What is Florida Controlled Substance Prescribing?
Chronic pain and opioid addiction is a major issue both in the United States and specifically in Florida. More than one-fourth of all Americans suffer from persistent pain. This concern is one of the most common that individuals bring up in a hospital setting, such as during emergency visits or outpatient consultations. Not properly addressing chronic pain can lead to serious health problems, even death, particularly when one becomes dependent on opioids as a form of treatment. One out of every five complaints made by patients in outpatient clinics is about pain, with over half of all patients consulting with their primary care provider for some kind of pain issue. So, it’s crucial for healthcare workers to understand how to manage patients suffering from chronic pain effectively.
The United States currently spends over $100 billion every year on healthcare costs dealing with pain management and opioid dependency. These costs are higher than total expenses for tackling cancer, diabetes, and heart disease combined. This underscores the significant effect that chronic pain management can have on a patient’s quality of life.
Chronic pain, as defined by the International Association for the Study of Pain, is any discomfort that lasts for more than three months. There are various sources of chronic pain. Combination therapy for pain combines pharmacologic treatments with non-pharmacologic interventions and is typically more effective than a single type of treatment. Chronic pain sufferers also often experience depression and anxiety and are at greater risk of suicide. Because of this, learning how to diagnose and manage patients with persistent pain is critical.
Unfortunately, most educational programs for healthcare providers fail to provide enough information about pain management. In response, several institutions have integrated CDC guidelines for prescribing opioids for chronic pain into their curriculum. Providers need to know how to prescribe the right amount of opioid medications, provide ongoing treatment plans and monitoring to ensure effective pain management, while at the same time avoiding misuse and potential abuse.
Prescribing opioids inappropriately can include not prescribing any, prescribing too little, prescribing too much, or prescribing it when it’s no longer beneficial.
Addiction as per the American Society of Addiction Medicine, is a treatable chronic disease influenced by many factors such as environment, genetics, life experiences, and how the brain functions. Those addicted to opioids may show compulsive behavior with harmful effects. The following characteristics are commonly seen:
1. Craving for the drug
2. Dysfunctional emotional response
3. Inability to recognize major problems affecting behavior and relationships
4. Inability to consistently abstain
5. Impairment in behavior control
Regrettably, most healthcare providers have a vague understanding of addiction, which can be frustrating because the addiction issue also extends to the legal and political sectors, affecting those writing and enforcing laws regarding the same. The lack of effective education and the use outdated terms contribute to a generalized lack of understanding on how to handle addiction.
In the past, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders separately defined “addiction,” “substance abuse,” and “substance dependence”, causing quite a lot of confusion. Nowadays, these terms have been replaced with “substance use disorder,” which varies from mild to severe.
Challenges in pain management, like underprescribing and overprescribing opioids are fairly common. This is particularly problematic in patients with chronic pain, leading to inadequately treated pain and potential issues of opioid abuse, addiction, diversion, and overdose. In consequence, providers might not give adequate, effective, and safe opioids to patients with persistent pain because of previously poor training and misinformation.
Prescribers of controlled substances in Florida can include Physicians, Physician Assistants, Podiatrists, Dentists, Optometrists, Advanced Practice Registered Nurses, and Veterinarians.
However, there’s a significant lack of knowledge around the certain aspects of opioid prescribing among providers. This includes understanding what addiction really is, recognizing high-risk populations, differentiating between prescription vs. non-prescription opioid addiction, and appreciating that addiction and dependence on opioids is not synonymous. Overcoming these challenges requires significant education and training.
The misuse of controlled substances, including opioids, depressants, and stimulants, often leads to serious health implications, as confirmed by the National Survey on Drug Use and Health (2016). In this survey, it was found that over 10 million people misuse prescribed pain medications, while over 2 million misuse sedatives, stimulants, and tranquilizers each year. The same study found that most of the misuse was mainly for treating physical pain. The CDC estimates that over 40,000 people die each year due to an opioid overdose.
Specific opioid medications such as Codeine, Fentanyl, Hydrocodone, Morphine Sulfate, Oxycodone, and Tramadol are used for different medical conditions such as for acute or chronic pain, cough, restless leg syndrome, prolonged cough, premature ejaculation, and other conditions. However, they can be prone to misuse and should be prescribed carefully.
Lastly, there are notable differences between addiction, pseudoaddiction, dependence, and tolerance which all healthcare providers need to understand. Misunderstanding and poor education over time led to significant societal challenges which is why knowledge and significant training is essential.
