Taking the Hoosier
Hysteria Out of
Indiana’s New Pain
Regulations
James Patrick Murphy, MD, MMM
O
n December 15, 2013 Indiana’s physicians became subject to “emergency”
regulations for prescribing opioids
for chronic pain. These rules will morph to
permanent status by November 1, 2014. The
Hoosier State now joins the growing trend of
stricter regulation to curb prescription drug
abuse.
The Licensing Board’s effort is commendable.
However, medicine is a hybrid of art and science, and crafting unambiguous laws to define good medical practice is difficult. When
faced with unclear regulations, prescriber anxiety is heightened.
This can deter physicians from prescribing the most appropriate
medications, causing patients to endure avoidable pain and unnecessary suffering. While not trying to over-simplify the matter, the
following is my attempt at providing some clarity, section by section.
SECTION One (Physicians Only)
These REGULATIONS are from the Medical Licensing Board of
Indiana and are only applicable to PHYSICIANS. They do not govern
all controlled substances - only opioids for chronic pain.
SECTION Two (Definitions)
This section offers definitions, some of which are examined below:
* Chronic Pain “means a state in which pain persists beyond the
usual course of an acute disease or healing of an injury, or that may
or may not be associated with an acute or chronic pathologic process
that causes continuous or intermittent pain over months or years.”
Note: This encompasses a generous range of chronic pain scenarios.
* Morphine Equivalent Dose “means a conversion of various opioids to a standardized dose of morphine by the use of accepted
conversion tables.”
Determining a morphine equivalent dose (MED) is an inexact science, and there are many “accepted” conversion tables from which
to choose. The Indiana State Attorney General’s office published an
online “First Do No Harm” Prescriber Toolkit that references the
online calculator from GlobalRPH. I also like the one from Practical Pain Management.
* “Outset of an opioid treatment plan” refers only to a patient who
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LOUISVILLE MEDICINE
has been prescribed: (1) more than sixty opioid-containing pills a
month for more than three consecutive months; or (2) a morphine
equivalent dose of more than fifteen (15) milligrams per day for
more than three consecutive months.
SECTION Three (Exemptions and Thresholds)
First, this section explains which patients are exempt from the
regulations.
(1) With a terminal condition
(2) Living in a licensed health facility
(3) Enrolled in a licensed hospice program
(4) Enrolled in a palliative care program of a licensed hospital
Note: If a non-terminal patient eventually leaves the health, hospice,
or palliative facility the opioid use during that time still counts in
the threshold calculation (see below).
Second, this section establishes thresholds that trigger the requirements of the Emergency Regulations.
(1) “More than sixty (60) opioid-containing pills a month” - for
more than three consecutive months or;
(2) “A morphine equivalent dose of more than fifteen (15) milligrams
per day for more than three consecutive months.”
Note: A sixty-milligram morphine equivalent dose threshold becomes an important issue in Section NINE.
SECTION Four (The DRAMATIC Section)
This section deals with the physician’s responsibility for performing the initial evaluation, including determination of level of risk.
It is clearly stated that the physician shall do the physician’s OWN
evaluation and risk stratification of the patient by doing the following:
1. Perform an APPROPRIATELY focused history and physical
exam;
2. Obtain or order APPROPRIATE tests “as indicated;”
3. Make a DILIGENT effort to obtain and review records & document the effort;
4. ASK the patient to complete an OBJECTIVE pain assessment
tool;
5. Use a VALIDATED screening tool for mental health and sub-