Several pieces of legislation regarding opioid prescriptions have just gone into effect, or will do so over the next several months, affecting health care providers across the state of Michigan. Other states may follow suit or may already have passed similar provisions.

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Each new requirement aims to chip away at the epidemic of misuse, addiction, overdoses and deaths related to opioids. By addressing the use of opioid-containing medications, the new laws aim to keep more people from falling into a spiral of dependence on the drugs or progressing to using illegal opioids like heroin.

Legislation background

"The spirit of the opioid legislation being passed is tied to this epidemic we're seeing and increased number of opioid overdoses. We have to crack down on the prescription process. My impression is that this will have a bigger impact on providers compared to patients," says Paul Hilliard, M.D. , assistant professor and medical director for Michigan Medicine's Institutional Opioid and Pain Management Strategy.

The requirements that went into effect in March of this year largely relate to providing opioid education to patients. Public Act 250 of 2017 requires licensees or registrants who treat patients for opioid-related overdose to provide information on substance abuse disorder services.

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Another requires the state's prescription drug and opioid abuse commission to provide recommendations for the instruction of school children about prescription opioid abuse (Public Act 254 of 2017). Also in effect is a new rule allowing acute treatment services and clinical stabilization services for opioid addiction to be a covered medical service under Medicaid (Public Act 252 of 2017).

On the education front, parental consent is now required for minors to receive an opioid prescription (Public Act 246 of 2017). Providers and parents must use a form called Start Talking, except if the opioid is necessary for treatment associated with a medical emergency, surgery, hospice or cancer care. The prescriber must provide a minor, their parents and all other patients with information regarding the danger of opioid addiction, how to properly dispose of opioids, and the short and long-term effects on a fetus if the patient is of reproductive age or pregnant.

Treating acute pain

What has most people concerned, Hilliard notes, is the opioid legislation going into effect on July 1, focusing on patients with acute pain but not those with chronic pain or a long-term illness

He adds that the Michigan Health Code definition of acute pain is pain that is the normal, predicted physiological response to a noxious chemical, or a thermal or mechanical stimulus, and is typically associated with invasive procedures, trauma, and disease and usually lasts for a limited amount of time. "In other words, this is normal, temporary post-surgery pain," he says.

The new law says that prescribers treating a patient for acute pain may not prescribe more than a seven-day supply of an opioid within a seven-day period. A pharmacist may partially fill a Schedule II drug in certain situations, and a pharmacist can take a Schedule II prescription via phone if the prescriber fills out a paper script and sends it to the pharmacy within seven days. Schedule II drugs have a high potential for abuse that can lead to psychological or physical dependence. 

The law was designed to keep patients from having more opioids on hand than they need, Hilliard says. Research has shown that if a doctor prescribes an opioid painkiller for a patient after surgery, some patients may feel they have to take all the pills they're given. However, this isn't always the case, and in fact some take none or very few.

"It's like getting a larger fries at McDonalds. If you get more fries, you're more likely to eat more than you would originally because they're right in front of you," says Hilliard.

If doctors prescribe the correct amount of an opioid for a surgery patient, there's less chance of excess pills being taken and potentially leading to dependence and addiction. There's also less chance of the pills being where they shouldn't, like within the reach of a child at home, a pet's mouth, or the hands of someone without a prescription for it.

Recent opioid legislation also requires providers to register for the Michigan Automated Prescription System. MAPS is a monitoring system that will help identify and prevent drug overprescribing for not only providers but pharmacists as well by tracking Schedule II-V controlled substances that are dispensed.

"We are very pleased to integrate MAPS within our electronic health record and feel this will help providers efficiently gain valuable information about their patients," says Heather Somand, PharmD, Manager of Medication Use Informatics at Michigan Medicine. "The response time of the new MAPS is mere seconds which is an enormous advantage over the previous system."  

Dealing with pain

"The more we learn about opioids, the scarier we realize they are," says Hilliard.

"Pain is a sensory and emotional experience. Most patients still have their pain after taking opioids. It's unclear whether opioids actually are treating pain or the emotion that goes along with it. Do opioids get rid of pain the way Ibuprofen does, at the molecular level? Or do opioids just promote a state of well-being because the molecules bind to our receptors, and we're not really addressing what's causing us the pain?" he continues.

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Patients who are worried they might have a dependence on opioids should seek help from a health care provider to talk about options for handling pain, Hilliard notes.

"There's topical lotions, nonsteroidal drugs, tricyclic antidepressants, physical therapy, TENS units, referral to specific experts … the last thing anyone should resort to is opioid usage," he says. Behavioral health is also correlated to pain, so mindfulness techniques are good to practice and may be beneficial.

For more information, learn about alternatives to opioids for treating pain and visit the University of Michigan Addiction Center for treatment services. For more information on controlled substance classifications, visit the U.S. Drug Enforcement Administration website.