The Future of Opioids and Pain Management

On Health

BY DR. FABIAN A. RAMOS SRQ DAILY SATURDAY PERSPECTIVES EDITION SATURDAY MAR 24, 2018

Florida has an opioid prescription crisis. The epidemic begins with pain, continues through the pen of redundant prescribers, and tears its way through our cities, neighborhoods and families.

According to a recent study, opioids claimed the lives of approximately 16 Florida residents per day in 2016, mostly from legally prescribed sources. This number is staggering on its own, but even more so when considering that there were 35 percent more deaths from opioids than the year before. While prescription abuses are accountable for the majority of overdoses, the spread of opioids through sale, theft, and sharing with others has added to the carnage.

Amid this rising tide of opioid overdoses, the balance of the opioid prescription issue lies between safeguarding the practice of responsibly prescribing pain management treatments and not harming the very patients they purport to protect. This balance has opened the eyes of Florida legislators.

The first wave of prescription reform was to shut down “pill mill” practices. The second wave is to educate physicians and patients on responsible prescribing. In data published by Medicare, 95 percent of prescription opioids are given by specialists other than pain management or interventional medicine physicians—namely primary doctors, surgeons and dentists. A significant element of monitoring current responsible dissemination of controlled substances by physicians relates to the MME (Morphine Milligram Equivalent) per day for their practices. Lowering effective milligram dosages proactively manages the risk of instances of addiction and overdose.

Enter Florida’s Bill on Opioids.

On Monday, March 19, Gov. Rick Scott signed HB 21 at the Manatee County Sheriff’s Office, highlighting more than $65 million to combat opioid abuse. HB 21 was drafted to help regulate acute and chronic pain prescriptions of opioids by imposing three main components:

  1. Opioid prescriptions written to treat acute pain will be limited to a three- to seven-day dose. Note that there has been a request made to amend this regulation to extend maximum dosage to 10 days.
  2. Mandatory physician review of the E-FORCSE (Electronic Florida Online Reporting of Controlled Substances Evaluation) database to determine a patient’s current prescribed medications prior to writing new prescriptions for controlled substances.
  3. Authorized physicians are required to complete a board-approved, two-hour continuing education course on prescribing controlled substances.

The bill also increases penalties for healthcare practitioners that provide medically unnecessary controlled substances to patients by fraud, misrepresentation or other deception. It also implements additional reforms to fight unlicensed pain management clinics. Prescription limits for pain related to cancer, terminal illness, palliative care, and serious traumatic injury are exempt from the bill.

As the director of the Ramos Center, one of the largest and most effective interventional medicine practices in the state of Florida, I have dedicated my career to ensuring a higher standard of responsibility. That’s why for over a decade, my team has actively lobbied alongside local and state law enforcement and government organizations and worked with nonprofit organizations to push for legislation to address the opioid issue. In fact, our practice has operated for nearly 20 years under the regulations that HB 21 will enact—with even more precautions in place.

With two offices serving Sarasota and Manatee counties, my team consists of three physicians, a physical therapist, a clinical hypnotherapist, and a staff of 60-plus, including physician assistants, nurse practitioners and other health care specialists. We are among only a few interventional medicine practices in the region with a licensed mental health counselor on site.

We believe the approach to pain medication management should always be conservative and focused on the many other modalities and interventions available to lessen pain intensity. From the very start of our interaction with new patients, we engage a screening process that includes an in-depth physician review and risk assessment in Florida’s Prescription Drug Monitoring Program – or E-FORCSE—and a mental health review. Once a patient is under our care, we administer drug tests a minimum of twice a year.

Nearly 25 percent of referred patients are not accepted into our practice, largely due to excessive opioid prescriptions. Before we can treat these cases, we require rehabilitation or detox. We have the best overall patient outcomes, with a “last resort” mentality for opioid initiation, allowing our practice to report an industry-low number of patients who are prescribed opioids. Of our 10,000-plus active patients, only 18 percent are prescribed opioids for pain management, 97 percent are insured—contrasting opioid-only clinics with a cash-based model—and only 1 percent are under 30 years old.

We often prescribe a new patient with just three days’ worth of medication, rather than a full month, so we can best evaluate effectiveness and risk assessment, which is what the bill is asking ALL opioid prescribers to begin doing. Conversely, 82 percent of our patients are treated with non-opioid alternatives, such as a comprehensive range of leading-edge technology interventional modalities, physical therapy or behavioral management.

When HB 21 is enacted on July 1, the Ramos Center will be there to guide you and continue to be your source of knowledge regarding current and best practices models in opioid management. Furthermore, we will continue to hold and organize local seminars, and are committed to educating the medical community and public in general regarding the new legislation, which will affect every physician’s current practice in reference to opioids. We understand these changes will be difficult to implement and inconvenient for both physicians and patients alike. However, the challenges we face are worth the countless lives we can save.

Dr. Fabian A. Ramos is director of the Ramos Center.

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