What Causes Florida Controlled Substance Prescribing?
People suffering from chronic pain often experience more than one type of discomfort. For instance, someone with persistent back pain might also have fibromyalgia, a condition causing widespread body pain. Many of these patients also struggle with mental health conditions like major depression and anxiety. In fact, over two-thirds of individuals with chronic pain are diagnosed with at least one psychiatric disorder.
Chronic pain can be categorized into different types based on its cause. This includes neuropathic pain, nociceptive pain, musculoskeletal pain, inflammatory pain, psychogenic pain, and mechanical pain.
Neuropathic pain is often either peripheral, such as with post-herpetic neuralgia or diabetic neuropathy, or central as a result of a stroke.
Nociceptive pain happens because of actual bodily injuries, like burns, bruises, sprains, or fractures.
Musculoskeletal pain often manifests as back pain or myofascial pain, which is discomfort in the muscles and the soft tissues that surround them.
Inflammatory pain is most often associated with autoimmune disorders like rheumatoid arthritis or infections.
Psychogenic pain is caused by psychological factors. This could manifest as headaches or abdominal pain brought on by emotional, psychological, or behavioral situations.
Mechanical pain typically happens with expanding malignancies, which is the growth of cancerous cells.
The role opioid manufacturers play in chronic pain management has come under close scrutiny. Several individuals and government bodies – at the federal, state, and local levels – have successfully sued opioid manufacturers. Purdue Pharma, specifically, was held liable for promoting its sustained-release form of oxycodone, an opioid medication.
Risk Factors and Frequency for Florida Controlled Substance Prescribing
More than 100 million people in the US suffer from chronic pain, with over 50 million experiencing severe chronic pain that interferes with their daily life. Chronic regional pain affects 11.1% of these patients, while chronic back pain, leg and foot pain, arm and hand pain, and headaches affect 10.1%, 7.1%, 4.1%, and 3.5% of patients, respectively. About 3.6% of patients have widespread chronic pain. It’s important to note that elderly patients receive up to 25% fewer pain medications than the average population.
- Chronic pain costs over $600 billion annually due to medical treatment and lost productivity.
- More than half of adults will experience chronic pain at some point in their lives.
- 40% of chronic pain patients say their pain is uncontrolled, and over 10% experience long-term disabling chronic pain.
- 5% to 14% of chronic pain patients have attempted suicide in their life; suicidal thoughts occur in approximately 20% of these patients.
- Around 53.6% of chronic pain patients who commit suicide die from firearm-related injuries, while 16.2% die from opioid overdose.
The number of chronic pain cases is rising due to increasing rates of obesity, a growing aging population, and better survival rates of trauma and surgical patients. Also, public awareness that pain is a treatable condition has increased.
Opioids, which come from synthetic compounds, are the most commonly used treatment for chronic pain. They work by acting on multiple opioid receptors in the body, primarily mu, kappa, and delta receptors. These receptors play key roles in pain control, mood modulation, and several other functions related to pain and emotion.
Previously, US healthcare providers hardly prescribed opioids except for chronic cancer pain. However, since the mid-1990s, the use of opioids for a variety of chronic pain conditions has drastically increased. This rise in opioid use has led to some problems such as opioid abuse and dependency.
In the US, more than 70,000 drug overdose deaths occur every year, with opioids being the most common cause. Particularly, deaths from synthetic opioids like fentanyl are on the rise. In Florida, nearly 70% of the around 5,000 reported drug overdose deaths involve opioids. Despite a slight decrease in deaths caused by prescription opioids, overdose deaths from both opioid and non-opioid substances continue to rise.
Florida healthcare providers write 53.7 opioid prescriptions for every 100 persons, slightly above the national average of 51.4. However, this rate has been decreasing.
Neonatal Opioid Withdrawal Syndrome (NOWS) and Neonatal Abstinence Syndrome (NAS) are common in infants born to women who used opioids during pregnancy. The reported rate is approximately 7 cases per 1,000 live births in the US and 7.3 cases per 1,000 live births in Florida.
Injection drug use (IDU) contributes to about 10% of new HIV diagnoses across the nation, and 5-8% in Florida. Similarly, approximately 85% of new Hepatitis C cases are attributed to IDU in the US, with similar figures reported in Florida.
