Strategies for Appropriate Opioid Prescribing: The Florida Requirement _ _____________________________
SICKLE CELL DISEASE-RELATED PAIN Managing pain in sickle cell disease requires a nuanced, multimodal approach that balances effective analgesia with safe opioid prescribing practices. Within the broader context of pain management education, SCD provides a clinically important example of recurrent acute and chronic pain requiring both pharmacologic and nonpharmacologic strategies. Clinicians must be prepared to individualize treatment, escalate therapy appropriately during vaso-occlusive crises, and incorporate disease-modifying and adjunctive therapies—all while applying principles of opioid stewardship, including appropriate selection, dosing, monitoring, and reassessment. No single treatment is effective for all people with sickle cell disease; instead, appropriate treatment options are determined according to symptom severity [101]. Nonpharmacologic prevention includes avoiding dehydration, extreme temperatures, high altitudes (including flying), and low oxygen levels from intense exercise or athletic training [101; 102]. For prevention of acute pain episodes in adults and children 2 years of age and older, hydroxyurea represents the backbone of sickle cell disease management [103]. It is effective in reducing pain crises, painful symptoms, need for blood transfusion, and mortality. Inconsistent adherence reduces its efficacy, and patient adherence can be challenged by the three- to six- month delay between treatment initiation and the onset of clinical response.
Florida law dictates that, for the treatment of acute pain, a prescription for an opioid drug may not exceed a three-day supply; an exception may be made for a seven-day supply if [54]: • The prescriber, in his or her professional judgment, believes that more than a three-day supply of such an opioid is medically necessary to treat the patient’s pain as an acute medical condition. • The prescriber indicates “ACUTE PAIN EXCEPTION” on the prescription. (For the treatment of pain other than acute pain, a practitioner must indicate “NONACUTE PAIN” on a prescription.) • The prescriber adequately documents in the patient’s medical records the acute medical condition and lack of alternative treatment options that justify deviation from the three-day supply limit. With postoperative, acute, or intermittent pain, analgesia often requires frequent titration, and the two-to four-hour analgesic duration with short-acting hydrocodone, morphine, and oxycodone is more effective than extended-release formulations. Short-acting opioids are also recommended in patients who are medically unstable or with highly variable pain intensity [55; 56; 57]. As part of House Bill 21, passed in 2018, the Florida Board of Medicine and the Board of Osteopathic Medicine are required to establish guidelines for prescribing controlled substances for acute pain; these guidelines are forthcoming [54].
RISK STRATIFICATION FOR PATIENTS PRESCRIBED OPIOIDS
Low Risk No or well-defined and controlled personal or family history of alcohol/substance use disorder No or minimal co-occurring psychiatric disorders or medical comorbidities Age 45 years or older High levels of pain acceptance and active coping strategies High motivation and willingness to participate in multimodal therapy, attempting to function at normal levels Medium Risk Moderate concomitant psychiatric disorders, well controlled by therapy Moderate coexisting medical disorders well-controlled by medical therapy and not affected by chronic opioid therapy (e.g., central sleep apnea) History of personal or family alcoholism/substance abuse/addiction Willing to participate in multimodal therapy, attempting to function in normal daily life Pain involving more than three regions of the body High Risk Widespread pain without objective signs and symptoms Pain involving more than three regions of the body Aberrant drug-related behavior History of alcoholism or drug misuse, abuse, addiction, diversion, dependency, tolerance, or hyperalgesia
Major psychologic disorders Age younger than 45 years Unwilling to participate in multimodal therapy, not functioning close to a near normal lifestyle Source: [1; 59; 60; 61]
Table 1
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MDFL0627
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