Florida Responsible Controlled Substance and Opioid Prescribing

What is Florida Responsible Controlled Substance and Opioid Prescribing?

Pain, both sudden and ongoing, is a common reason why people visit their doctors. In fact, about 1 in 5 complaints in an outpatient clinic are related to pain. Over a quarter of the people in the U.S. experience chronic pain, which is pain that lasts for a long time. How this pain is managed can greatly affect a patient’s quality of life. In the 1990s, doctors began to focus more on treating pain, which led to an increase in prescriptions for opioid painkillers. However, this increased prescription resulted in widespread abuse of these drugs, leading to what’s known as the opioid epidemic. This crisis became so severe that it prompted state and federal responses. For example, in Florida, a law was passed in 2018 that greatly limited how many opioid prescriptions could be given for non-chronic pain and established strict rules around prescribing opioids for acute and chronic pain.

Misuse of opioids is a major problem in the U.S., particularly in Florida. The rate of addiction and overdose from opioids has been rising. In 2020 alone, more than 68,630 people in the U.S. died from an opioid overdose, accounting for about 75% of all drug overdose deaths. This was a 31% increase from the previous year. In Florida, there were over 6,000 deaths, a 42% increase from the 2019 figures. In total, about 165,000 people in Florida are affected by opioid addiction, contributing to the 2.1 million people all over the country with this condition.

Healthcare professionals need to have a thorough understanding of how to manage patients with pain. Failure to do so, or improper treatment leading to opioid addiction, can cause significant health problems and even death. Every year, the US spends over $100 billion on healthcare costs related to pain management and opioid addiction. The cost related to pain exceeds the combined costs of treating cancer, diabetes and heart disease.

According to the International Association for the Study of Pain chronic pain is defined as any pain that lasts more than three months. Treatment for pain can involve medications and non-medication options, and a combination of both usually results in better pain control. Treatment should be gradually increased, with opioids only considered as a last resort. Conditions like depression and anxiety, which are common in people with chronic pain, should also be treated. It’s important to recognize that people with chronic pain have an increased risk of suicide and that chronic pain can affect every aspect of a patient’s life. As such, knowing how to diagnose and manage chronic pain is crucial.

Unfortunately, most medical schools and training programs don’t provide enough education on pain management. Recognizing this, the Association of American Medical Colleges has encouraged schools to include education and training on opioid prescription in their curriculum.

Prescribing opioids involves ensuring that the right amount of medication is given to provide pain relief and improve quality of life, while avoiding problems like addiction and overdose. Doctors also need to understand federal and state laws around prescribing controlled substances like opioids. Problems can arise if opioids are underprescribed, overprescribed, or continued to be prescribed when they are no longer effective. Patients with chronic pain are particularly at risk of these issues, as they often become tolerant to opioids and can develop psychological, behavioral, and emotional problems such as anxiety and depression.

Prescribing opioids comes with challenges. Doctors can face problems like failing to provide enough pain relief, losing their license, and even facing criminal charges if they are suspected of misuse or diversion of drugs. For this reason, all doctors who prescribe opioids need additional education and training.

There are still significant gaps in knowledge regarding proper and improper opioid prescribing among doctors, including understanding addiction and the risk populations for opioid use disorders. Clinicians often misunderstand that drug addiction and tolerance to the drug are the same, and they also often mistake it as a psychological issue rather than a complex issue relating to chronic pain.

Prescribing opioids has resulted in problems in society that can only be addressed through comprehensive education and training for all healthcare team members. To further complicate things, there’s confusion among clinicians about the definitions of key terms related to addiction, and there’s a lack of clarity among the people writing and enforcing the laws and the ones paying for the costs of treatment. There’s a need for better education and up-to-date terminology to overcome these problems.

The American Psychiatric Association used to define addiction, substance abuse and substance dependence as separate things. Now, they use the term ‘substance use disorder’, which is divided into mild to severe categories. Addiction is described as a treatable chronic disease linked to environmental pressures, genetics, a person’s experiences and interactions in their brain. People with an addiction to opioids or other medications often have compulsive behaviors that result in dangerous consequences. There are five key behaviors identified by the American Society of Addiction Medicines, including a craving for the drug, dysfunction in dealing with emotions, not recognizing problems with behavior and relationships, an inability to consistently abstain and a lack of control over behavior. Understanding these issues can help clinicians in effectively dealing with patients experiencing addiction.

