The Journal of the Arkansas Medical Society Issue 5 Volume 115 | Page 10

Post-changes, the rule
essentially accomplishes two
things: it defines once and for
all what is “excessive” when
prescribing narcotics, and it
establishes some stipulations
for prescribers to follow.
pain, as prescribing opioids at a level that
exceeds ≥ 50 Morphine Milligram Equiva-
lents (MME) per day, unless the physician/
physician assistant documents each of the
following:
a. Objective findings, which include, but are
not limited to, imaging studies, lab testing
and results, nerve conduction testing, biop-
sy, and any other test that would establish
pain generating pathology
b. Specific reasons for the need to prescribe
≥ 50 MED per day
c. Documented alternative treatment plans
as well as alternative therapies trialed and
failed prior to considering chronic-opioid
therapy
i. Regular urine drug screens should be per-
formed on patients to insure the patient is
taking prescribed medications and is not
participating or suspected in participating
in diversion or abuse of non-prescribed
medications. The treatment of chronic pain
shall be consistent with the CDC guidelines
as they relate to baseline drug testing, and
at least annual follow up testing as war-
ranted for treatment
j. A pain treatment agreement must be signed
and reviewed by the patient when initiat-
ing chronic opioid therapy. This agreement
should discuss the following: informed risk
and addictive nature of prescribed medi-
cations, outline the specific expectations
between patient and physician, informed
consent for periodic urine
drub screening and ran-
dom pill counts with urine
screening as well as the
provisions for termination
of opioid therapy.
There is more, of course, and
it’s all pertinent information on
things like checking the PDMP,
newly required CME, etc. Read
the rule in full at armedical-
board.org.
consensus of anybody involved in this fight, is
not for doctors to ‘keep on keeping on,’ Rather,
we want them to scale way back and still pro-
vide good care for their patients. That said, I
don’t think this rule is the problem or even the
reason for the dramatic prescribing adjustments
that we’ve seen. For instance, from Jan. 1-June
30, 2017, and for the same period in 2018, there
[were around] 248,000 fewer prescriptions writ-
ten. [Regulation] 2.4 wasn’t even in effect at that
point. I know a lot of people are pointing to 2.4 as
a reason. That’s fine, I think, as long as they’re
reducing their prescribing.”
To Help, Not Hinder
With all of this in mind, physicians should
be aware – not afraid – of Regulation 2.4. This
from ASMB member Omar Atiq,
MD, who was involved in passing
the amendments. “The rule was
passed because of the opioid crisis
in our cities and towns and the rest
of our country to see if we could try
and reduce the morbidity associat-
ed with it,” said Dr. Atiq “Arkansas,
unfortunately, is one of the states
where the prescription of opioids is
in the top 10%.”
Omar Atiq, MD
Clarification: A Note About Limits
As opposed to being some-
thing to confuse physicians or patients, the rule
is there to help physicians. “It really CLARIFIES
things and essentially helps a physician follow
certain steps when they prescribe higher doses
or longer durations of opioids,” he stressed. “It
helps them detail in their notes the reason, the
rationale, for giving the opioids and helps them
make sure that patients are well served by each
prescription.”
d. Documented risk factor assessment detail-
ing that the patient was informed of the risk
and the addictive nature of the prescribed
drug Last month, we published a quote from Dr.
Smith that read “… the new regulations limit the
first prescribing of opioids for acute pain to seven
days or less.” e. Documented assessment of the potential
for abuse and /or diversion of the pre-
scribed drug, To clarify, the regulations call not for a “limit,”
but for “documented justification.” Dr. Smith was
referring to the section of 2.4 that addresses
acute pain. That section states, “for the treatment
of acute pain, excessive is further defined as an
initial medical justification for more than seven
(7) days without detailed, documented medi-
cal justification in the medical record. If the pa-
tient requires further prescriptions, they must be
evaluated in regular increments with documented
medical justification for continued treatment in
the medical record.” Related Research
“You can write it for 30 days if you show a
detailed, documented justification in the medical
record. There’s no ambiguity in that,” explained
O’Dwyer. “However, physicians don’t need to ‘just
come up with a justification and you’re good.’
Clearly, the intent of recent legislation and the 1. Shah A, Hayes CJ, Martin BC. Characteristics
of Initial Prescription Episodes and Likeli-
hood of Long-Term Opioid Use — United
States, 2006–2015. MMWR Morb Mortal
Wkly Rep 2017;66:265–269. DOI: http://
dx.doi.org/10.15585/mmwr.mm6610a1.
f. That the Prescription Drug Monitoring Pro-
gram had been checked prior to issuing the
prescription
g. A detailed clinical rationale for the prescrib-
ing and the patient must be seen in an in-
person examination every three (3) months
or every 90 days
h. The definition of “excessive” as contained
in this Regulation shall not apply to pre-
scriptions written for a patient in hospice
care, in active cancer treatment, palliative
care, end-of-life care, nursing home, as-
sisted living or a patient while in an inpa-
tient setting or in an emergency situation
106 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Are you an Arkansas physician who, con-
sidering the opioid epidemic and ongoing re-
lated work, has recently changed (or is in the
process of changing) your opioid prescribing
patterns? Are you willing to share, for the good
of the order, changes you’ve made or are mak-
ing? Contact the author at casey@pennwords.
com or David Wroten at AMS [phone].
VOLUME 115