Are we looking at the beginning of the end of the opioid epidemic in Florida? In March 2018, Legislation was passed in Florida to limit health care providers duration of opioid and narcotic pain management medication prescriptions. House Bill 21 rolled out on July 1st, 2018 ruling that prescriptions for opioids for "acute pain" may not exceed a three-day supply. There are exemptions and HB21 does allow a seven-day supply to be prescribed if:
• If deemed appropriate by the professional judgment of the prescriber (which I'm sure prescribers will be avoiding as much as possible, and may result in underprescribing and inadequate treatment for pain for some patients) patients can receive an extended 7-day prescription.
• Prescribers must indicate “ACUTE PAIN EXCEPTION” on the prescription; the prescriber will need to documents in the medical records the acute medical condition and lack of alternative treatment options that justify deviation from the 3-day supply limit.
If a prescriber writes a prescription for opioid for the treatment of pain other than acute pain, such nonmalignant pain, or for a pain that is excluded from the definition of "acute pain" the prescriber must indicate “NONACUTE PAIN” on the prescription.
Under the HB21, Acute pain is defined as “the normal, predicted, physiological, and time-limited response to an adverse chemical, thermal, or mechanical stimulus associated with surgery, trauma, or acute illness." Which in turns go against what we were taught that pain is subjective, and what is normal for some are severe for others. What about complications?
It was only after intense lobbying by the Florida Medical Association and other healthcare groups that the Legislature exempted from this definition pain related to:
• Terminal condition (defined as a “progressive disease or medical or surgical condition that causes significant functional impairment, is not considered by a treating physician to be reversible without the administration of life-sustaining procedures, and will result in death within one year after diagnosis if the condition runs its normal course”)
• Palliative care to provide relief of symptoms related to an incurable, progressive illness or injury;
• Traumatic injury with an Injury Severity Score of 9 or greater.
The House Bill 21 also enforces the use of a statewide database, or prescription drug-monitoring program (PDMP), which requires action from both pharmacists and doctors. Both healthcare providers and pharmacists have to consult the database before prescribing or dispensing controlled substances. The Bill also requires a prescriber to co-prescribe an opioid antagonist when prescribing controlled substances for serious traumatic injury.
What will this mean for hospitals and the opioid dependents we currently treat? Are we seeing a definite fix for the opioid problem or are we entering another conundrum? Will patients seeking opioid prescriptions make our currently overflown emergency rooms even more chaotic? Are we going to experience higher readmission rates due to pain management? How will post-surgical non-trauma related patients be managed?
We have a real problem with opioid dependency and overdosing in the US, in Florida alone, fentanyl caused 1,390 deaths, heroin caused 952 deaths, oxycodone caused 723 deaths and hydrocodone claimed 245 lives in the year 2016. Is reducing the number of prescription drugs in circulation the answer?
It may still be too early on to assess the patient’s perspective and the effect of this new law, but the inconvenience of having to travel to a provider’s office in 3 days for a possible refill prescription will be on top of complaint list. Pain management physicians will have full schedules with follow up patient visits that are almost certain. Nurses should be given continuing education to work with prescribers in encouraging patients to attempt alternative pain management and possible taper down dosing. In Florida, we have seen over-prescription of opioids for many years, and multiple pain management clinics were raided by DEA agents in the past few years, with decreased prescription medications, we have seen a spike in illicit drug use such as heroin and illegal distribution of other controlled substances.
We are 10 days in and I have yet to deal with an upset patient receiving a 3-day prescription for acute pain management, but I am preparing to deal with some harsh words. I am not sure this is the best and proper solution, but I agree with taking a stand to end this epidemic, as long as the stand does not inhibits or hurt those patients with chronic or malignant pain seeking comfort.
The Dude Nurse
Klaus Campos, BSN-RN