[V]ermont will limit how many opioid painkillers doctors can prescribe to patients and require them to counsel patients on the risks of addiction before prescribing.
A legislative committee has finished the rulemaking process on the bill Gov. Peter Shumlin signed into law to prevent overprescribing. The law will go into effect July 1.
Vermont is one of 22 states to either adopt or toughen prescribing limits for opioid painkillers in 2016, according to Kaiser Health News. The U.S. Centers for Disease Control and Prevention has also given prescribing guidance to doctors.
Under the new rules, doctors and other prescribing clinicians will be allowed to prescribe no more than seven days’ worth of opioid painkillers at a time for adult patients who don’t take them on a regular basis.
Much as they do today, pharmacists will be able to reach out to doctors to discuss the dosage prescribed for a specific patient. The Board of Medical Practice will be able to take complaints of overprescribing from patients or others and investigate doctors who break the rules.
The rules lay out specific dosages of drugs such as OxyContin (oxycodone), Vicodin (hydrocodone) and Percocet (acetaminophen-oxycodone) that doctors should prescribe for pain judged to be minor, moderate, severe and extreme.
The rules prohibit prescribing opioids for “minor pain” such as ankle sprains, nonspecific low-back pain, headaches, fibromyalgia, molar removal and undiagnosed dental pain.
Doctors can prescribe up to five days’ worth of opioids for moderate pain, such as a broken bone, and severe pain, such as a joint replacement. They can prescribe up to seven days’ worth of painkillers to patients in extreme pain.
Providers would be able to refill those prescriptions for their patients as long as the clinicians document them in the patient’s electronic health records and justify why the patient needed more.
For children, the rules say not to prescribe opioid painkillers for minor pain and to prescribe up to three days’ worth if they have moderate to severe pain.
The rules do not apply to patients in palliative care or end-of-life care, those in nursing homes, patients with certain medical complications, people with “significant or severe trauma,” patients who had a “complex surgical intervention,” patients in medication-assisted substance abuse treatment, or those who are taking opioid painkillers for chronic pain.
When the doctors do prescribe opioid painkillers, they will have to give to their patient, or the patient’s parents, educational material from the Department of Health on the risks of opioid addiction.
“Among the most critical pieces is patient education because they don’t necessarily know (the risks),” said David Englander, the legal adviser at the Vermont Department of Health.
Englander said that among the rules being adopted across the country, Vermont’s is the best. He said the state held 25 meetings with dozens of people to come up with the right rule and reviewed hundreds of pages of medical research on the subject.
“I think it provides the best guidance and emphasizes education,” Englander said. “There are other states that have limitations, such as Maine, and those are very blunt instruments, and what we tried to do was be sensitive to the needs of doctors and the needs of patients, and we believe that this rule does that.”
The Vermont Medical Society, which lobbies for doctors, expressed caution when Shumlin first proposed in January to limit first-time opioid prescription to a maximum of 10 pills per patient. The organization is more supportive now.
“Overall, we are very pleased with where it ended up and the department’s changes that they made to the rule through the public comment process,” said Jessa Barnard, the lobbyist for the Vermont Medical Society.
“The big factor for us was pushing out the implementation date (to July 1) to give time for practices to put in place all of the policies and procedures and protocols they need for complying with the rule,” Barnard said.
She said the only remaining concern is that “in almost all instances,” doctors cannot prescribe more than seven days’ worth of pills. She asked whether the rule’s exception for complex surgical interventions will be enough to protect patients.
Barnard said the tricky part of implementing the rule is that the Vermont Medical Society supports evidence-based prescribing but there is very little evidence in the field so far.
“We’re willing to work with the department and hope going forward we’re going to be able to make changes,” Barnard said. “We’re going to be keeping a close eye on that and asking for feedback from prescribers going forward to make sure there’s not overprescribing of medication but also not underprescribing.”
Englander said the Health Department would welcome further research. “Because this area is so young there aren’t evidence-based practices yet, and we will adopt them as soon as available,” he said. “Is this rule perfect? No. Is it good? It is better than good. It is excellent.”
He said the rule is “evidence-informed” but that “evidence-based” is a scientific term that’s hard to meet, and it will take time for the Department of Health to work with pharmacists, patients and others to find the right evidence.
“The only way to get evidence-based practices is to start practices,” he said. “You don’t find them in a vacuum.”