Mind and Body

Pain management is redefined in Rhode Island

New regs seek to tighten rules for prescription painkillers

Photo By Richard Asinof

Dr. Michael Fine, director of the R.I. Department of Health, has led an effort to combat the epidemic of addiction and deaths from accidental overdoses in Rhode Island, building a collaborative coalition. One of this latest efforts is the creation of new rules and regulations governing prescription of opioids and pain management.

By Richard Asinof
Posted 12/15/14
New rules and regulations seek to tighten the way that prescription painkillers are prescribed will be the subject of a hearing Monday, as the state continues its efforts to control the over-prescription of addictive opioids. The new regulations are facing some push back from dentists, who are upset about changing some of the traditional prescribing practices.
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PROVIDENCE – A public hearing will be held Monday morning, Dec. 15, by the R.I. Department of Health, on changes to rules and regulations governing “Pain Management, Opioid Use, and the Registration of Distributors of Controlled Substances in Rhode Island.”

The new rules and regulations are part of a continuing response by the state health agency to the epidemic in deaths caused by accidental overdoses and the role that prescription painkillers [known as opioids] play in addiction.

“About 115,000 Rhode Islanders get a prescription for Schedule 2, 3 or 4 [controlled substances] every single month,” Dr. Michael Fine, director of the R.I. Department of Health, told ConvergenceRI in a recent interview. The new regulations, Fine continued, are an effort “to change prescribing behavior.”

Fine emphasized that the regulations are being changed in response to the crisis Rhode Island is facing. In particular, the new regulations “govern the use of opioids in the treatment of chronic pain,” according to the proposed changes.

They establish minimum requirements for pain management and opioid prescriptions, including patient evaluation, documentation of a treatment plan, duration of the prescription, and a written patient treatment agreement. The new requirements also establish a periodic review of the patient’s treatment, including an in-person visit, at least once every 12 months.

The new regulations also define the qualifications for becoming a pain medicine/addiction physician, the multidisciplinary approach to the treatment of chronic pain, and the transition of care for patients on long-term opioid therapy.

One of the big changes under the rule changes is that practitioners will no longer be able to prescribe a controlled substance to his or herself or to an immediate family member, under any circumstances.

Also, an unlicensed staff member will not longer be permitted to telephone or otherwise transmit a prescription for a controlled substance to a pharmacy.

Further, the new regulations encourage physicians and practitioners to make use of the Prescription Monitoring Program database when prescribing controlled substances.

Push back
Fine acknowledged that there had been some push back from the professional community to the new regulations, saying that some of the regulations have been “hotly contested.” In response, Fine said his agency has been trying to work collaboratively with them to find common ground.

“Some of our colleagues in dentistry are not comfortable with some of the restrictions on prescribing to family members and themselves,” Fine told ConvergenceRI, saying the new regulations marked a change in tradition for the dental community. Professionals often emphasize their traditions and can be relativity slow to respond to change, Fine added.

The hearings, he continued, would provide “an interesting opportunity to understand some of the current opinions that exist.”

Some good news

Fine reported that the total number of prescriptions written to people who have been seen at more than four pharmacies and have prescriptions written by four prescribers have “fallen off,” a sign of potential abuse, as a result of collaborative efforts undertaken by state authorities.

Fine also said that the number of accidental deaths from drug overdoses appeared to be leveling off, so that the 2014 number of deaths will be close to the 2013 numbers.

“It’s the beginning of a tiny success,” he said, particularly when the numbers in other states are still rising. “But the real success will be when the numbers go to nothing. The number of deaths [in Rhode Island] is something we should all be ashamed about.”

Fine also talked about the emergence of a mothers' movement in Rhode Island, to change what’s culturally acceptable, to fight back against the dealers.

Changes in distribution strategy by drug cartels
Fine also told ConvergenceRI that what authorities have heard, anecdotally, is that the drug cartels are changing their distribution strategy, creating a vertically integrated organization.

“What we have heard, anecdotally, is that the cartels have cut out the middle man, creating a kind of big box store for drugs, so that they deliver heroin more cheaply,” he said. “People who are doing the dealing work directly for the cartels, creating a supply process that is very efficient.”

More resources
Fine said that there will need to be difficult choices made in the upcoming budget deliberations about the need for additional resources. “I think it is going to be a difficult choice,” he said. “We’re trying to do what we’ve done without any additional expenditures.”

But, he continued, “to provide adequate treatment to people 24 hours a day, how it ought to be available, without expenditure of any additional funds,” will prove to be difficult.

“We all have a collective choice to make,” Fine said, framing the issue. “We need to reduce the number of people [who are addicted]. We need to reduce the cost of drug use, not just deaths, but in academic and work performance and family dysfunction.”

How much are we willing to tolerate? Fine asked. “Whether it’s for treatment and prevention, or whether we pay for it in funeral expenses and loss of productivity, we’re going to pay for it, one way or another.”

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