What Causes Florida Responsible Controlled Substance and Opioid Prescribing?

Pain can be grouped into different categories and types, including nerve-related, tissue damage-related, muscle and bone, inflammation-related, psychological, and mechanical. Pain is also divided based on how long it lasts. Normally, pain that is under 3 months old is called acute pain, while pain that’s been going on for more than three months is known as chronic pain. This understanding is particularly important in Florida, where prescribing medicines is regulated based on this division into acute and chronic pain. Acute pain, as defined by law, is a regular and expected body response to harmful chemicals, heat, or physical harm related to surgery, trauma, or sudden illness. This definition does not include pain linked to cancer, terminal diseases, care aimed at relieving symptoms of incurable, progressive illness or injury, severe traumatic injury, and other pain not fitting this temporary definition, which is classified as chronic.

Both acute and chronic pain can be caused by several factors and may not fall perfectly into one category of pain, like nerve-related or inflammation. This is especially so for chronic pain. Most patients with chronic pain report more than one type of pain. For example, someone with constant back pain could also suffer from fibromyalgia. Besides, many people with chronic pain also have depression and anxiety disorders. In fact, over 67% of chronic pain sufferers also have a psychiatric disorder.

Opioids, while effective in managing various types of pain, are linked to health deterioration, death, and misuse. The misuse of opioids results from medical, psychological, social, and economic factors. Two decades ago, there was a push for healthcare providers to treat pain more aggressively, and around the same time, a new opioid was introduced which was believed to have a low risk of addiction. Patients and providers began to believe that prescription opioids were better and safer than drugs from the street, which led to a spike in prescription opioid use with grave consequences for patients and communities.

Opioid use also increased because of direct marketing to consumers, promotion to doctors and pharmacists by sales representatives, and the illegal production and distribution of opioids. The possibility of making large profits led some dishonest healthcare professionals to establish “pill mills”, where opioids were prescribed with little or no proper documentation. This was widespread in Florida, which was considered the center of these operations in the United States. As these opioid sources declined, people with opioid misuse disorders have turned to alternatives, and illegal use of Fentanyl and Heroin has rebounded.

Since the early 2000s, many lawsuits have been filed against opioid makers and distributors, claiming that manufacturers did not adequately warn about the addiction potential of opioids or knowingly concealed information about the dangers of opioids. Prescribers who give higher than normal doses, long-acting formulas, and large volume prescriptions for non-cancer related chronic pain without sufficient follow-up may increase the risk of opioid misuse or abuse among patients. They might also face severe penalties from their affiliated boards. It’s important for pharmacists and prescribers to have open discussions about prescriptions to ensure the safe care of patients. Pharmacists can reach out to prescribers if they have concerns about controlled substance prescriptions for patients.

Risk Factors and Frequency for Florida Responsible Controlled Substance and Opioid Prescribing

Acute pain is a common issue, especially in emergency departments where over three-fourths of patients report it as their main problem. It’s harder to determine how many people live with chronic pain, but in 2016 about 20.4% of adults in the United States reported experiencing it. Additionally, roughly 8% of U.S adults face severe chronic pain that heavily affects their daily life and work.

Chronic pain is more common in women, older adults, people with a lower socioeconomic status, those with public health insurance, and adults without a high school education. In the group of people suffering from chronic pain, here’s a breakdown of other types of pain:

• Chronic regional pain affects 11.1%
• Chronic back pain affects 10.1%
• Leg and foot pain affects 7.1%
• Arm and hand pain affects 4.1%
• Headaches affect 3.5%
• Widespread pain affects 3.6%

The economic burden of chronic pain is enormous, costing roughly $560 billion each year in lost productivity and medical treatments. Research has also revealed a serious mental health concern, noting that between 5% and 14% of chronic pain patients have attempted suicide.

The number of people living with chronic pain is increasing, primarily due to conditions related to obesity, an aging population, and greater awareness of pain management. However, it’s important to note that older patients receive 25% fewer pain medications compared to the general population.

