Rhode Island's updated pain management regulations now require healthcare providers who are writing opioid prescriptions:
1. to have a conversation with their patients on the risks of taking an opioid prescription, 2. indicate the diagnosis code(s) on the prescription. 3. to co-prescribe naloxone to patients at higher risk for overdose.
The regulations apply to anyone who can prescribe a controlled substance including physicians, dentists, physician assistants, and advanced practice registered nurses (APRNs).
In communications about the regulation changes, Rhode Island Department of Health (RIDOH) officials also firmly reiterated to healthcare providers that effective, non-opioid pain management treatments are available with much less risk to patients, and that these treatments should be considered before opioids. These alternatives include non-prescription ibuprofen (i.e., Advil, Motrin) and/or acetaminophen i.e., Tylenol), physical therapy, chiropractic care, acupuncture, massage, exercise, and cognitive behavioral therapy, among other modalities.
1. The regulations allow for patient education to happen either through a conversation with the patient or in writing. The patient education must include a conversation that includes:
- Risks of developing dependence and the potential of overdose or death. - Risks related to the concurrent use of opioids and alcohol or benzodiazepines. (Benzodiazepines are sedatives, such as Xanax and Valium.) - The effect of opioids on one's ability to safely operate any motor vehicle. - Patient's responsibility to safeguard all opioid medications in a secure location. - Alternative treatments for managing pain (non-opioid and/or non-pharmacologic options). - Risks of relapse for those who are in recovery from substance dependence. RIDOH has provided material to healthcare providers in English and Spanish that they can use to guide conversations with patients about the risks of opioids.
"Honest, direct conversation from healthcare providers about risks is a critical part of providing safe, quality care for patients who are prescribed opioids," said Director of Health Nicole Alexander-Scott, MD, MPH. "Rhode Island has made significant strides in reducing the number of opioids being prescribed, and in making sure that those prescriptions are being written and filled safely. These newest updates to our pain management regulations will keep us moving in that direction, and will continue to reduce the number of overdoses in our state that are associated with prescription pain medication, while maintaining compassionate care for patients who deal with chronic pain. Prescribers, patients, and all Rhode Islanders have a role to play in saving lives."
2. The requirement that healthcare providers include the diagnosis code on the prescription allows the pharmacists to understand why the controlled substance in being dispensed to the patient. Pharmacists are then able to use this information to have follow-up conversations with prescribers or patients to ensure that patients are being treated with the appropriate medication.
Ensuring the safe prescribing of opioids is a key effort within the prevention strategy of the Strategic Plan of Governor Gina M. Raimondo's Overdose Prevention and Intervention Task Force. The other three strategies are treatment, rescue, and recovery. The Task Force is chaired by Dr. Alexander-Scott; Rebecca Boss, the Director of the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH); and Tom Coderre, a Senior Advisor to Governor Raimondo.
"Addiction and overdose are claiming lives, destroying families, and undermining the quality of life across Rhode Island," stated BHDDH Director Rebecca Boss. "Updating the Pain Management Regulations is a necessary step as we cannot fight the overdose epidemic without the support and assistance of our medical community. Education by a trusted provider, and co-prescribing Naloxone to those at risk for dependence on opioids, is crucial in this fight to save lives."
3. Naloxone, with a brand name, Narcan, is a medication that can reverse the effects of an overdose Prescribers must co-prescribe naloxone in these three different clinical scenarios:
- When prescribing an opioid individually or in combination with other medications that is more than or equal to 50 morphine milligram equivalents (MMEs) per day. - When prescribing any dose of an opioid when a benzodiazepine has been prescribed in the past 30 days or will be prescribed at the current visit. - When prescribing any dose of an opioid to a patient with a prior history of opioid use disorder or overdose. Prescribers must also document in the patient's medical record the medical necessity of prescribing an opioid to this high-risk individual and explain why the benefit outweighs the risk, given the patient's previous history.
Opioid prescription pain medications are a type of medicine used to relieve pain. Some of the common names include oxycodone and acetaminophen (Percocet); oxycodone, (OxyContin); and hydrocodone and acetaminophen (Vicodin).
Rhode Island's pain management regulations were last updated in March 2017. Among other changes, those updates required that initial prescriptions for acute pain be limited to 20 doses and no more than 30 MMEs per day; prohibited long-acting or extended-release opioids for initial prescriptions for acute pain; and required continuing medical education training for prescribers on topics such as appropriate prescribing for pain, pharmacology, potential for dependence, and alternatives to opioids for pain management.
The number of new opioid prescriptions has been steadily declining in Rhode Island, particularly as the pain management regulations have been updated. In first quarter of 2018, 34,564 people received new opioid prescriptions, down from 43,373 in the first quarter of 2017. Rhode Island has also seen a decline in the number of people co-prescribed opioids and benzodiazepines. In 2017, 32,609 people were co-prescribed opioids and benzodiazepines, down from 46,452 in 2014.
The most recent updates to Rhode Island's pain management regulations come two weeks after RIDOH and BHDDH hosted a second Community Overdose Engagement (CODE) Summit with more than 300 attendees. The event celebrated the success of 25 Rhode Island cities and towns that committed to developing comprehensive, local overdose response plans.
- Rhode Island's Hope and Recovery Support Line is available to connect people in crisis with treatment and recovery support. To access services through an English and/or Spanish-speaking counselor who is licensed in chemical-dependency and available 24 hours a day, seven days a week, people should call (401)-942-STOP. - Overdose data and treatment and recovery resources are available at Rhode Island's overdose dashboard and website: PreventOverdoseRI.org [health.us5.list-manage.com].