Strategies for Appropriate Opioid Prescribing: The Florida Requirement _ _____________________________
Abuse, Diversion, and Addiction-Related Surveillance System, which monitors prescription drug abuse, misuse, and diversion [98]. Almost all states, including Florida, have enacted PDMPs to facilitate the collection, analysis, and reporting of information on controlled substances prescribing and dispensing [1]. All prescribers must consult the Electronic Florida Online Reporting of Controlled Substances Evaluation (E-FORCSE) to review a patient’s controlled substance dispensing history before prescribing or dispensing a controlled substance to a patient 16 years of age or older [99]. This is mandated even for existing patients and should be done each time a controlled substance is prescribed or dispensed [43]. If the system is nonoperational or cannot be accessed due to a temporary technologic or electrical failure, the prescription may be issued (with documentation of the exception) for up to a maximum three-day supply. All clinicians who dispense controlled substances are required to report the action to E-FORCSE as soon as possible, but no later than the close of the next business day [99]. This should be repeated each time the substance is dispensed. This reporting requirement is waived in certain circumstances, including for [99]: • All acts of administration of a controlled substance • The dispensing of a controlled substance in the healthcare system of the Department of Corrections • The dispensing of a controlled substance to a person younger than 16 years of age IDENTIFICATION OF DRUG DIVERSION/ SEEKING BEHAVIORS Research has more closely defined the location of prescribed opioid diversion into illicit use in the supply chain from the manufacturer to the distributor, retailer, and the end user (the patient with pain). This information carries with it substantial public policy and regulatory implications. The 2021 National Survey on Drug Use and Health asked non-medical users of prescription opioids how they obtained their most recently used drugs [100]. Among persons 12 years of age or older, 33.9% obtained their prescription opioids from a friend or relative for free, 39.3% got them through a prescription from one doctor (vs. 17.3% in 2009–2010), 7.3% bought them from a friend or relative, and 3.7% took them from a friend or relative without asking [100]. Other sources included a drug dealer or other stranger (7.9%); multiple doctors (3.2%); and theft from a doctor’s office, clinic, hospital, or pharmacy (0.7%) [100].
As discussed, UDTs can give insight into patients who are misusing opioids. A random sample of UDT results from 800 patients with pain treated at a Veterans Affairs facility found that 25.2% were negative for the prescribed opioid while 19.5% were positive for an illicit drug/unreported opioid [50]. Negative UDT results for the prescribed opioid do not necessarily indicate diversion but may indicate the patient halted his/her use due to side effects, lack of efficacy, or pain remission. The concern arises over the increasingly stringent climate surrounding clinical decision-making regarding aberrant UDT results and that a negative result for the prescribed opioid or a positive UDT may serve as the pretense to terminate a patient rather than guide him/her into addiction treatment or an alternative pain management program [49]. In addition to aberrant urine screens, there are certain behaviors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [47; 48; 82]: • Selling medications • Prescription forgery or alteration • Injecting medications meant for oral use • Obtaining medications from nonmedical sources • Resisting medication change despite worsening function or significant negative effects • Loss of control over alcohol use • Using illegal drugs or non-prescribed controlled substances • Recurrent episodes of: – Prescription loss or theft – Obtaining opioids from other providers in violation of a treatment agreement – Unsanctioned dose escalation – Running out of medication and requesting early refills Behaviors with less association with opioid misuse include [47; 48; 82]: • Aggressive demands for more drug • Asking for specific medications • Stockpiling medications during times when pain is less severe • Using pain medications to treat other symptoms • Reluctance to decrease opioid dosing once stable • In the earlier stages of treatment: – Increasing medication dosing without provider permission – Obtaining prescriptions from sources other than the pain provider – Sharing or borrowing similar medications from friends/family
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