Laws to Restrict Opioid Rx: Easier to Enact than Enforce?

(Summer 2018) According to Governor Kasich, this fall Ohio will implement new rules designed to keep patients managing chronic pain from becoming addicted to doctor-prescribed medication. The rules shy away from limits on what can be prescribed and instead place an emphasis on “safety checkpoints.” The guidelines require that physicians re-evaluate patients after dosages are increased to 50, 80 and 120 morphine equivalent doses (MED) a day. Starting at 80 MED daily, a pain management agreement will need to be signed and doctors must consider prescribing naloxone to combat overdoses. Patients who are already being treated for chronic pain will not be subject to the new rules unless their dosage is increased. Inpatients and the terminally ill are exempt as well.

Meanwhile, Iowa recently passed HF2377, a measure aimed at slowing down the state’s increasing opioid problem. The state estimates that opioid misuse and abuse currently costs an average of $748 per resident annually. Iowa’s bipartisan bill will require all prescribers to consult the state’s Prescription Monitoring Program to cross-check for “doctor shopping” by patients before opioids are written. The law also mandates that prescriptions will be submitted electronically, as those are less likely to be altered than their paper counterparts. Offices that don’t have the ability to make electronic prescriptions will be given until 2020 to come into compliance. Additionally, physicians and other providers will be given a statistical rundown of painkillers they have prescribed along with a comparison to amounts other providers have written.

The bill also includes a “good Samaritan” clause that guards against prosecution when someone in possession of illicit drugs reports another individual’s overdose.

With all the good intentions behind these new rules, though, North Carolina’s foray into a law geared toward reducing the number of opioids issued for acute pain may underscore how difficult establishing effective (and enforceable) prescription drug rules can be. Between 1999 and 2016, over 12,000 North Carolinians lost their lives to opioids. To curb this unnecessary loss, legislators enacted NC STOP Act at the beginning of 2018. The law restricts opioid prescriptions in the Tar Heel State to five days for acute-pain patients prescribed an opioid for the first time and seven days for individuals following surgery. The NC STOP Act does not pertain to nursing homes, hospitals, hospices and residential care situations, and the law does permit a patient to receive an additional prescription if the pain warrants more medication.

After the NC STOP Act was in place, however, the state health department’s prescription monitoring system revealed that 16,000 physicians in North Carolina had written an opioid prescription for longer than seven days to one or more patients classified as a “new” opioid recipient. Investigating why this is taking place has proven to be cumbersome, and the legislation is turning out to be very difficult to enforce. The health department also stated that more data would need to be gathered to judge if those prescriptions broke the new law.

Even if health care practitioners in North Carolina did violate the fledgling legislation, they would not be subject to criminal charges. Instead, punishment for the infraction will be left up to medical licensing entities. However, North Carolina’s Medical Board states that it does not have the needed funds and employees to follow up on prescriptions written by thousands of physicians and estimates it will be this fall or later before it could begin issuing warnings to doctors.

On the other hand, one involved party has been very agile in acclimating to the NC STOP Act. Insurer Blue Cross completed a study of prescribers in its commercial plans throughout the state. The company’s results reveal that approximately 4,500 health professionals issued prescriptions that broke the law’s limits between January 1 and April 13 of this year. In April, the insurer stopped filling opioid prescriptions written for more than a week of dosages using an electronic system. Blue Cross also shares that it flagged over 1,100 prescriptions and stopped between 25,000 and 30,000 opioid pills from being given to patients within its program’s first two weeks. Using these statistics as a benchmark, Blue Cross says that doctors over-prescribed between 225,000 and 275,000 opioids on its commercial plans between January 1 and the middle of April.

Why are instances of overprescribing occurring at such a high rate in North Carolina? It’s been noted that many doctors still aren’t aware of the NC STOP Act, while some feel strongly that for select procedures it is necessary to prescribe opioids for longer than seven days. Others know about the law but are confused by its intricacies.

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