Historically, healthcare professionals hesitated to prescribe opioids except for chronic cancer pain. This trend shifted in the 1990s when health professionals began considering pain as the “fifth vital sign”. By 2004, a specific form of oxycodone had become the most abused drug in the United States, with the country now consuming over 80% of all opioids produced globally. Unfortunately, alongside increased use, the number of individuals misusing opioids has shot up significantly.

Signs and Symptoms of Florida Responsible Controlled Substance and Opioid Prescribing

When assessing a patient’s pain, doctors should talk to the patient about how the pain feels, where it is, how severe it is, and what makes it better or worse. Questions can help identify any changes in their muscles, temperature, movement, and skin or hair. One method doctors could use is a number scale from 0 to 10 to determine the intensity of the pain.

Alongside assessing the physical symptoms, the effect of pain on a patient’s daily routine is also essential. Clinicians should discuss how the pain has impacted the person’s relationships, hobbies, work, sleep, mood, and daily activities.

Doctors may use different tools to measure a patient’s pain and its impact, such as the Pain, Enjoyment, General activity tool, the 4-item Patient Health Questionnaire, or the Defense and Veterans Pain Rating Scale. For children, pictures or different kinds of pain rating scales can be employed to understand their discomfort level.

Finding out how much pain a non-speaking child with a neurological condition is experiencing can be tough. Caregivers might need to help identify changes in the child’s behavior, such as changes in facial expression, body movement, noise level, and ability to be comforted, as these can be indicators of pain. Tools like the Revised Face, Legs, Activity, Cry, Consolability tool can be used for infants and small children.

Patient’s beliefs about their pain and its influence on their daily life can be assessed utilizing the Brief Pain Inventory. The McGill Pain Questionnaire can be applied to note down the location of the pain in the human body, inquire about previous use of pain medication, and past experiences with pain. If the pain is caused by the nervous system (neuropathic pain), the Neuropathic Pain Scale could be used.

In cases where controlled substances for pain management are needed, it’s essential to know the patient’s history of substance abuse and other health or social factors that could increase the risk of misuse. This careful evaluation includes a detailed history, a thorough physical examination, reviewing the patient’s medical records, and querying the state or regional Prescription Drug Monitoring Program.

A comprehensive physical examination, which includes examinations of the musculoskeletal, neurologic, and psychiatric systems, should be done, as well as a targeted examination of the area of the body where the pain is.

Testing for Florida Responsible Controlled Substance and Opioid Prescribing

When dealing with chronic pain that has been previously examined, regular blood tests and scans are not always necessary. However, doctors may order them when they suspect specific causes of pain, or when the chronic pain appears to be getting worse or changing in nature. It’s recommended for people taking chronic pain medication – such as nonsteroidal anti-inflammatory drugs or paracetamol – to regularly get blood tests. For people using opioid treatment to manage chronic pain, random urine drug tests should be done initially and then annually. This is to ensure the treatment is being followed correctly and to check for any non-prescription drugs.

Psychiatric disorders can affect how intense pain feels, often making it worse. People with chronic pain are more likely to also have mental health disorders like depression, anxiety, and substance use compared to the general population. They are also more likely to have suicidal thoughts. By having chronic pain and a psychiatric disorder at the same time, it can make diagnosing either condition more challenging. This can make treatment more difficult as often people with these conditions are prescribed more opioids. Because of this, routine depression screening is important for people with chronic pain.

In Florida, there are strict rules on prescribing opioids. Doctors prescribing them must finish a 2-hour course about safe prescription practices every two years and must refer to a statewide electronic database before prescribing. Before opioids are given, the following should be considered: the patient’s history, the type, location, and intensity of the pain, how previous pain treatments have worked, any other illnesses the patient has, family support, job, housing, and any history of substance misuse or abuse. If there are any concerns about drug misuse, consulting with a psychiatrist or addiction specialist is recommended.

The World Health Organization has a structured approach to managing pain that should be followed before considering opioids. This approach includes trying non-opioid painkillers and other treatments alongside or before considering opioid medication.

