New opioid law comes with challenges for hospitals

Florida has a new opioid law.

It’s a law that will affect many state residents and all hospitals, including Indian River Medical Center.

IRMC’s chief medical officer Dr. Kathy Grichnik and emergency department director Dr. Brian Wiley say they are prepared for challenges posed by the new law.

That’s a good thing, because it’s a big challenge.

For starters, the new law requires all Florida physicians – including those in hospitals – to check a state database every time they prescribe opioid drugs. If the patient’s records show a history of multiple prescriptions for certain medications, a big red flag will be raised.

What will probably grab the most attention, however, is the law’s new three-day supply limit for drugs such as codeine, oxycodone, hydrocodone, Demerol and Percocet for patients with acute pain due to surgery, trauma or acute illnesses.

If the prescribing doctor decides – and can document – that those drugs are medically necessary, that prescription be expanded to a seven-day supply. After that, patients will need to be reassessed by a physician in order to get a refill – not a bad idea, but inconvenient for patients that need the drugs for a longer period of time.

(There are some exemptions to the new three-to-seven-day rule, including for cancer patients and those in palliative care or end-of-life care.)

What will likely go unnoticed by the public at large, however, is what the new law is requiring from hospitals. That includes mandatory opioid education for the entire staff, which Grichnik explains, “has to be accredited or certified education.”

Emergency department director Wiley jumps in to add, “I am actually in process of going through all our discharge software and making sure we’re in full compliance with all the new narcotics regulations. In addition, all our care providers are currently in the process of going through their opioid education.”

Wiley’s work has already paid at least one dividend.

“We had somebody come into the emergency department yesterday,” Wiley recalls, “and we did an E-FORCSE (Electronic Florida Online Reporting of Controlled Substance Evaluation) search and found out he had just gotten three scripts from three different providers within the last week.”

That is the scourge of opioid addition. Addicts will do anything – including going to multiple doctors, clinics or hospitals – to try to get the drugs they crave, and frankly, emergency departments shoulder some of the blame for that. According to a July 28 article in the Washington Post, a study in the journal “Annals of Emergency Medicine” covering the years 2011 to 2015 found that fully “one quarter of adults who went to hospital emergency departments with sprained ankles were prescribed opioid painkillers.”

As Orlando Health points out, “When taken for a short duration by prescription, opioid pain relievers are considered safe. But these drugs interact with the nerve cells in the body and brain, producing a sense of euphoria in addition to bringing pain relief, which makes them inviting to take beyond the need for relieving pain. As the brain becomes used to the dosage, it requires more of the drug to provide pain relief and the feeling of well-being. This makes it easy to become addicted.”

How easy? Current estimates are that up to 30 percent of patients who are prescribed opioids for chronic pain end up misusing these drugs. In fact, opioid addiction and overdoses are now the leading cause of accidental death in this country.

In 2016 alone, over 5,700 Floridians lost their lives to opioid drugs. Add that to more than 50,000 additional deaths nationwide and it’s easy to understand why the term “opioid crisis” has become a staple on the nightly news.

Oddly, the word “opioid” itself is largely a misnomer today.

It is derived from the word opium, a hypnotic drug first made from the seeds of the poppy flower sometime around 3400 B.C. in lower Mesopotamia and Babylon.

Today, however, the vast majority of opioid drugs are purely synthetic.

Naturally, no one wants to be in pain and ‘opioids’ are quite effective at relieving it, but Grichnik says that there is an even better way.

At IRMC, she says, “there’s been a big push around the hospital, in the ED, in the OR and on the floors, to use multimodal analgesia.”

What’s multimodal analgesia?

Grichnik explains it this way: “If I choose four or five different kinds of drugs, I can reduce the amount of opioid I get because I’m going to get a better efficacy, better pain control and reduce side effects.

“Part of our opioid crisis in the U.S. is because we have relied on opioids as the sole method of pain control when we actually know that multimodal analgesia is a better.

“If you add some intravenous Tylenol,” Grichnik continues, “or you add a drug called gabapentin, you can use smaller doses of each drug and they actually work together. When they work together, you have better pain control and decreased side effects [than with opioids alone].”

“The No. 1 side effect of opioids is going to be respiratory depression. People die because they take too much and they don’t breathe.”

Grichnik points to two new programs that have been launched at IRMC.

“We now have a new pain team for optimizing pain management all the way through the hospital: what’s best for patients, what’s not. It’s being led by our pharmacists.

“The other program we’re starting is called Enhanced Recovery after Surgery, or ERAS. The goal is exactly the same. Prepare patients ahead of time. Teach them, educate them, get them ready for the surgery. Have them be physically ready. In the OR, minimize your analgesics. Minimize your opioids. Use multimodal analgesia and regional anesthesia, if you can.”

Will changes like the ones above at hospitals across the state put an end to the opioid crisis? No. Will there be hiccups? Will changes be needed? Yes. But if the new law does begin to slow the rate of opioid addiction and opioid-related deaths, it will be an important step in the right direction.

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