May 1st, 2017

New England states limit painkiller prescriptions

In March 2016, Massachusetts became the first state in the nation to enact a law limiting first-time opioid medication prescriptions for adults and all opioid prescriptions for minors to a maximum of seven days, with certain exceptions.

That was the same month the U.S. Centers for Disease Control and Prevention published national standards recommending doctors write scripts for the “lowest effective dose” of painkillers like OxyContin, Percocet and Vicodin.

The federal guidelines represented a radical departure from the longstanding practice of prescribing for two weeks or even a month’s worth of pills amid growing alarm over how highly addictive opioids can be.

Other states, including the rest of New England, have since passed laws or adopted regulations limiting prescription painkillers to combat the epidemic of U.S. drug overdose deaths, which rose more than 2.5 times between 1999 and 2015, according to the CDC’s National Center for Health Statistics.

Across the region, opioid prescribing restrictions vary by number of days or dosage. The policies are welcome news to Andrew Kolodny M.D., executive director and co-founder of Physicians for Responsible Opioid Prescribing (PROP), which advocates for more cautious prescribing practices. Three PROP board members were on a committee that reviewed the first draft of the CDC guidelines.

“What I like about these laws is they show policymakers are finally recognizing that the problem is not kids getting into Grandma’s medicine chest but the fact that every Grandma now has opioids in her medicine chest and that the medical community is just prescribing much too aggressively without an appreciation of how dangerous and addictive the drugs are,” said Kolodny, a senior scientist at the Heller School for Social Policy and Management at Brandeis University.

A new study on the risk of addiction to a narcotic painkiller after initial use strengthens support for prescribing limits. The study published March 17, 2017, in the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, found that a person taking an opioid for one day had only a 6 percent probability of still using the drug one year later and 2.9 percent three years later.

When the opioid prescription was for eight days or more, the likelihood of still using the drug one year later jumped to 13.5 percent.

For those initially prescribed opioids for more than 30 days, the likelihood of still using the drug a year later was 29.9 percent, according to the study by researchers from the University of Arkansas for Medical Sciences College of Pharmacy.

In Maine, a seven-day limit on initial opioid prescriptions for adults took effect Jan. 1, 2017. An original 100 morphine milligram equivalents (MME) average daily dose limit was amended to allow patients over that dosage to have a 300 MME limit until July 1 when new rules for exceptions are expected. The limit can be overridden with documentation of medical necessity.

The Maine Medical Association initially opposed prescribing limits, said its president Charles Pattavina M.D., who is medical director and chief of emergency medicine at St. Joseph Hospital in Bangor, Maine. But after surveying membership, the Association found widespread support and worked with Gov. Paul LePage’s office to craft a proposal that would not disrupt patient care.

“It may be a bit of an oversimplification, but sometimes it’s hard to say no to patients when they have certain long-term expectations,” Pattavina said. “So this (law) gave people more of an ability to say no.”

But Pattavina said physicians need latitude to determine the appropriate number of days for a painkiller prescription. Maine’s original proposal called for a three-day limit.

“The majority of prescriptions by far are more like three days, but it just doesn’t always fit everybody,” Pattavina said. “In the Emergency Department, if we see somebody on a Friday of a holiday weekend, then three days isn’t reasonable.”

Maine’s original proposal also sought to limit scripts for chronic pain to 15 days, but the limit was increased to 30 days. Pattavina said the 15-day limit would have increased the burden on doctors who would otherwise see their patients for a monthly office visit. “The last thing we need to do is tie up more doctors doing unnecessary things,” he said.

In Connecticut, a seven-day limit on initial opioid prescriptions for adults took effect on July 1, 2016, although some had pushed for a three-day limit. Connecticut State Rep. Prasad Srinivasan M.D. (R-Glastonbury), ranking member of the House Public Health Committee and an allergist with a private practice, called the seven days “a fair compromise.”

“I’ve not heard on the physician side any pushback that this is too difficult, this is too constraining, this is too restrictive, I’ve not heard that at all,” Srinivasan said. While calls to tighten the restriction to three days and limit prescribers to only pain specialists persist, he said he did not think the Public Health Committee had the political will at present to tighten the limits.

The New Hampshire Board of Medicine adopted final rules last November directing licensed practitioners to prescribe opioids for the “lowest effective dose for the shortest duration.”

However, scripts written in New Hampshire hospital emergency rooms, urgent care or walk-in clinics shall not be prescribed for more than seven days while in most cases three or fewer days is considered sufficient. When a patient has unresolved acute pain that extends beyond 30 days, the provider must conduct an in-office follow-up before issuing any new opioid prescription.

Vermont’s law, which will take effect July 1, 2017, limits prescriptions based on pain category as determined by the prescriber’s medical judgment.
No opioids may be prescribed for adult patients experiencing only minor pain associated with tooth extraction, non-specific lower back pain, headaches or fibromyalgia.

Vermont providers can prescribe a total of 72 MME for up to three days or 120 MME for up to five days for adult patients in moderate pain such as that from non-compound bone fractures, most soft tissue surgeries and outpatient laparoscopic surgeries and shoulder arthroscopy.

The maximum dosage can increase to 96 MME over three days and 160 MME over five days for patients in severe pain from non-laparoscopic surgery, maxillofacial surgery, total joint replacement or compound fracture repair.

For patients with severe and extreme pain, a Vermont provider may make a clinical judgment to prescribe opioid medication for up to seven days and must document the reason in the medical record.

Rhode Island limits the initial prescription for acute pain to 20 doses and no more than 30 MME per day while also prohibiting the prescribing of long-acting or extended-release opioids. For chronic pain, the threshold for adults is 90 MME per day.

Between 2005 and 2014, hospitalizations related to opioid misuse and dependence increased 64.1 percent and emergency department visits increased 99.4 percent, according to a December 2016 statistical brief from the Healthcare Cost and Utilization Project.

Massachusetts had the highest rate of opioid related emergency room visits in the nation with 450.2 visits per 100,000 population, followed by Maryland (300.7) and Rhode Island (298.3).

By Janine Weisman

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