As I argued in my May 4 blogpost “Louisiana NEEDS a Drug Formulary,” dealing with the opioid epidemic within workers' compensation – and society in general – means using “every tool at our disposal.” It's obvious from the title that in my opinion a work comp drug formulary as codified in House Bill 592 would be part of that solution. It helps to create a “pause” moment in the status quo of prescribing so that medications whose risks outweigh the benefits and whose use is inappropriate outside of the acute/sub-acute phase of pain are reconsidered. And when they are reconsidered, better choices of less dangerous drugs or maybe even a non-drug treatment plan are often made so the patient / injured worker can achieve better clinical outcomes and a quicker recovery.
Well, there are two other bills pending in the Louisiana legislature that also fit that mold of “every tool at our disposal”:
Senate Bill 55, which promotes a more educated prescriber. It requires a new “controlled dangerous substance” license issued by the Board of Pharmacy (the name of this new license indicates the seriousness of the issue) and upon issuance the prescriber will be automatically registered for access to the state's Prescription Monitoring Program (PMP). There are new requirements for continuing education for all prescribers by their corresponding licensing board (comprehensive and accurate education about opioids and appropriate pain management remains woefully inadequate in medical schools and for practicing physicians). Even beyond that, the bill requires the prescriber to “access and review” the patient's record before an initial prescription of an opioid and then every ninety days (with appropriate exceptions). In other words, each prescriber must use the PMP. Excellent! That's exactly what I fought for in California with SB 482 (read “A CURES for the Disease” for more context) that mandated use of their PDMP. The evidence is absolutely clear – using a PDMP changes prescribing behavior because of the transparency in identifying risky behavior – doctor shopping (multiple prescribers), pharmacy hopping, paying cash, visits to the ER, consistently running out of pills early, excessive MED's, concurrent use of opioids and benzodiazepines – that should make a prescriber think twice before writing the script. So consider me enthusiastically in favor of SB 55.
House Bill 192, which limits the days' supply that can be prescribed at any one time. In this case, no more than a 7-day supply for an acute condition. For pain (including chronic) that needs more than a 7-day supply in the prescriber's opinion, documentation needs to be clear as to the condition being treated and why “a non-opioid alternative was not appropriate to address the medical condition.” This corresponds to changes already enacted around the country for similar restrictions. A 7 day cap is mandated now in Connecticut, Maine, Massachusetts, New York, Ohio, Rhode Island, and Vermont (there may be more at this point). A 5 day cap is mandated in New Jersey and Florida. Other states are joining that trend because the CDC Opioid Guidelines, published in April 2016, state emphatically that the “lowest effective dose” should be prescribed, with 3 days or less often being sufficient. Subsequent published clinical studies agree with that assessment. It is clear the more pills given, for a longer time period between doctor visits, the more likely it becomes that the patient / injured worker will become at least dependent upon those painkillers – maybe even addicted at some point - with less function and quality of life. So reducing the number of pills, and requiring more frequent in-person visits, will help reduce that possibility. What Louisiana is proposing here is keeping pace with other states that have already decided on these caps. It not only makes clinical sense, it makes common sense. So consider me enthusiastically in favor of HB 192.
Do these bills mention workers' compensation? No. Will they have an impact on work comp? Absolutely, because whatever the state mandates to be done has to be done by everybody for every payer … even work comp.
Not so coincidentally, in my blogpost advocating for a drug formulary via HB 592, I listed “mandatory use of PDMPs” and “day supply and MED caps” – exactly what is included in SB 55 and HB 192. Because the opioid epidemic is complex and diffuse, no single tactic exists that can resolve the epidemic by itself. It literally takes everything we have to make a positive impact. So you could say, in Louisiana, they have the “Trifecta” to keep making progress against this man-made tragedy that has killed and impacted so many people around the state and the country. I hope the legislature agrees and decides to pass all three bills.
Mark Pew, Senior Vice President of PRIUM, has been focused since 2003 on the intersection of chronic pain and appropriate treatment. That ranges from the clinical and financial costs of opioids and benzos, to the corresponding epidemic of heroin use, to the evolution in medical cannabis. Educating is his job and passion. Contact Mark at email@example.com, on LinkedIn at markpew, or on Twitter @RxProfessor.
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