December 4, 2013 – Counting today there are twelve days until Indiana’s Emergency Pain Regulations go into effect …on December 15, 2013.

Let’s look at the first two sections (By the way “The Painful Truth” is my opinion):

SECTION 1

These REGULATIONS are from the Medical Licensing Board of Indiana and are applicable to PHYSICIANS only; and specifically with regards to OPIOIDS for CHRONIC PAIN.

The Painful Truth: In my opinion, every provider (i.e. dentists, podiatrists, nurse practitioners, physicians, etc.) should understand that the Attorney General’s Office supports the “First Do No Harm” guidelines for every provider.

SECTION 2

This section offers definitions, some of which I examine below:

* Chronic Pain “means a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.”

The Painful Truth: I take this as meaning any type of pain, for whatever reason, regardless of the severity, that is a problem for two months or longer; even if it is intermittent pain. This encompasses a generous range of chronic pain scenarios.

* Morphine Equivalent Dose “means a conversion of various opioids to a standardized dose of morphine by the use of accepted conversion tables.”

The “First Do No Harm” Toolkit gives some examples of equianalgesic doses to SIXTY MGM of MORPHINE (i.e. hydrocodone 50 mg; oxycodone 40 mg; fentanyl patch 25 mcg/hr), and notes “Equianalgesic tables should only serve as a general guideline to estimate equivalent opioid doses.”

The Painful Truth: This is an inexact science, and there are many “accepted” morphine equivalent conversion tables from which to choose – none of which are perfect. The Toolkit references an online calculator from GlobalRPH. I also like the one from Practical Pain Management. The state of Washington has a nice one as well. When making these conversions try to err on the low side. Better to underestimate than overestimate (i.e. Once someone takes a medicine it is impossible to get it back). Murphy’s laws:  (1) Start low and go slow; (2) Every dose is a test dose.

 * “Outset of an opioid treatment plan” refers only to a patient who has been prescribed: (1) more than sixty opioid-containing pills a month; or (2) a morphine equivalent dose of more than fifteen (15) milligrams per day; for more than three consecutive months.

The Painful Truth: This is very important, somewhat confusing, and will be discussed later. For now, just realize that there is definitely a threshold where these regulations become relevant.

Disclaimer: This is not legal advice. This is not medical advice. I represent no organization. All opinions, unless specifically referenced, are my own. If you have a medical condition please seek advice from your personal physician. Every patient, practitioner, and facility should consult its own counsel for advice and guidance. If you rely upon information from this website, you do so at your own risk.

December 1, 2013 – counting today there are fifteen days until Indiana’s Emergency Pain Regulations go into effect. On December 15^th the way physicians prescribe pain medications in the Hoosier State will change.

Between now and December 15^th I will regularly be posting this pain specialist’s take on the Indiana situation.  Having said that, it is time for a disclaimer:

This is not legal advice. This is not medical advice. I represent no organization. All opinions, unless specifically referenced, are my own. If you have a medical condition please seek advice from your personal physician. Every patient, practitioner, and facility should consult its own counsel for advice and guidance. If you rely upon information from this website, you do so at your own risk.

Here we go…

One should begin this journey by understanding the difference between a law, a regulation, and a guideline.

A law is a rule that has been passed by elected officials. Violation of a law may be viewed as a criminal act.

Indiana’s new pain law (a.k.a. additions to Senate Bill 246) is fairly concise and does not directly apply to physicians. Instead, it says the medical board must come up with regulations – which they did.

A regulation is a rule that is usually created by a government agency (i.e. a “bureaucracy”) as opposed to the legislature. Regulation determines how laws will be enforced. Violation of a regulation may not be a criminal act but can incur a wide-range of penalties.

As previously stated, Indiana’s Emergency Pain Regulations go into effect on December 15, 2013 and are subject to revision until November 1, 2014, at which time the permanent regulations are due.

A guideline, especially when endorsed by a governing body, is a set of opinions that offer insight into the manner in which regulations and laws can be properly followed. Violating a guideline may or may not be considered a wrong move, but generally will require a legitimate explanation as to the decision-making process.

The Indiana State Attorney General’s Office has published a detailed set of guidelines, called “First Do No Harm,” which offer insight as to what regulators will consider as proper medical practice, should they be called upon to investigate a controlled substances related issue.

In summary, Indiana physicians who prescribe controlled substances do not need to know details of the new law, as it does not apply directly to them.

However, physicians should clearly understand the Emergency Pain Regulations and how these regulations will affect their practice after December 15, 2013.

Also, physicians are strongly urged to become familiar with the “First Do No Harm” guidelines and to start incorporating as many of the recommended practices as possible.

Stay tuned.  It’s only December 1^st.

There’s more painful truth in the days to come.