Doctors who prescribe relatively high doses of opioids to treat long-term pain are now required to offer patients an additional prescription—for the overdose antidote naloxone.
The rule, which went into effect in December, is among a handful of new regulations for opioid prescribing in Ohio that aim to increase awareness about the risk of misuse and addiction by strengthening doctor-patient communication.
"We want people to get good treatment, but we want it to be safe," said Dr. Mark Hurst of the Ohio Department of Mental Health and Addiction Services. "The point of all this is to enhance the dialogue between patient and prescriber."
Hurst, who will move into a new position Monday as assistant director of clinical services, said Ohio has made good progress in recent years reducing both prescriptions and overdoses of opioid medications. The state counted 4,854 unintended fatal overdoses in 2017, the latest year for which data are available, with the majority caused by fentanyl and heroin.
But prescription abuse remains a serious problem. "We still lose a lot of people," Hurst said.
The new rules vary depending on the dosage prescribed. At a daily morphine-equivalent dose of 80, which is about the same as 16 (5 milligram) hydrocodone pills, prescribers are required to look for signs of prescription misuse, consult with a specialist, obtain a written pain-management agreement with the patient and offer a prescription for naloxone.
The State Medical Board of Ohio stopped short of requiring the naloxone prescription to be written, as many advocates had urged. Doctors have to offer it and document that they did.
"In my practice, most of the reaction has been fairly positive," said Dr. Kiran Rajneesh, a neurologist and pain physician at Ohio State University's Wexner Medical Center.
Rajneesh said he tries to engage patients in a conversation that touches on many aspects of opioid painkillers, from the straightforward medical effects to social and legal concerns, rights and responsibilities. After the naloxone discussion, "A lot of them say yes," Rajneesh said. "Some say, 'Let me think about it.'"
He has, however, heard from other doctors that a few chronic-pain patients have taken offense at being offered a medication commonly used to revive addicts. "It is an uncomfortable conversation sometimes," he said.
A bigger concern for some of those on high doses is that the new rules might require them to see more than one doctor, such as a specialist or certified pain-medicine physician, Rajneesh said. Some of his patients are on long-term pain medication because they aren't good candidates for surgery due to age or poor health.
Not every patient on high doses has easy access to a board-certified, pain-management physician, Dr. John Naveau of Coldwater in Mercer County, western Ohio, told the State Medical Board of Ohio in May, before the rules were adopted. "This will be a problem for many patients."
The rules do not apply to patients receiving medication for terminal conditions or those being closely monitored in a hospital.
Ohio has been especially hard-hit in the nation's epidemic of drug addiction, with an average of 14 deaths a day in 2017, according to the federal government. At 46.3 deaths per 100,000 residents, the state's rate was more than twice that of the nation as a whole. Only West Virginia, at 57.8, had a worse rate.
Ohio has enacted various restrictions on the prescribing of painkillers, including setting limits last year for prescriptions to treat acute pain caused by injury or illness.
Marcie Seidel, executive director of the Prevention Action Alliance, said her organization had hoped that naloxone co-prescriptions would be mandatory at high doses. "Sometimes conversations just don't happen," she said. "That sort of forces the conversation."
Ohio is among just a few states to require either conversation or prescriptions for the overdose antidote, said Thom Duddy, a vice president at Adapt Pharma, makers of the Narcan brand of naloxone.
The idea is not to tell patients their behavior is risky, he said. "It's that this is a risky medication. If you have a gas stove in your home, I would hope that you have a fire extinguisher."