Requires that boards regulating practitioners prescribing, administering and dispensing controlled substances adopt rules for management of chronic pain.
Prescription Drug Abuse
Prescription drug abuse is a growing problem, both in New Hampshire and in the United States. Three categories of prescription drugs are those most likely to be abused:
- Central nervous system depressants (tranquilizers)
Of late, there has been particular concern over the abuse of opioid painkillers. The remainder of this article focuses on facts and policies related to opioid abuse.
What are opioids?
Opioids are drugs that work by attaching themselves to special receptors in the brain and other areas of the nervous system, causing a reduction in the perception of pain and a feeling of well-being or euphoria. Opioid drugs include oxycodone (OxyContin, Percocet), hydrocodone (Vicodin), meperidine (Demerol), and fentanyl.
It's generally agreed that these drugs can be a safe and effective means of treating acute pain or pain related to cancer or end-of-life.
However, use of opioids to treat other forms of chronic pain, such as back pain or arthritis, is more controversial. Long-term use of opioids can result in a patient’s body becoming desensitized to the drugs, an effect called ‘tolerance’. This may lead to long-term patients being given higher and higher doses. Additionally, long-term use can inhibit the production of natural opioids in the body, which contributes to negative symptoms (withdrawal) when the patient tries to stop.
Risks of addiction
Opioid drugs target the same areas of the brain as heroin and morphine, both highly addictive drugs, but there is some debate over the addictiveness of prescription opioids. The risk of addiction certainly increases when the drugs are used improperly: for example, when they are crushed and snorted, or combined with other substances. Taking opioids in larger or more frequent doses than prescribed also increases risk.
There is also a growing body of evidence connecting opioid abuse with increased risk of heroin abuse. Some users report turning to heroin after developing tolerance for their prescription painkillers, or when they can no longer afford or acquire prescriptions. Heroin is both cheaper and, in many areas, easier to acquire than black market prescription drugs.
The abuse of prescription opioids has been rising across the United States in recent years, as has the rate of deaths related to these drugs. Some experts argue that the rapid increase in the rate of prescribing opioids in recent years has made them more readily available, and point to surveys that reveal that a majority of those using painkillers for nonmedical reasons acquire them from a friend or relative.
Other potential contributing factors include the greater social acceptability of taking opioids and aggressive marketing campaigns by pharmaceutical companies.
Prescription opioid abuse in NH
Prescription drug abuse is an increasing problem in NH.
- Drug related deaths have been rising, with an estimated 470 deaths in 2016, up from 439 in 2015. A total of 404 of those deaths involved opioids, including heroin and/or fentanyl.
- The number of fatal overdoses from prescription painkillers more than tripled between 1999 and 2012.
- In 2010, oxycodone abuse was the second-most common reason (behind alcohol abuse) for patients entering state-funded substance abuse treatment programs.
- NH ranks 3rd in the nation for per-capita prescriptions of long-acting opioid drugs, such as OxyContin or fentanyl. The state ranked 7th for high-dose opioid drugs, but 39th for overall opioid prescriptions.
- 10.46% of NH adults aged 18-25 reported nonmedical use of painkillers in 2012-2013, ranking the state 14th in the nation. The national average was 9.47%.
Current policies in NH
The following are policies that have been enacted in New Hampshire to combat prescription drug abuse:
- Pharmacies and other licensed dispensers of prescription drugs are required to submit weekly reports to the state's prescription monitoring program, and medical professionals are required to access data for their patients before writing a prescription.
- State law forbids someone from knowingly attempting to acquire a controlled drug through “doctor shopping”: consulting with multiple physicians for the same ailment as a way of getting larger quantities of medication.
- Doctors and nurses have to do an addiction risk assessment and create a written pain treatment agreement with patients before issuing a prescription.
- Prescriptions written in an emergency room, urgent care or walk-in clinic can only be for seven days or less.
- Patients using prescription opioids for chronic pain for more than 90 days are subject to random urine tests to check for unexpected drug use (except for patients in long-term care homes or who have very low-dose prescriptions).
- Starting in January 2020, all prescription opioid containers will have a bright orange sticker identifying them as 'opioid'. The bottles or boxes will also need to sport a label warning of the risks of addiction.
Additional potential policy responses
- Limiting the quantity of opioids a doctor can prescribe at a given time in regular practice.
- Requiring medical professionals who prescribe opioids to take part in training and education programs.
- Restricting Medicaid reimbursement for opioid prescriptions.
- Laws regulating pain management clinics by specifying personnel requirements, inspections, license procedures, standards of care, or other practices.
PROS & CONS
“NH should more closely regulate prescription drugs.”
- Increasing rates of abuse, addiction, and death caused by prescription opioids make these drugs a public health crisis, justifying state intervention.
- Nonmedical or excessive use of painkillers has a significant economic cost, burdening state health programs.
- Abuse of prescription painkillers has been linked to increased risk of heroin addiction, which fuels criminal activity and entails greater risk of overdose and death.
- Opioid prescription drugs are not appropriate for long-term use by chronic pain patients who are not seeking treatment for cancer or end-of-life care.
“NH should be cautious of overregulating prescription drugs.”
- Doctors know better than state officials what medications will best answer the needs of their patients, and their ability to do so should not be inhibited by overregulation.
- Stringent policies regarding prescription painkillers could result in legitimate pain patients being denied access to needed medication.
- Making it more difficult for chronic pain patients to access legal medication may turn them to the black market and more dangerous substances.
- Legitimate pain patients who take prescription opioids in the manner prescribed by their doctors have little to no risk of addiction.
Requires the Department of Health and Human Services to develop a uniform voluntary non-opioid directive form which may be used by a patient to refuse a controlled substance containing an opioid. The bill also requires insurers to cover evidence-based nonopioid treatment of pain, including chiropractic treatment, osteopathic manipulative treatment, and acupuncture treatment.
