The FMA has set up an Opioid Resource Center at flmedical.org/florida/Florida_Public/Resources/Opioid/Opioid_Resources.aspx, where physicians prescribing controlled substances can sign up for the required Continuing Medical Education course, access a summary of House Bill 21 which passed, view opioid statistics and find a link to CDC prescription guidelines.
Dr. Sergio Seoane, president of the Polk County Medical Association, speaking on his own behalf, says the law likely will discourage doctors from writing opioid prescriptions. “I don’t think it‘s going to fix the real problem,” says Dr. Seoane, who represents central western Florida on FMA’s Board of Governors. “It will stop the doctor from prescribing narcotics.”
Citing a decline in opioid prescription rates, he points out the medical community has recognized the problem. “The Florida legislature cannot solve this problem by creating new laws. Any more than the Florida Legislature can solve alcoholism by creating new laws. Or solve child abuse be creating new laws,” he says. “This is a multifactorial complex social-economic, psychological, and medical problem.”
According to a Florida Department of Law Enforcement report, opioid-related deaths statewide climbed 35 percent from 2015 to 2016, rising from 1,483 to 5,725. All drug-related deaths increased by 22 percent during the time period.
Physicians interested in CDC guidelines for the control of chronic pain can read more about it in the CDC Guideline for Prescribing Opioids for Chronic Pain.“While benefits for pain relief, function, and quality of life with long-term opioid use for chronic pain are uncertain, risks associated with long-term opioid use are clearer and significant. Based on the clinical evidence review, long-term opioid use for chronic pain is associated with serious risks. These risks include increased risk for opioid use disorder, overdose, myocardial infarction, and motor vehicle injury,” the guide notes.
The guide also says:
- The risk of complications is greater if the patient has sleep apnea or another sleep-disordered breathing condition. Renal or hepatic insufficiency, depression or mental health issues, or alcohol/substance abuse issues also cause complications. Other risk factors include advanced age and pregnancy.
- The risk is dose dependent, meaning the higher the dose the greater the risk.
- Using benzodiazepines and opioids together can increase the risk for a fatal overdose.
by CHERYL ROGERS