______________________________ Strategies for Appropriate Opioid Prescribing: The Florida Requirement
PATIENT EVALUATION AND ASSESSMENT OF ADDICTION RISK Information obtained by patient history, physical examination, and interview, from family members, a spouse, or state prescription drug monitoring program (PDMP), and from the use of screening and assessment tools can help the clinician to stratify the patient according to level of risk for developing problematic opioid behavioral responses ( Table 1 ). Low-risk patients receive the standard level of monitoring, vigilance, and care. Moderate-risk patients should be considered for an additional level of monitoring and provider contact, and high-risk patients are likely to require intensive and structured monitoring and follow-up contact, additional consultation with psychiatric and addiction medicine specialists, and limited supplies of short-acting opioid formulations [44; 58]. Anxiety disorders, major depressive disorder, and intense emotional distress alter pain perception and response. Intensity and perception of reported pain is also influenced by factors such as mood, cultural background, social supports, and financial resources. A biopsychosocial model is required to inform pain assessment in order to address the biologic basis of pain and presence of social and psychologic contributors [51].
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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MDFL0626
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