In response to a dramatic increase in the use of opioid therapy for chronic, non-malignant pain and an increase in opioid analgesic deaths related to addiction and misuse nationwide, the Alabama Legislature passed new laws last year in an effort to decrease the abuse and diversion of these drugs in our state.

According to the Centers for Disease Control and Prevention, in 2012 Alabama had one of the highest rates of prescription painkillers sold per 10,000 people. In 2011, Alabama was one of the top 20 states in the country for the number of deaths attributed to opioid drug overdose. Three bills signed into law in August 2013 by Governor Robert Bentley are aimed at decreasing opioid misuse while protecting the rights of patients.

Scott Kendrick, MD, of Southside Pain Specialists in Birmingham, supports the new legislation and thinks the laws benefit both physicians and patients. “I think the legislation is a good thing for our state. It more clearly establishes guidelines for prescribing opiates for chronic pain,” he says. “From a patient safety standpoint, the legislation requires training for medical directors of pain clinics and stringent monitoring of patients and the medicines they are given for an established diagnosis. It also provides guidelines for acute and chronic pain treatment without excluding a patient from beneficial treatments.”

Information provided by the Office of the Governor indicates that House Bill 150 clarifies language for the Board of Medical Examiners to regulate use of a monitoring program, which lists individuals who receive controlled substances as well as the names of the medical professionals who prescribed them. Physicians now can designate staff members to access the database on their behalf. The bill also grants the Alabama Medicaid Agency access to the database to check prescription drug use by Medicaid beneficiaries.

Kendrick says his clinic employs a comprehensive monitoring program for his patients. “Most important is to evaluate a patient’s history and look for objective findings,” he says. “Next, we screen the patient during an initial evaluation to establish risk factors. During the course of treatment, we check the patient’s pharmacy profile to see if he or she is filling the prescribed prescription at appropriate time intervals, and if he is getting prescriptions from other physicians.”

If Kendrick’s staff determines that a patient is non-compliant, the patient may be required to come to the clinic for a pill count. “We verify that they have a proper prescription and the proper number of pills. We also do a drug screen at that same time,” Kendrick says. “As a pain clinic, these are the tools we use to monitor patients. We are set up to follow patients to make sure they are medicated properly.”

House Bill 151 increases the regulation of pain management clinics, where drugs are prescribed for chronic, non-malignant pain. It also gives the Alabama Board of Medical Examiners subpoena power to investigate those clinics when needed. The clinics must have a medical director who is a licensed physician in Alabama, and the clinic must acquire pain management registration from the Board.

Kendrick and his clinic have all the necessary licenses and registrations. “From my standpoint, meeting these criteria is advantageous. It makes my practice more transparent, but I have no problem having my records reviewed,” he says. “I am open to explaining how I treat my patients and how I monitor them. The law makes it more clear how patients with chronic pain should be cared for and encourages the use of therapies other than opioid medications. It is in the patient’s best interest.”

The third bill, House Bill 152, has been called the “doctor shopping bill.” It establishes criminal penalties for patients who “doctor shop” for prescription drugs. The bill makes it a crime for a patient to get prescription drugs by deceptively concealing from a doctor that he or she had received the same or similar prescription drugs from another physician during a concurrent period of time. If convicted, the offense is a Class A misdemeanor, which is punishable by up to one year in jail. If a patient is convicted four times within five years, the offense becomes a Class C felony, which is punishable by up to 10 years in jail.

New policy proposed by the Federal Drug Administration would limit the number of refills a patient can obtain before returning to the doctor for a new prescription. Hydrocodone, the most commonly abused opioid in Alabama as well as the United States as a whole, will likely be rescheduled from its current schedule III classification to a schedule II medication. This would mean that a patient must physically bring each prescription to the pharmacy, instead of allowing physicians to call in the prescription. Kendrick thinks this policy will be adopted soon.

“Historically, doctors have felt that they under-treated pain, which, subsequently, has led to the increased prescribing of opioid analgesics. These drugs have often been misused, and this is reflected in the increase in opioid diversion and deaths related to opioid abuse” he says. “If used in large doses, opioid medicines can cause a patient to become sedated or drowsy and can cloud his thought processes. Other potential downsides are nausea and vomiting, constipation, and itching. Some patients get euphoria that will more frequently lead to abuse. Some patients who have legitimate pain complaints, may then have an escalation of their opioid dosing and can begin to show patterns of misuse.”

Kendrick points out that while opioid drugs do carry the risk of side effects and addiction, these medicines can be beneficial in the alleviation of pain when used appropriately. It is important, therefore, to identify addiction or aberrant behaviors through closer monitoring of the patients in a pain management environment while continuing to provide appropriate pain therapies to patients who have chronic pain. “The purpose of alleviating pain is to improve a patient’s function. As doctors, we should make medical decisions to improve a patient’s pain, overall quality of life, well-being, and social interaction. These medicines can help, but we as physicians have to be rational about who we prescribe them to and how much we give,” he says.