Signs and Symptoms of Florida Controlled Substance Prescribing
When taking a patient’s medical history, it is crucial to include the onset and description of the pain they experience, and more if there has been an injury. Other useful information includes where the pain is, if it spreads, what it feels like, how severe it is, how often it occurs and if there is anything that makes it better or worse. A common scale used to measure pain ranges from 0 to 10. Doctors also check for additional symptoms like muscle spasms, feelings of heat or cold, stiffness in the morning, weakness, changes in muscle strength, sensory changes, or unusual hair, skin, or nail conditions.
Along with these symptoms, understanding just how much the pain is impacting the patient’s daily life is also important. Questions that evaluate how pain is affecting someone’s personal life, hobbies, mental wellbeing, sleep, physical activity, work, and basic activities like dressing, bathing, eating, or walking can provide crucial information.
Sometimes, patients have difficulty describing their pain. This is particularly common in older adults. When this happens, they might use different terms like ‘soreness’ or ‘discomfort’. There are helpful outlines to aid in understanding a patient’s pain history like the “COLDERAS,” “OLDCARTS” and “PQRST” acronyms. These summarize different aspects of the pain experience like what triggers it, what relieves it, the character of pain, etc. A multidimensional assessment of the patient’s experience of pain is used to measure the pain’s impact on function and quality of life.
There are various tools that help assess the level of pain, including the “PEG” score or “Pain, Enjoyment, General Activity” tool, and the Four-item Patient Health Questionnaire (PHQ-4) which evaluates depression and anxiety.
For children, there are other methods to evaluate pain because they might not always verbalize it. Young children might use visual aids depicting different expressions that match their level of distress. The Pediatric Pain Questionnaire and the Adolescent and Pediatric Pain Tool can be used to identify pain’s location with a body map drawing. Infants and young children that cannot communicate can be assessed with tools looking at their nonverbal behavior to rate their pain.
Special concern is given to nonverbal children with neurologic impairment as pain detection can be challenging. Their caretakers play an essential part in identifying changes like grimacing, moaning, or atypical behavior.
A detailed physical exam is also imperative. This exam should focus on the musculoskeletal system, central nervous system, and mental health, concentrating on the areas causing pain.
Testing for Florida Controlled Substance Prescribing
Health professionals are equipped with knowledge to prescribe pain medications which can, unfortunately, sometimes be misused. It’s important to follow certain guidelines to ensure that these medications, also known as controlled substances, are prescribed safely. These instructions include:
- Reviewing the primary health concern
- Reviewing current and past health conditions and medications
- Reviewing the patient’s medical history
- Examining the patient’s pain levels
- Investigating family and personal history for alcohol, drugs, and mental health
- Evaluating the risk of opioid abuse
- Performing a detailed physical exam and a urine drug test
In cases of chronic pain, standard blood work and imaging are not usually necessary but can be ordered if specific causes of pain are suspected. In certain situations, a urine toxicology test may be ordered to ensure that the patient is following the medication regimen and not taking any unauthorized drugs.
Psychiatric disorders can worsen symptoms of physical pain. In patients with chronic pain, the two conditions that often coexist are major depressive disorder and generalized anxiety disorder. Health professionals need to be mindful that patients with chronic pain are at an increased risk for suicidal thoughts and actions, so screening for depression in these patients is crucial for their safety.
Another important consideration is the risk of addiction to pain medications. Health professionals can use various tools to evaluate this risk and develop an appropriate treatment plan. These tools can help them understand if the patient is at low, moderate, or high risk.
Before prescribing opioids, a health professional should collect extensive information about a patient. If red flags like a history of substance abuse are identified, a psychiatrist or addiction specialist should be consulted.
There are various tools available that can help determine the risk level of a patient developing an addiction. These include the Brief Intervention Tool, the CAGE Questionnaires, Current Opioid Misuse Measure, and others. They are mainly questionnaires that gather information about a patient’s history of alcohol or drug misuse, mental health issues, and other risk factors.
It’s also key to consider whether a patient is using their medication appropriately and to detect any unauthorized drug use. Urine drug tests are generally recommended before starting opioid therapy and should be conducted at least once a year. The frequency of these tests can vary depending on the patient’s level of risk.
If the urine test results suggest misuse of opioids, the issue should be discussed with the patient in a positive and supportive manner, and it should also be properly documented.
Treatment Options for Florida Controlled Substance Prescribing
Generally, non-controlled substances such as basic pain relievers are the first option your doctor will consider to manage pain. However, if these don’t work, your doctor may decide to try controlled substances like opioids. In this case, you would need to give permission for this treatment (known as informed consent), and both you and your doctor would need to sign an agreement about the treatment plan, what your responsibilities are, and what will happen if the treatment plan is not followed.