In assessing addiction risk, a variety of sources should be used. These include the patient’s history, a physical exam, family input, data from the state prescription monitoring program, and screening tools. Based on their risk level, patients can fall into one of three categories: low, medium, or high risk, each of which requires different degrees of monitoring and treatment plans. Lastly, there are numerous tools and questionnaires available to help evaluate a patient’s potential for opioid misuse.

The decision to prescribe opioids should be balanced against their risks which include substance abuse, adverse drug reactions, overdose, and dependence. Patients with a history of substance abuse may need a consultation with addiction experts and may have their prescriptions delayed until they enroll in a monitoring or treatment program. Non-drug treatments like physical therapy or psychological therapy may also be considered.

Florida physicians are required by law to consult the state’s electronic prescription monitoring database every time they prescribe controlled substances. The Center for Disease Control advises that prescribers check the prescription drug monitoring program when starting opioid treatment and every three months afterwards.

To ensure the responsible use of controlled substances, doctors and dispensers should adhere to a checklist when prescribing and dispensing these medications. Red flags to look out for in patients include early refills, lost prescriptions, multiple prescribers, and concerning results from drug monitoring programs. Verification measures include checking photo ID and keeping an eye out for unusual prescription patterns.

Deciding not to prescribe or dispense controlled substances should be done calmly, without accusing the patient of wrongdoing. Any concerning prescriptions should be reported to the authorities.

Treatment Options for Florida Responsible Controlled Substance and Opioid Prescribing

Healthcare professionals dealing with patients who suffer from short-term or long-term pain should be knowledgeable about the best practices in prescribing painkillers that contain opioids. They should know how to evaluate pain, manage pain through various methods including mixed treatment strategies, and apply opioids properly for pain control. They should also be aware of local and state laws about prescribing opioids. Evaluations should include drug and non-drug approaches. For moderate-to-extreme short-term pain, patients can be given a short course of opioids. However, under Florida law, an opioid prescription for acute pain can last no more than 3 days. This can only be extended to 7 days if there is sufficient medical evidence to support such use.

On the other hand, patients diagnosed with chronic pain are not subject to the same limit. If these patients have been evaluated and given non-opioid therapy without satisfactory pain relief, they may be eligible for opioid therapy if the benefits are deemed greater than the risks. The initial treatment should attempt the lowest effective dose with plans for discontinuation if it turns out that the risks actually outweigh the benefits. The decision to use opioid therapy initially does not mean it will be a long-term treatment. updated federal guidelines on prescribing opioids for chronic pain address when and if to begin or maintain opioids for chronic pain, which opioid to choose, the dosage, duration, follow-up, and when to stop treatment. Moreover, the guidelines stress the significance of evaluating the risk of opioid misuse and how to address potential harms associated with opioid use.

For patients with chronic pain who do not respond to initial treatment options, they may be referred to a pain management clinic. There are numerous treatment options available to manage chronic, severe, and persistent pain, including drug, adjunct, non-drug, and interventional approaches.

Numerous non-drug options are available for pain management, such as heat and cold therapy, massage therapy, cognitive-behavioural therapy, relaxation therapy, group counselling, ultrasounds, acupuncture, aerobic exercise, chiropractic therapy, physical therapy, occupational therapy, and transcutaneous electrical nerve stimulation. The effectiveness of these treatments varies. For example, cognitive behavioural therapy has been shown to reduce pain and disability in patients who endure chronic pain. however, the data on the effectiveness of transcutaneous electrical nerve stimulation for treating chronic pain is inconclusive.

There are also interventional techniques used to treat acute and chronic pain. Nerve blocks are typically performed either for preventing pain pre-surgery or for treating new pain or ongoing pain. Some procedures frequently performed for ongoing pain include trigger point injections, nerve blocks, radiofrequency, or cryo-ablations, in-the-joint injections and epidural steroid injections. Stimulation of the spinal cord, peripheral nerve stimulation, and intrathecal drug delivery systems are also possible ways to treat pain in patients who have exhausted more conservative treatments.

The spectrum of drugs available for pain relief is extensive. Treatments for muscle and bone conditions that involve pain-causing changes in both the central and peripheral nervous system should be approached in a step-by-step manner, incorporating a combination of non-opioid pain relievers, opioids, and non-drug therapies. Initial therapy should be with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), which can be effective for arthritis and back pain.

