Sanctioning Doctors for Prescription Drug Abuse

The Opioid Abuse and Overdose Epidemic

Opioid abuse has become a serious problem nationwide. The Centers for Disease Control and Prevention (CDC) issued a press release in 2011 to announce that the opioid crisis had reached “epidemic levels.”

Opioid overdoses quadrupled between 1999 and 2015. In 2015, over 31,000 people died from drug overdoses nationwide, over half of them from opioids. After the Surgeon General determined these deaths were largely due to the overprescription of opioids, government agencies acted quickly to create new opioid laws. Although these laws were created to protect patients, they may cause problems for doctors concerned about being sanctioned for prescribing opioids, even for patients with legitimate needs.

Federal and state laws were created in the 2010s to curb opioid abuse. Federal initiatives include the Controlled Substances Act, which categorizes drugs by their potential for abuse and imposes penalties for illegal drug activity, and state initiatives include prescription drug monitoring programs (PDMPs), which track drug prescriptions, and other regulations enforced at the state level.

The Controlled Substances Act (CSA)

One of the most important opioid laws is the Controlled Substances Act (CSA), which regulates all federally controlled substances and places them into one of five schedules according to their potential for abuse. The CSA also imposes rules about how drugs are regulated, reported, distributed, and dispensed. These include the registration of each person who handles controlled substances with the Drug Enforcement Administration (DEA), the recording of all drug transactions, creating preprinted order forms for Schedule I and Schedule II drugs, and controlling who may dispense drugs to patients.

The DEA limits the quantities of Schedule I, Schedule II, and other chemical products that may be produced in the US. Schedule I and II drug manufacturers and distributors must store drugs in a secure, electronically monitored vault. Hospitals and pharmacies are also required to maintain secure storage. Should any loss or theft occur, registrants must notify DEA and the police within one day of the incident. They must also complete a DEA Form 106 to record the incident. Failure to comply with federal opioid law may result in penalties and sanctions under the Controlled Substances Act.

The Anti-Drug Abuse Act of 1988 requires schools to educate children about the dangers of drug abuse. It also requires businesses contracting with the federal government to maintain a drug-free workplace. This Act holds individuals accountable for illegal drug activity by adding civil penalties in addition to criminal penalties or sanctions they may already incur under other laws.

Opioid Rules and Best Practices by State 

Currently, states regulate and control prescribed drugs, although the CDC may provide guidance. Federal rules create consequences for the illegal misuse of controlled substances, including civil and criminal penalties, sanctions, fines, and jail time, especially at the manufacturing and distribution levels, to ensure that drugs cannot be obtained illegally.

However, legally prescribed drugs can also be abused, and that’s why states issue controlled substance agreements and regulations. Since providers must be licensed in the states in which they practice, states issue rules and best practices for their own physicians and maintain databases.

Prescription drug monitoring programs (PDMPs) monitor how drugs are prescribed and dispensed to patients at the state level. This helps states monitor and enforce opioid regulations and provides data for the purposes of research and education. These records also prevent patients from doctor shopping to obtain controlled substances. Results of PDMP use vary according to how the program is administered, but PDMPs can improve outcomes, as New Mexico demonstrates.

PDMP mandates vary by state. According to Pew Charitable Trusts, 19 states have a comprehensive mandate, 18 a different mandate, and 14 no mandate. Additionally, many states require continuing education for physicians that includes pain management and the use of controlled substances. Some states, such as Texas, impose additional regulations.

