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Proposals For Prescribing Opioids to Arkansas Patients
On Feb . 1 , I attended a public hearing at the Arkansas State Medical Board . The hearing was to receive public comment on a proposed amendment to Regulation 2.4 , which deals with prescribing excessive amounts of controlled substances . The primary purpose of the amendment is to define the term excessive . Prescribing excessive amounts of controlled substances is a violation of the Medical Practices Act , but what has been missing is a working definition of exactly how much is too much .
The main focus of the amendment is , justifiably , the prescribing of opioids . That may also explain why the room was full . Among those testifying were a good mix of physicians and patients . The patients were mostly those who have had serious , often heartbreaking , injuries ( one gentleman spoke of waking up in the hospital after being hit head on by an 18-wheeler ) who are destined to live out their lives in some level of pain . They all spoke of fear that their physicians would be unable or unwilling to continue caring for them out of concern that this rule would put their physician licenses in jeopardy .
What became clear early in the meeting was that there is misunderstanding and confusion about the provisions in the rule and much of the “ fear ” is unfounded , both from patients and physicians . Tweaking the rule in a couple of places and good communication from the Board should help alleviate some of these concerns .
The rule defines excessive as “ any amount without a detailed medical justification for the prescription , documented in the medical record .” If there is documented medical justification , at least for opioids , excessive is defined as “ exceeding the CDC Guidelines for Prescribing Opioids for Chronic Pain .” For starters , that means ≥ 50 morphine milligram equivalents per day ( MME ). However , the proposed rule also says that ≥ 50 MME will not
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be considered excessive if the prescriber documents several requirements listed in the proposal . Among those requirements are objective findings establishing pain-generating pathology , specific reasons for exceeding the 50 MME , informed consent , clinical rationale , regular drug screens and a pain treatment agreement ( when initiating chronic opioid therapy ). These items are not required if the daily dosing is less than 50 MME .
One provision that has generated much confusion among physicians is the requirement to consult a pain management specialist if the proposed level of opioid prescribing is ≥ 90 MME . Some have thought this meant the patient had to be referred to a pain management specialist . That is not the case . The rule refers to documenting that the prescriber consulted the pain management specialist . There was also considerable testimony on what exactly qualifies as a “ pain management specialist .” In fact , of the numerous calls to AMS about this proposal , that was the most common question . My prediction , based on comments from the hearing , is that this provision is likely to be removed .
The other major provision in the proposed rule establishes a threshold for treatment of acute pain . For acute pain , excessive would be defined as an initial prescription written for more than seven days , without detailed medical justification in the medical record ( same applies for subsequent prescriptions ). So again , as long as the documentation supports a prescription for longer than seven days , this should not be a problem for most physicians .
What ’ s next ? The board will consider the comments submitted during the public comment period ( and today ’ s hearing ) and either move forward with the rule as is or make changes . A vote on the rule is expected to take place at the board ’ s April meeting . If adopted , it must be approved by interim legislative committees before it can become effective . We are still several months away from anything final .
196 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY VOLUME 114