For patients with nerve pain as part of their chronic pain condition, a combination of many drug therapies may be necessary. Drug treatment for nerve pain often starts with gabapentinoids, such as gabapentin and pregabalin. Other possible drugs for managing pain include antidepressants and topical agents.

Opioids are a primary treatment for moderate-to-intense short-term pain but are held as a secondary option for chronic pain conditions. However, they may be suitable for pain management in patients with severe, persistent pain that doesn’t respond to other treatments or in cases of pain related to cancer. The side effects of opioids, however, are significant and may include sensitization to pain, constipation, dependence, sedation, suppression of the immune system, osteoporosis, and neuroendocrine dysfunction.

Important factors, like potential side effects of drugs, should be considered in pain management. Patient should make an informed decision before starting opioid treatment after weighing the risks, benefits, and alternatives to opioids. The risk of overdosing increases with the dosage of opioids. Thus, When starting opioid treatment, the clinicians should start with a dose that is as low as reasonably achievable (ALARA) for the patient. These are just a few key factors to consider when managing pain in patients.

What else can Florida Responsible Controlled Substance and Opioid Prescribing be?

When trying to identify the source of chronic pain, doctors must consider many potential causes. Determining the actual cause of the pain helps them start the right treatment. For instance, chronic pain in the hip and leg might be due to osteoarthritis in the hip, a nerve condition called lumbar radiculopathy, or a dysfunction in the joint connecting the spine and hip (the sacroiliac joint).

Each of these conditions might need a different treatment approach. Some conditions might be more effectively treated with common painkillers, while others might benefit more from medication specifically for nerve pain. Doctors also have to think about the different ways to treat a diagnosis directly – for instance, surgery, steroid injections into the joint or around the spine, blocking nerve signals, or using radio waves to reduce pain.

Additionally, doctors must remember to consider other overlapping diagnoses. For instance, patients who have been using opioids for a long time to manage their pain may develop a condition called opioid-induced hyperalgesia that can increase their sensitivity to pain. Chronic pain is also often accompanied by other conditions like severe depression and sleep disorders.

Recognizing these accompanying conditions can help doctors choose the right medications, like ones that can address both nerve pain and symptoms of depression. On top of this, doctors should also consider if the widespread chronic pain is a sign of autoimmune diseases (where the body’s immune system mistakenly attacks its own cells) such as systemic lupus erythematosus or psoriasis, fibromyalgia (a condition that causes pain all over the body), or central pain syndromes (conditions that cause pain and discomfort in the central nervous system). Therefore, it’s crucial to understand that chronic pain could be a symptom of one or several diagnoses.

What to expect with Florida Responsible Controlled Substance and Opioid Prescribing

The outlook for both short-term and long-term pain can vary a lot. What triggers the pain, personal aspects such as social and genetic influences, the presence of other medical conditions, and several other factors all influence how well someone might recover.

Key things that can shape how long-term pain will progress include how long a person has been in pain, their mental health, and their age.

Preventing long-term pain is very important. If immediate and mid-term pain is treated correctly and long-term pain avoided, patients are less likely to have reduced quality of life. Having a long-term history of pain is linked to more severe pain, disability, and emotional stress.

There’s a higher chance of having mental health problems when people suffer from chronic pain conditions. The stress of enduring long-term pain tends to lead to increased emotional stress.

Possible Complications When Diagnosed with Florida Responsible Controlled Substance and Opioid Prescribing

Chronic pain can cause a substantial dip in life quality, impacting daily productivity, increasing medical conditions, causing loss of income, and leading to mental health issues like depression, anxiety, and substance abuse. This type of pain can also increase the risk of suicide and suicidal thoughts. It’s also important to note that some of the medications used to manage chronic pain can have negative effects.

Acetaminophen is a frequently prescribed medication for chronic pain. It can be taken alone or combined with other painkillers, including opioids. However, it’s crucial to avoid taking more than 4 grams per day because it can seriously harm the liver. This drug is even known to be the leading cause of sudden liver failure in the US. Moreover, it can harm those with a pre-existing liver disease, even when used responsibly.