State Opioid Regulations

• Alaska: First fills of prescription opioids are limited to a seven-day supply, but prescriptions may be extended if the physician provides a valid reason, such as chronic pain or travel barriers, for the extension.
• Arizona: Adults are limited to five days for initial prescriptions. Law enforcement has increased access to Naloxone to treat overdoses. The Arizona Opioid Epidemic Act also improves access to addiction treatment, aligns dosage levels with federal guidelines, and mandates opioid education for prescribers.
• Colorado: Colorado created a seven-day limit on new prescriptions, with exceptions for chronic pain patients, cancer patients, hospice care patients, and post-surgical pain patients. Physicians may write an additional seven-day prescription as necessary.
• Connecticut: The state imposed a seven-day new prescription limit for adults and a five-day limit for minors.
• Delaware: Prescriptions are limited to seven days for both minors and children, but this limit may be extended if the doctor decides it’s medically necessary as long as the doctor examines the patient, reviews the patient’s prescription history, and educates the patient about the dangers of opioid addiction.
• Florida: Florida patients are limited to three-day prescriptions, although the limit may be extended to seven days in some exceptional cases. Physicians must also review the patient’s prescription drug history and participate in opioid education.
• Hawaii: Patients are limited to seven-day initial prescriptions with some exceptions for cancer, post-operative care, and palliative care.
• Indiana: Adults and minors are both limited to seven-day prescriptions. Exceptions can be made for palliative care and medical necessity.
• Iowa: Doctors are required to register for and use a prescription monitoring program. HB 2377 also establishes criteria for recognizing signs of abuse and addiction, requires electronic prescriptions, and allows licensing boards to penalize doctors who don’t follow rules for opioid prescriptions.
• Kentucky: HB 333 established three-day limits for initial prescriptions with exceptions for chronic pain, cancer-related pain, or post-surgery pain.
• Louisiana: Patients are limited to three-day prescriptions, with the exception of chronic pain, cancer, or hospice.
• Maine: Current prescription limits are 100 morphine milligram equivalents (MME) per day, seven days for acute pain, and 30 days for chronic pain.
• Maryland: Maryland doesn’t have any time restrictions for opioids, but doctors are required to prescribe the minimum effective dose.
• Massachusetts: Seven-day limits for adults and minors are required unless the patient is receiving cancer care, palliative care, or chronic pain care.
• Michigan: Michigan imposes seven-day limits on opioid prescriptions to manage acute pain. Prescriptions to minors require parental consent. Doctors must have a relationship with their patients, inform them of the dangers of opioid abuse, and conduct follow-up care.
• Minnesota: In Minnesota, four-day limits are imposed on prescriptions for acute dental or ophthalmic pain.
• Missouri: A seven-day initial limit applies only to Medicaid recipients. Since 2019, dentists must keep a record and explain prescriptions of extended-release opioids or doses greater than 50 morphine milligram equivalents.
• Nebraska: Medicaid patients are limited to 150 tablets per 30 days. Patients under the age of 19 are limited to seven-day prescriptions. Additional legislation requires doctors to educate patients about opioid dangers and requires patients to present a photo ID when filling prescriptions.
• Nevada: Current limits are 90 morphine milligram equivalents per day and 14-day initial limits for acute pain. Doctors must consider 16 factors for 30-day prescriptions. For more than 90 days of pills, blood and radiology tests are required.
• New Hampshire: Medical professionals may not prescribe opioids for longer than seven days in the emergency room, urgent care, or walk-in clinic settings. Patients must also be prescribed the lowest effective doses.
• New Jersey: The law requires a five-day initial limit for acute pain but does not apply to cancer treatment, hospice care, long-term care facilities, or substance abuse treatment. Healthcare providers must also offer 180 days of substance abuse disorder treatment without preauthorization.
• New York: Seven-day initial prescriptions for acute pain apply generally, but not to chronic pain, cancer pain, and hospice and palliative care.
• North Carolina: North Carolina imposes a five-day initial limit for acute pain and a seven-day limit for post-operative pain. Exceptions may be made for cancer patients, chronic pain, hospice, and palliative care, or substance abuse treatment.
• Ohio: Opioid prescriptions are limited to seven days for adults, five days for minors, and 30 morphine equivalent doses per day for acute pain. These limits do not apply to cancer patients, chronic pain, hospice and palliative care, or the treatment of substance use disorders.