It’s recommended that if your pain is mild, your doctor will likely begin treatment with common pain relievers, or possibly a combination of these and non-drug therapies like physical therapy or massage.
If your pain is moderate, your doctor may prescribe light opioids along with the previous treatments mentioned.
However, if your pain is severe, your doctor could prescribe stronger opioids. In this case, your dosage would be adjusted gradually until it’s just right, and you’ll likely continue using non-drug therapies too.
In case of chronic pain, doctors should know how to prescribe opioids properly and assess pain. They should also know how various pain management methods can be used together with opioids. If non-opioid therapy doesn’t relieve chronic pain, opioids might be a consideration for treatment. However, this should be a trial, not a firm course of treatment. Finally, if pain continues despite initial treatment, referral to a pain management specialist may be necessary.
Various drugs can be used to treat chronic pain. These include OTC pain relievers, prescription-only drugs like opioids, epilepsy medications, certain types of antidepressants, topical pain relievers, muscle relaxers, and others.
Different types of pain may require different treatments. For example, chronic musculoskeletal pain may be treated differently than severe nerve pain. Your doctor could need to use multiple medications to help treat your nerve pain. Also, less than half of patients with nerve pain achieve full relief with one single drug.
Chronic musculoskeletal pain is often treated with OTC pain relievers or prescription opioids, and sometimes a combination of both. However, opioids have a range of side-effects, including increased sensitivity to pain, constipation, addiction, and sedation. Therefore, they should be used with caution and only after other medications have failed to alleviate pain.
Severe nerve pain is usually first treated with antiepileptic medications like gabapentin or pregabalin. Antidepressants could also be used. Topical treatments, such as lidocaine or capsaicin cream, can also help.
In addition to medications, non-drug therapies can also help manage chronic pain. These include methods like heat and cold therapy, cognitive behavioral therapy, physical therapy, chiropractic, acupuncture, aerobic exercise, and a range of others. More invasive techniques could also be considered if other treatments have not worked. These include methods like nerve blocks, spinal cord stimulation, and pain pumps among others. Some of these interventions are still being studied to demonstrate their effectiveness.
What else can Florida Controlled Substance Prescribing be?
Understanding the cause of a person’s chronic pain is far more important than just recognizing the pain itself. Just like you would try to find the source of a leak instead of just mopping up the water, a doctor needs to understand what is causing the patient’s pain to provide effective treatment. For instance, when dealing with nerve pain, it’s crucial to know whether it originates from the central nervous system or the peripheral nerves.
Taking another example, if a patient has intense knee pain, the doctor needs to know the underlying reason. Could it be severe osteoarthritis? If yes, an injection or even knee replacement could help. But the treatment would be different if the cause were something like rheumatoid arthritis, gout, an infection, or an injury to the knee’s meniscus.
When it comes to generalized chronic pain, the possible causes could be many. It could be due to the misuse of painkillers, existing mental health problems like depression, sleep problems like insomnia, or autoimmune diseases like lupus or psoriatic arthritis. Pain that affects the whole body could also be due to fibromyalgia or “central pain syndromes.” The four main types of pain are nerve-related, musculoskeletal (affecting muscles, bones, and joints), mechanical (resulting from physical injuries), and inflammatory.
When early signs of pain are not treated properly, chronic pain could develop. Chronic pain can change the way our body’s nerves function, and can eventually become a long-standing health issue in itself. Therefore, it’s essential to treat pain swiftly and effectively before it becomes a persistent issue.
What to expect with Florida Controlled Substance Prescribing
Currently, treatments for chronic pain can reduce a patient’s pain by about 30%. This level of pain reduction can greatly enhance a patient’s daily functions and overall quality of life. However, for those with long-term chronic pain, their quality of life and functionality can often decrease.
Patients with chronic pain may see improved outcomes if they are concurrently treating any present mental health conditions. It’s important to note that chronic pain can lead to a higher rate of chronic diseases, obesity, and in some extreme cases, even suicide, making the patient’s overall health and well-being more challenging.
Treatments like spinal cord stimulation only provide sufficient pain relief in about half of the patients. Furthermore, up to 40 percent of patients might develop a tolerance to this treatment, making it less effective over time. Similarly, patients who rely on opioids for chronic pain are likely to build tolerance, resulting in increased health concerns as their dosage increases.