Commonly prescribed drugs such as gabapentin or pregabalin carry their own set of potential side effects, including forgetfulness, change in mood, peripheral swelling, and sleepiness. Absorption of these drugs can disproportionately affect the ability to breathe in older users or those who combine them with opioids.

Opioid therapy is a well-recognized source of addiction and overdose, which can result in breathing difficulty. Another concern is opioid-induced hyperalgesia, which can make patients more sensitive to pain. The other after effects and poison control strategies for opioids have already been examined earlier.

Issues with Misuse of Prescribed Opioids

Regrettably, some people misuse prescribed opioids for non-medical reasons like getting high or financial benefit. Prescription opioids can be gotten from friends or family, bought illegally, obtained by visiting multiple doctors, or even through theft from medical facilities.

Several signs may hint at a patient misusing or diverting drugs:

• Aggressively demanding more opioids
• Requesting opioids by their specific name
• Displaying behaviors suggesting opioid addiction
• Forging prescriptions
• Increasing alcohol use or medication dose without permission
• Injecting oral medications
• Getting medication from non-healthcare sources
• Obtaining opioids from multiple clinicians
• Losing or stealing prescriptions
• Reluctance to decrease opioid dosage
• Resisting change in medication
• Repeatedly requesting early refills
• Selling prescriptions
• Sharing or borrowing similar medication
• Stockpiling medications
• Using drugs illegally
• Using pain medications for unrelated symptoms

Preventing Misuse of Prescription Opioids

Doctors and pharmacists should take several precautions to prevent misuse of opioids:

• Open communication between healthcare providers and pharmacies to avoid filling prescriptions from multiple doctors
• Educate patients about the risks of sharing opioids
• Advise patients to keep their opioid medications secure and private
• Dissuade patients from publicly disclosing their opioid use
• Report prescription history to the state’s central database if accessible.

If someone is suspected of misusing or diverting the drug, necessary steps should be taken, which may include urine drug screening, thorough examination, pill count, and prescribing smaller quantities of the opioid.

If a patient is discovered to be abusing prescribed opioids, they could be removed from the practitioner’s care. However, if the patient-practitioner relationship is terminated, it must be done legally to avoid charges of patient abandonment. This means the practitioner must ensure continuity of care for the patient and provide enough notice for them to find another healthcare provider. Patients with a substance abuse problem should receive a referral to an addiction specialist. Theft or loss of controlled substances must be reported to the Drug Enforcement Administration (DEA). Any diversion should be noted and reported to law enforcement.

Preventing Florida Responsible Controlled Substance and Opioid Prescribing

The patients and their families can play a crucial role in managing the use of opioid pain medication. Their involvement can lead to conscious decisions about whether to continue or stop the opioid treatment. Family members are often the first to notice signs like depression or lessened daily functioning in the patient. Should the patient agree, the doctor may ask the family several questions: Does the patient structure their day around the medication? How often does the patient take the medication? Are there signs of other substance misuse? Is the patient less active than usual? Does the patient seem depressed? Can the patient function normally?

If a patient is prescribed opioid medications, certain guidelines should be followed for patient safety:

• Stay clear of driving or using heavy machinery while on the medication.
• Never stop taking opioids abruptly.
• Avoid combining the medication with other substances, like alcohol or certain sedatives, which might slow the breathing.
• If the medication isn’t providing enough pain relief, consult the doctor.
• Dispose of any unused medication responsibly. This might mean returning it to a registered pharmaceutical take-back program, flushing it (if it’s labeled as safe to do so), or mixing it with something like coffee grounds or kitty litter, sealing it in a sturdy container, and throwing it away. Never share your medication with others.
• Stick to the prescribed dosage.
• Make sure you fully understand the specifics of the medication you’ve been prescribed.

A collaborative approach can be the best defense against opioid misuse. Doctors, pharmacists, and other healthcare professionals should work together to uphold safe and suitable use of the medication – doctors start the process with prescribing the medicine, while pharmacists double-check the prescription’s appropriateness. Not picking up on potential misuse can lead to substantial problems for the patient and the community. So, a team-based approach is crucial for the most favorable outcome.