State Medical Board OKs new rules for opioid doses

A state board approved regulations Thursday adding requirements for doctors who prescribe high doses of opioids, despite hearing more complaints from chronic-pain patients whose prescriptions for such medications have been reduced.

Some Arkansas State Medical Board members said doctors appear to be misinterpreting the rules as limiting the dosage that can be prescribed, rather than requiring they take extra precautions when the dosage exceeds certain amounts.

“The goal is not to cut back everyone’s treatment,” said board member Don Phillips, a Fort Smith obstetrician-gynecologist. “It’s to make inappropriate treatments become appropriate treatments.”

Approved in a 12-1 vote, the rules would require doctors to take certain steps when they prescribe a daily dose of more than 50 morphine milligram equivalents, which is equal to about 10 5-milligram tablets of hydrocodone, for chronic pain.

Those steps include examining the patient every three months and ensuring that the medical record contains a detailed medical justification for the prescription, including X-rays, tests or other evidence of the patient’s condition.

The patient’s records also must show that alternative treatments were explored, that the risks of opioids were explained and that the patient’s potential to abuse the drug was assessed.

The rules say doctors should avoid increasing a patient’s dosage to above 90 morphine milligram equivalents per day and “carefully justify a decision” for such a high dosage when it is prescribed.

The rules also would limit opioid prescriptions for acute pain, such as after a surgery, to a seven-day supply.

Based on guidelines is-

sued in 2016 by the federal Centers for Disease Control and Prevention, the rules are aimed at reducing the abuse of opioid medications such as hydrocodone, oxycodone and morphine.

They would not apply to prescriptions issued to patients in active treatment for cancer or in hospice care, end-of-life care, palliative care, nursing homes, assisted-living facilities, hospitals or during emergencies.

“We don’t want you to not get what you need, but we want you to be functional, and we don’t want you to be a zombie because of your treatment, and we don’t want you to die because of your treatment,” board member John Weiss, a Fayetteville heart surgeon, told a chronic-pain patient who spoke at a public hearing before the vote.

Robert Breving Jr., who cast the lone vote against the regulation, said after the meeting that requirements for doctors prescribing a daily dose of more than 50 morphine milligram equivalents are too extensive.

Some doctors might simply refuse to prescribe more than that amount to avoid running afoul of the rules, he said.

“It’s almost like you’d have to have a list of those posted and make sure that you checked off each one of those things,” said Breving, a general surgeon in Hot Springs. “If you miss just one, you could be labeled an excessive prescriber.”

The board’s action came a day after the U.S. Food and Drug Administration called on Internet providers to help rid the Web of illegal offers of prescription opioids.

On Thursday, U.S. Surgeon General Jerome Adams issued an advisory urging more Americans to keep on hand and learn how to use the drug naloxone, which can save the lives of people overdosing on opioids.

Naloxone has already revived thousands of overdose victims, but rescue workers

have usually been the ones to administer it.

At public hearings in February and on Thursday, chronic-pain patients told the Arkansas Medical Board their doctors have already started reducing their dosages of pain medication in anticipation of the board’s proposed rules.

Among the dozen patients who spoke Thursday was Debbie Wood, 61, of Springdale, who said she has taken medication since 2013 for pain caused by lupus and joint damage from the steroid she takes to treat the autoimmune disease.

Since her diagnosis in 2012, she said, she’s had both shoulders and her left hip replaced, and she found out this year that the top four vertebrae in her neck have collapsed.

Citing the proposed regulations, her doctor about three months ago stopped prescribing her morphine and reduced her oxycodone prescription from 90 milligrams a day to 60 milligrams, which is equal to 90 morphine milligram equivalents.

When the dosage went down, she said, her pain increased, so much so that she now spends most of her day in bed and no longer cooks or cleans the house.

“Opiates are a problem for a few, but for many, they are a new lease on life,” Wood told the board. “Please do not sentence us to a life of pain.”

Heather Pomplun, 43, of Mabelvale, who said she has degenerative disc disease and other back problems, said she’s been similarly limited since her doctor reduced her pain medication dosage last year.

“It’s horrible,” she said. “I don’t want to leave the house just to enjoy basic things.”

She questioned how she can demonstrate that she’s tried alternative therapies when she can’t afford the $35 per visit she would have to pay under her insurance plan to see a physical therapist.

Phillips said Pomplun’s doctor would be in compliance by simply noting Pomplun can’t afford the physical therapy.

“If you can’t afford therapy,

it’s not an option for you,” he said.

David Wroten, executive vice president of the Arkansas Medical Society, said some doctors may not understand the regulations, while others are responding to a nationwide effort to reduce opioid prescriptions.

“Some of it really boils down to physicians who have realized maybe the prescriptions they’ve been writing for valid pain patients are too high, and we need to get it to as low a point as possible,” he said.

The Medical Society supports the proposed rules, he said.

In recent years, Arkansas has had a higher rate of opioid prescriptions per resident compared with other states even though its rate of overdose deaths has been lower.

In 2016, for instance, Arkansas pharmacists dispensed 114.6 opioid prescriptions per 100 residents, according to the CDC. That was a higher rate than in any other state except Alabama, where pharmacists dispensed 121 prescriptions per 100 residents.

That same year, Arkansas ranked No. 37 in its age-adjusted rate of deaths from prescription opioid overdoses, according to an analysis of CDC data by the San Francisco-based Kaiser Family Foundation, which researches health policy issues.

The state had 152 such deaths, giving it a rate of about 5 prescription opioid overdose deaths per 100,000 residents.

Nationally, 32,445 people, or about 10 people per 100,000 residents, died of prescription opioid overdoses that year.

Act 820, passed by the

Legislature last year, calls on the state boards that license doctors, pharmacists, nurses, dentists, optometrists and veterinarians to develop rules limiting the amount of opioids that can be prescribed or dispensed to patients.

According to the Federation of State Medical Boards, at least 24 other states have adopted laws or rules limiting prescriptions for acute pain since 2015. Most or all states also have rules on chronic-pain prescriptions, according to the group.

Arkansas’ current regulations on prescriptions for chronic pain include requirements for the patient’s doctor to have a contract with the patient setting requirements such as random drug screens or pill counts. Act 820 also requires doctors to check a state database of prescriptions for painkillers and other frequently abused drugs before prescribing such a drug.

After the public hearing in February, the Medical Board removed a proposed requirement for doctors to consult with a pain management specialist when prescribing 90 morphine milligram equivalents or more per day.

Instead, the rules reflect the CDC guidelines, which say doctors should avoid or “carefully justify” such doses.

If approved by the Legislative Council, the rules should take effect by the end of next month, Kevin O’Dwyer, an attorney for the Medical Board, said.