New Barriers to Treating Patients with Chronic Pain

Florida’s new pain management law sparks a discussion about restricting access to controlled substances.

Recent state laws governing physician and patient procedures for the treatment of chronic pain are serving to further restrict availability of crucial pain medications and essential drugs that are used in hospitals and clinics.

New laws that went into effect on January 2, 2012 in some states—and have already been solidified by other states in 2011—will have a negative impact on patients’ access to treatment. For every patient who abuses pain medications, there is a patient who legitimately needs the drugs to battle chronic pain. But the new laws will not only affect the patient population, but also members of the health care team, including pharmacists, who are feeling repercussions of the new policies.

The new regulations, which were created as a response to the misuse of pain medications, the increase in number of prescription drug overdoses and drug-related hospitalizations, and deaths from opiate medications, will seek to help eradicate the “pill mills” that have popped up nationwide over the last decade.

Florida bill targets abuse

A bill regarding the treatment of pain has already passed in Florida. This 98-page initiative contained an exhaustive list of new requirements for pain management specialists to follow when dealing with a patient seeking pain management treatment. Under the new rules—physicians prescribing opioids to patients—must be designated as controlled substance prescribers and must comply with statutory requirements and applicable board rules. The rules do not apply to those in chronic pain caused by cancer, and certain specialists and surgeons are exempted from these standards of practice. The standard of practice outlined in the bill direct physicians to:

• Obtain a complete medical history and physical examination, the exact components of which are left to the judgment of the clinician.
• Develop a written individualized treatment plan for each patient, with objectives for treatment success and other treatment modalities.
• Discuss with the patient the risks and benefits of the use of controlled substances.
• Create a written controlled substance agreement between the physician and the patient that includes reasons for which drug therapy may be discontinued and explains that controlled substances shall be prescribed by a single treating physician.
• Schedule regular follow-up appointments at least every 3 months to assess the efficacy and appropriateness of treatment.
• Refer patients to specialists when indicated.
• Maintain accurate and complete records on each patient.

Washington state’s version of the Florida bill, “An act relating to pain management” has similar directives, according to Washington State Department of Health. One of the major differences of the Washington state bill, however, is that physicians are restricted from prescribing any more pain medication once they have reached a certain dosage level. This limit is preventing doctors from practicing as freely as many of them would desire, and numerous doctors are abandoning the pain management field. According to a report by the Seattle Times, 84 clinics and hospitals are now refusing new pain patients, and have stopped treating some existing patients due to the liability they present. Pharmacists can review their state’s legislation regarding the prescribing of controlled substances for pain management using the Federation of State Medical Boards’ Overview of Pain Management resource.

Finding the right balance

For pharmacists, keeping informed about patterns of abuse is the first step in preventing its spread.

A new report by the Substance Abuse and Mental Health Services Administration (SAMSHA), “Treatment Episode Data Set (TEDS) 1999 to 2009, State Admissions to Substance Abuse Treatment Services,” reveals more specific information about the types of drugs that are most commonly abused. SAMSHA reported that although overall rate of substance abuse treatment admissions remained the same from 1999 to 2009, there was a 430% rise in the rate of treatment admissions for the abuse of prescription pain relievers during this period.

“The increasing numbers of people entering treatment for prescription drug abuse is the latest indicator of the severity of the problem,” noted Pamela S. Hyde, JD, administrator of SAMHSA.

Additional resources

Please refer to the following links from Cmdr John Burke, Pharmacy Times’ Drug Diversion & Abuse columnist, for further information on this topic:

Drug Diversion and Abuse: Florida’s Prescription Drug Epidemic

Drug Diversion and Abuse: Kentucky Takes Step to Reduce Pill Abuse

For more information about opiod use, refer to the following Pharmacy Times article by William Yarnall, RPh, CCP:

Opiods in an Era of Shifting Attitudes