WHAT HAVE WE DONE FOR YOU LATELY ? Excessive Prescribing – Regulation 2.4
Iattended the Arkansas State Medical Board ’ s public hearing on “ excessive prescribing ,” April 5 , 2018 . One thing was apparent ; either patients are being terribly misled by someone or many physicians are misinterpreting the implications of the rule .
Regulation 2.4 lists many of the offenses for which a physician can be found guilty of “ ignorant malpractice .” One of those offenses is excessive prescribing . After many years of being challenged by attorneys on what exactly constitutes excessive , the Board is attempting to adopt language that would define excessive as it relates to controlled substances and specifically opioids .
Patient after patient stepped up to testify before the Board that their physician had told them that the Board ’ s proposed rule meant they could no longer write prescriptions for narcotics . Others testified that their physician , in anticipation of the rule , had cut them back by 50-75 % of the amounts they had previously been taking . Most cited fear of Board reprisal as the motivating factor behind their physician ’ s actions . Now , just to be clear , these were patients whose medical conditions appeared to be so severe that without adequate pain control , they could not function as productive citizens . These were patients that had been on opioids for 10 , 15 , and 20 years . There was the gentleman whose encounter with an 18-wheeler , followed by years of multiple surgeries , left him nearly incapacitated . With his prescription opioids , however , he was able to function again and work to support his family . Now that his physician had reduced his prescription , he was struggling to function and afraid of losing his job and his family .
There are a few facts to keep in mind . The State Medical Board ’ s proposed rule on excessive prescribing does not limit the quantity , dosage , or number of days that a physician prescribes . It does not create a system of witch hunts whereby the Board simply goes out looking for physicians to punish .
DAVID WROTEN EXECUTIVE VICE PRESIDENT
What it does say is that if you write a prescription for any drug in any amount without detailed justification documented in the medical record , it can be considered excessive . That is and always has been the case . For opioids , if you prescribe a quantity or dosage that exceeds a specified amount , you must have adequate documentation to support that prescribing . If the Board receives a complaint on a physician for overprescribing , which is nothing new , part of the investigation will be to review their records to determine whether or not the physician complied with the documentation requirements and provisions of the rule . Those specified levels are , greater than or equal to 50 morphine milligram equivalents ( MME ) per day for chronic pain and seven days for acute pain .
What must be documented for chronic pain ( exceeding 50 MME per day )? Objective findings , specific reasons to exceed 50 MME , options for alternative pain management including those that have been tried and failed , an assessment of the potential for abuse and / or diversion , that the patient is being seen at least once every three months , regular drug screens , pain management contract , etc . For acute pain , initial prescriptions written for a quantity that exceeds seven days , the physician must have a detailed documented reason or rationale for exceeding the seven days and any subsequent prescriptions must be medically justified as detailed in the medical record .
Furthermore , excessive does not apply to prescriptions written for patients in hospice , active cancer treatment , palliative care , end-of-life care , nursing homes , assisted living , or while in an inpatient setting or emergency department .
The rule must still be approved by the Legislative Council of the General Assembly and will not likely become effective until summer . For a full reading of the rule — and to dispel any other rumors — please visit the Arkansas State Medical Board website , www . armedicalboard . org , Look under “ Forms and Publications ” and then click on “ Proposed Amendments to Regulation 2 .”
David Wroten Executive Vice President
Penny Henderson Executive Assistant Journal Advertising
Nicole Richards Managing Editor
Jeremy Henderson Art Director
EDITORIAL BOARD
Appathurai Balamurugan , MD , DrPH , MPH Family Medicine / Public Health
Robert Hopkins , MD Pediatrics / Internal Medicine
Sandra Johnson , MD Dermatology
Issam Makhoul , MD Oncology
Naveen Patil , MD , MHSA , MA , FIDSA Internal Medicine / Infectious Disease
Benjamin Tharian , MD , MRCP , FACP , FRACP Gastroenterologist / Hepatologist
EDITOR EMERITUS Alfred Kahn Jr ., MD ( 1916-2013 )
ARKANSAS MEDICAL SOCIETY 2017-2018 OFFICERS
Amy Cahill , MD , Pine Bluff President
Scott Cooper , MD , Rogers Immediate Past President
Lee Archer , MD , Little Rock President Elect
William Dedman , MD , Camden Vice President
Chad Rodgers , MD , Little Rock Secretary
Bradley Bibb , MD , Jonesboro Treasurer
Michael Saitta , MD , Fayetteville Speaker of the House of Delegates
Eugene Shelby , MD , Hot Springs Vice Speaker of the House of Delegates
Danny Wilkerson , MD , Little Rock Chairman of the Board of Trustees
268 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY VOLUME 114