A law that went into effect last July requires medical providers to check a statewide database before prescribing opioids for patients. Now, lawmakers are being asked to consider an exemption for doctors whose patients are terminally ill.
The law, known as House Bill 21 (HB21), targets controlled substances that are labeled as Schedule II or higher. That includes painkillers like OxyContin and codeine. These drugs are classified as having a high potential for abuse.
Claudia Kemp, executive director of the Florida Board of Medicine, recently told the Senate Health Policy Committee about the implementation of HB21.
“The new law limits a prescription for a Schedule II opioid to treat acute pain to a 3-day supply. There is an exception. A practitioner may prescribe up to a 7-day supply if the practitioner determines more than a 3-day prescription is necessary. But if they do go up to the 7-day supply, they have to indicate acute pain exception on the prescription and document the justification for deviating from the 3-day limit.”
Each time a controlled substance listed as Schedule II or higher is dispensed, it must be reported to the state’s Prescription Drug Monitoring Program, known as the database. In most cases, when a controlled substance is prescribed or dispensed, practitioners must check the database to review a patient’s history. The goal is to prevent “doctor shopping,” when drug abusers seek multiple doctors to write them prescriptions.
Database program manager Rebecca Poston says database registrations have increased by more than 40 percent since July, and prescriptions have declined. “We’ve seen so far in the data a 3.8 percent reduction in the number of patients receiving controlled substances in the state of Florida. We’ve also had an 8.6 percent reduction in prescriptions for hydrocodone sustained actions that have been dispensed.”
Now, the committee is considering whether the law should be tweaked for doctors treating people who are dying. The law exempts hospice and palliative care patients from the required prescription limit, but their providers still have to check the database in order to prescribe the controlled substances that are often needed at the end of life.
“These are not patients that are at risk of going out there and doing the things that we don’t want them to do,” says Dr. Stephen Leedy, a board member of the Florida Hospice and Palliative Care Association. He says Florida had about 137,000 hospice patients last year. That makes up 10 percent of the hospice patients nationwide. He says their average stay was three weeks before they died.
“That three weeks is an important number," Leedy said. "During those three weeks, these patients were not out there doctor shopping. They were not out there looking for opioids in the streets. They were mainly bedbound and in pain, short of breath, being managed by hospice providers.”
Leedy says checking the database each time controlled substances are ordered leads to delays in medicating a dying patient.
“It’s not unusual for a patient to require 6 to 7 dosage adjustments of their opioid pain medications within the first 72 hours of hospice care. Each of those dosage adjustments requires a query of the database to make sure that the patient has not doctor shopped in the two hours since the previous administration of the dose of opioid," Leedy said. "You can imagine if you do the math and think about it how ridiculous this process becomes after a while in terms of the number of queries that need to be done.”
Leedy says the association’s members recognize opioid abuse as a significant issue in Florida. But he says hospice providers and patients aren’t contributing to the state’s opioid problem.
“There’s a pharmacy provider in the state of Florida – OnePoint Patient Care – who provides only medications to hospice patients, and they indeed met the requirement of House Bill 21 by performing the queries." Leedy says out of 68-thousand queries on hospice patients, the provider found "zero opportunities for identifying diversion" for issues like doctor shopping.
The Florida Hospice and Palliative Care Association wants the Legislature to exempt physicians from having to query the database -- or require them to check it only once, when a dying patient is admitted for care. In order to make that change, a new bill will have to be filed. Supporters haven’t found a lawmaker yet who’s willing to sponsor the legislation.