Prevention plays an all-important role in managing chronic pain. Providing appropriate treatment for acute and subacute pain could avoid the transition into chronic pain, letting patients maintain a much better quality of life.
Possible Complications When Diagnosed with Florida Controlled Substance Prescribing
Chronic pain can dramatically lessen quality of life and even result in lost wages and psychiatric issues like depression and anxiety. It can aggravate chronic illnesses and increase the risk of suicide. Many drugs used to manage chronic pain have potential risks, side effects, and complications.
Acetaminophen, often used for chronic pain, can be harmful to the liver, especially when exceeding a dose of four grams per day. It’s the most common cause of sudden liver failure in the United States. Also, even at normal therapeutic doses, patients with chronic liver disease can experience liver damage.
Medications like gabapentin or pregabalin, often used along with analgesics, can cause drowsiness, swelling, mood swings, confusion, and respiratory problems in elderly patients. They should be used carefully in the elderly, especially those with painful diabetic neuropathy. When combined with opioid analgesics, these drugs have shown an increased mortality rate in patients.
Duloxetine can also cause mood changes, headaches, nausea, and other side effects. Because of these potential risks, it should be avoided in patients with a history of liver or kidney diseases.
Opioid therapy, often used for pain management, can result in addiction, overdose and breathing problems. Long-term risks and side effects of opioids include constipation, dependence, nausea, stomach discomfort, heart rhythm issues, and hormonal problems leading to issues like impotence, hormonal imbalances, and lowered libido and energy. The risk of an opioid overdose also increases with the daily dosage.
Spinal cord stimulators, used for pain relief, have a high rate of complications ranging from 5% to 40%. Some of these complications can involve improper placement of the lead, leading to less effective pain relief and possible revision surgeries. Infections can also occur after placing the stimulator, with risks varying from 2.5% to 12%. The most severe complication would be an infection in the spinal cord, often requiring surgery. Up to 70% of patients can experience headaches after a puncture in the dura mater covering the spinal cord. In some cases, patients can develop a dangerous condition like a spinal epidural hematoma, requiring urgent surgical intervention.
Common indicators of opioid misuse might include:
- Insistent requests for more opioids
- Asking for specific opioids by name
- Signs hinting at opioid use disorder
- Forged prescriptions
- Increased alcohol consumption
- Unapproved increase in medication dosage
- Injecting medications intended for oral use
- Acquiring medications from nonmedical or multiple sources
- Loss or theft of prescriptions
- Resistance to reducing opioid dose
- Early refill requests
- Selling prescriptions
Prescribers and dispensers can take several steps to avoid misuse of prescribed opioids. These include doctor-pharmacy communication to prevent “doctor shopping”, educating patients about the dangers of sharing opioids, encouraging secure storage of opioid medications and avoiding disclosure of opioid use.
If there is a suspicion of opioid misuse or diversion:
- Inquire about prescription and illicit drug usage
- Request a urine drug test
- Perform a thorough medical examination
- Count pills
- Prescribe smaller quantities of opioids
If a patient is found to be abusing prescribed opioids, it breaches the treatment agreement, and the healthcare provider may choose to end their relationship with the patient legally. Patients struggling with substance abuse or addiction should be referred to a pain management specialist. Any theft or loss of controlled substances should be reported to the Drug Enforcement Administration. If drug diversion has occurred, it should be recorded and reported to law enforcement.
Preventing Florida Controlled Substance Prescribing
The patient and their family members can play a vital role in deciding whether to continue or stop opioid therapy. Often, families can identify if a patient is dealing with depression or struggling with regular activities. Some important questions to ask family members could include:
- Does the patient seem to focus their day around taking their opioid pain medication?
- How often does the patient need to take pain medication?
- Does the patient struggle with alcohol or other drug issues?
- Does the patient avoid doing activities?
- Does the patient seem depressed?
- Is the patient able to carry out daily routines?
There are also essential guidelines that patients using opioids should follow:
- They should avoid driving or using power equipment
- Stopping opioids suddenly can be harmful, so they should avoid it
- They should avoid consuming substances like alcohol or anxiety medication that could suppress their breathing when taken with opioids
- If their current pain medication isn’t offering enough relief, they should contact their doctor
- Proper disposal of opioids is important. They can usually be disposed of by flushing them down the toilet or mixing them with cat litter or coffee grounds
- Chewing opioid tablets is not recommended
- Sharing opioids with friends or family members is dangerous and should be avoided
- They should strictly follow the dosing instructions given by their doctor
- Opioids should only be taken as prescribed by a doctor