• Oklahoma: Seven-day limits apply to acute pain patients.
• Oregon: Oregon does not set a pill or day limit but recommends the lowest effective dose.
• Pennsylvania: In Pennsylvania, there is a seven-day limit for emergency rooms/urgent care centers and for minors. Exemptions for cancer patients, chronic pain, and hospice and palliative care are permitted.
• Rhode Island: Prescriptions are limited to 30 morphine milligram equivalents (MME) per day, seven-day limits for adults and minors, for a maximum of 20 doses, with exceptions to patients with cancer pain, chronic pain, and hospice and palliative care. Pharmacies must transmit prescription information to the PDMP within 24 hours.
• South Carolina: Supplies are limited to five days or 90 morphine milligram equivalents per day. There are exceptions for cases of chronic pain, cancer pain, sickle cell disease-related pain, palliative care, or treatment of substance abuse disorders.
• Tennessee: Generally, there is a three-day opioid supply limit, but 10-day or 30-day prescriptions are allowed when certain requirements are met.
• Texas: Texas limits opioid prescriptions to 10 days and prohibits refills. These rules do not apply to chronic pain, cancer treatment, hospice, and palliative care, or FDA-approved opioids prescribed to treat substance addiction.
• Utah: First fill prescriptions of opioids are limited to seven days for acute pain, but complex or chronic conditions are exempted.
• Vermont: Doctors must consider non-opioid treatment options before prescribing opioids and discuss treatment decisions with patients. Prescription limits are determined by four categories: minor, moderate, severe, and extreme pain. Adult moderate pain patients are limited to an average of 24 morphine milligram equivalents per day, white severe pain patients may be prescribed an average of 32 morphine milligram equivalents per day. Minors suffering from moderate to severe pain are allowed an average of 24 morphine milligram equivalents per day.
• Virginia: Generally, acute pain prescriptions are limited to seven days. Virginia regulations define the differences between acute pain and chronic pain. If pain lasts less than three months, it’s defined as acute and is limited to a seven-day supply. In the case of post-surgical pain, patients are limited to a 14-day supply. Extenuating circumstances are the only exceptions. For pain that lasts longer than three months, there are no specific limits, but providers must provide reasons for prescriptions of more than 50 morphine milligram equivalents per day. For more than 120 morphine milligram equivalents per day, the doctor must also document reasons and refer or consult with a pain management specialist.
• Washington: The Washington Health Care Authority limits opioid prescriptions for Medicaid patients. If the patient is under the age of 20, they may only be prescribed 18 tablets or about a three-day supply. Patients aged 21 and over may be prescribed 42 tablets (about seven days’ worth). This does not apply to cancer patients, long-term opioid prescriptions filled in the last 120 days, and cases of medical necessity.
• West Virginia: Prescription limits include a seven-day period for short-term pain, four days for emergency room prescriptions, and three days for prescriptions written by a dentist or optometrist, with exceptions for cancer and hospice patients or residents of nursing homes and long-term care facilities. The state Pharmacy Board and the physician licensing board must also work together to identify suspicious prescriptions.

Screening Providers for Sanctions

If doctors don’t follow opioid law as they treat patients, they are subject to sanctions. This means that they are forbidden by their state professional licensure board from participating in federal healthcare programs. At the very least, sanctioned medical professionals are added to a database that prevents them from providing services to Medicare and Medicaid patients. Sanctioned providers may also face the revocation of their license, license restrictions, fines, and jail time.

To avoid sanctions, it’s vital for medical professionals to understand and comply with opioid law. If providers travel between states or provide telehealth services (as has become increasingly common during the COVID crisis), it can become difficult to keep track of opioid regulations and the providers who issue prescriptions.

A credentials verification organization can help with these issues by ensuring providers are fully screened in the states where they practice. Verisys can assure healthcare entities that the providers they hire have been verified with primary source data. Verisys provides both DEA Registration Verification and Controlled Substance Registration Verification to ensure that providers are certified to handle and prescribe controlled substances. By verifying providers’ credentials, healthcare entities are protected from hiring sanctioned providers which keeps their patients safe.
 

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