Authorizes the Department of Health and Human Services to access information from the controlled drug prescription health and safety program.
Requires prescribers of controlled drugs to do so electronically in most circumstances.
Requires prescription drug manufacturers to participate in an approved drug take-back program or establish and implement a drug take-back program.
Requires a health care provider or pharmacy dispensing an initial prescription for an opioid to receive a verbal acknowledgment from the patient of the risk of addiction and overdose.
Requires prescribers of controlled drugs to do so electronically in most circumstances.
Requires persons required by federal law to conduct biennial controlled substance inventories to conduct them every odd-numbered year, rather than specifically on May 1. This would allow flexibility if May 1 falls on a Sunday.
Requires any drug which contains an opiate to have a colored sticker and a warning label regarding the risks of the drug.
Requires health care providers writing prescriptions for substance use disorders to use the prescription drug monitoring program.
Directs health care providers to refer or prescribe treatment alternatives, such as physical therapy, before prescribing an opioid. The bill also creates a "nonopioid directive form" that patients could choose to sign to refuse all opioid prescriptions. This bill also requires health insurances to cover nonopioid treatment for pain, including but not limited to, chiropractic care, osteopathic manipulative treatment and acupuncture treatment.
Requires health care providers to require patients to sign a form upon dispensing opioids explaining the addictive nature of such drugs.
Revises the regulation of the prescription drug monitoring program. For example, this allows bill de-identified data to be kept indefinitely for analytical purposes. The bill also transfers responsibility for the program from the Board of Pharmacy to the Office of Professional Licensure.
Requires both a health care provider and a patient to sign a form explaining the addictive nature of controlled opioid drugs before a prescription for those drugs is issued.
Requires manufacturers to pre-package class II controlled drugs in blister packs with serial numbers on each pill.
Regulates the sale and possession of products containing ephedrine and pseudoephedrine.
Only allows patients and authorized representatives to pick up a prescription for a schedule II-IV controlled drug at a pharmacy, and requires them to present ID.
Requires police and fire stations to collect prescription drugs and over-the-counter medications surrendered by individuals.
Authorizes the chief medical examiner to access the Prescription Drug Monitoring Program (PDMP). This bill also appropriates 5% of the revenue collected by various boards (such as the Board of Medicine) to fund the PDMP.
Requires workers' compensation to cover addiction treatment if an employee becomes addicted to painkillers after an injury at work.
Establishes a commission to study enhancing the program of donating, accepting, and redispensing unused drugs.
Establishes a seven-member controlled drug review board to adopt rules related to scheduling controlled substances, investigative trials of scheduled substances, shipping of such substances in-state, investigations and hearings, and communications with federal regulatory authorities.
Declares that if substance use disorder services are a covered under a health benefit plan, prior authorization for prescribed medications for a substance use disorder is only required once a year.
Only allows opioid prescriptions via telemedicine if the patient already has an in-person relationship with the prescriber. The Senate amended the bill to also add some rulemaking authority for the pharmacy board and insurance department.
Authorizes pharmacists to fill a prescription for certain controlled drugs for a 34-day supply or 100 dosage units, whichever is less.
Requires individuals who have access to controlled drugs to report suspected or attempted drug diversion to the drug diversion unit of the Division of State Police. The bill also permits non-licensed individuals who suspect drug diversion to make such a report, provides immunity for persons who make such reports based on a good faith belief, and authorizes the drug diversion unit to investigate such reports.
Gives law enforcement more access to the Prescription Drug Monitoring Program database.
Originally written to make various changes to the Prescription Drug Monitoring Program. The Senate amended the bill to instead create a commission to study the overdose-reversing drug Narcan.
Requires the Board of Medicine, the Board of Dental examiners, the Board of Nursing, the Board of Registration in Optometry, the Board of Podiatry, the Naturopathic Board of Examiners, and the Board of Veterinary Medicine to adopt rules for prescribing controlled drugs, and requires the use of the Prescription Drug Monitoring Program database.
Establishes the statewide drug court grant program.
This bill includes many regulations aimed at combating heroin and prescription drug abuse. For example, this bill increases the penalties for abusing fentanyl and provides funding for an upgrade to the Prescription Drug Monitoring Program.
Appropriates $130,000 for technology upgrades to the controlled drug prescription health and safety program to support mandatory use and enhanced reporting and information gathering. The House amended the bill to also limit the ability of law enforcement to seize assets in criminal cases.
Establishes a commission to study requiring controlled drugs and controlled drug analogs to be provided in abuse-deterrent formulation. Also adds naturopaths to the list of practitioners for the purpose of the prescription drug monitoring program.
As originally written, this bill included various measures related to drug addiction, such as adding fentanyl to drug laws. The Senate amended the bill to instead revise the Governor's Commission on Alcohol and Drug Abuse Prevention, Treatment, and Recovery and make additional appropriations for drug abuse prevention and treatment.
Makes some changes to the prescription monitoring program, for example to include veterinarians.
Establishes a committee to study opioid misuse.
Requires pharmacies, hospitals, and prescribers to accept unused prescription drugs.
Repeals the ability of registered nurses to dispense noncontrolled prescription drugs in clinics that have a contract with the Department of Health and Human Services (such as Planned Parenthood).
Should NH take regulatory action to combat prescription drug abuse?
Several NH counties, cities and towns have filed lawsuits against the manufacturers of prescription opioid drugs, contending that companies such as Purdue Pharma and Johnson & Johnson misrepresented the risks of addiction when marketing the drugs. An Ohio judge has consolidated some 400 such lawsuits from around the country and is currently mediating possible settlements.
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