Page 15 - Volume 70 Number 2
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 7-Day Limit on Opioid Prescribing for Acute Pain
I didn’t know that acute pain, defined in the law as “the normal, predicted physiological response to a noxious chemical or thermal or mechanical stimulus and is typically associated with invasive procedures, trauma, and disease and usually lasts for a limited amount of time,” was now limited to 7 days or less. Expect lots of refill requests, each requiring a new MAPS inquiry. This will mean a lot of co-pays for patients who need refills.
The difference between acute and chronic pain remains ill defined (I guess it’s like pornography: you should know it when you see it) except to acknowledge that acute pain may turn into chronic pain. The CDC offers a more sensible definition of chronic pain as lasting “longer than 3 months or past the time of normal tissue healing.” (See CDC Guideline)
Requirement for Informed Consent
The new regulation requires obtaining informed consent before prescribing an opioid or Schedule 2-5 drug.
For minors, the prescriber must discuss the risks of addiction, the danger of taking an opioid in combination with a benzodiazepine, alcohol or system depressant and must document the informed consent on a “Start Talking Consent Form,” which is to be developed by the Michigan Department of Health and Human Services. It must be signed by parent, guardian or other responsible adult.
For adults, with the exception of hospitalized patients, the consent must delineate the risks of addiction, how to dispose of unused medication, state that delivery of a controlled substance is a felony under Michigan law, and the possible effects on fetal development.
In the past, of course, patient identified as having substance abuse problems have been asked by their caregivers to sign forms acknowledging that they under- stand their obligations with regard to medication use and will comply with instructions. This is something new, with probable good intentions, but requiring this kind of consent proactively to all patients receiving Schedule 2-5 drugs is going way overboard. It will become another pro-forma exercise that no one seems to be paying much attention to, except to make sure it can be found in the chart somewhere in case if an audit.
To actually improve opioid prescribing, you need to do a lot more than give patients forms to sign. You have to change the whole system, the expectations, and the environment in ways that facilitate good practice. Inform- ing patients is clearly part of this, but another piece of paper is not evidence of information received and under- stood, and will not necessarily prevent patients who are predisposed to substance abuse from becoming abusers.
Unintended Consequences
If nothing else in striving to improve quality of care, we have learned that guidelines are just that: guidelines, not rules. There must be room for flexibility and interpretation of guidelines if physicians are to meet individual patient needs. Most critically, guidelines should never become laws. Some good will likely come of the new law, but also unintended consequences will come as well.
Volume 70 • Number 2 Washtenaw County Medical Society BULLETIN 15

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