You cannot legislate common sense. Even with a legal mandate.
California’s Bill 2760, which mandates a prescriber to offer a prescription for naloxone, was a valiant attempt to address the opioid epidemic. But, like other well-meaning legislative action, it had unpredicted and unintended consequences.
Unlike most laws, this one is a short read. The essence of the legislation is that the prescriber should offer a prescription for naloxone if: a patient has a prescription for 90 milligrams or more of morphine (or a morphine equivalent) a day; a patient has any amount of opioid prescribed concurrent with a benzodiazepine; or if patient is at increased risk for overdose (e.g., has a history of addiction). It doesn’t matter if the prescriber prescribed the original opioid or not. If, for example, you are the dermatologist seeing the patient, you should offer the prescription for naloxone. Similarly, it doesn’t matter how much of the benzodiazepine the patient is taking. If the patient once had a hydrocodone prescription for a procedure, and has an active prescription for Ambien, they should be offered naloxone.
When Bill 2760’s dictates are combined with the CURES ruling and dual authentication for electronic prescribing of controlled substances, suddenly, even in the hands of a “super user” of the EHR, it is, at best, a cumbersome requirement. (My opinion on CURES has already been published.)
The scenario is not infrequently this: Patient fell off the dockless electric scooter and sustained a radial fracture. As a compassionate urgent care provider, you have splinted the fracture and arranged for an orthopedic appointment on Monday morning. To get the patient through the weekend, you want to prescribe 12 Vicodin. You check with the patient to be sure the correct pharmacy is noted. You leave the EHR to check CURES, but your password has expired, as it does every 90 days. So, you have to create a new password and find your phone to click the link in the email. Now, you can enter the patient’s name, date of birth, and verify their home address on the Department of Justice website. (The patient, sitting next to you, continues to ask questions: “Will I be able to play the piano again?” “Are you prescribing something that’s dangerous? I don’t need anything.”) You pause to answer the questions. Your session times out. You log back in. You find that the patient had one prior prescription for hydrocodone in 2016. He describes the episode that prompted that prescription in excruciating detail. He also has a prescription for Xanax, 0.25mg, half a tablet when flying. This was last filled nine months ago, for a quantity of 10. You go back into the EHR and document your findings from CURES. Now, finally, you discuss naloxone with the patient. The patient declines naloxone and the Vicodin. (He often declines prescriptions.) At this point, he says he’ll elevate and use Advil. You document the naloxone discussion. You add the naloxone information to the patient instructions in the after-visit summary. You are behind, and the waiting room is full.
The above scenario is more on par with my experience than the oft-cited story of the patient that is hooked on heroin, seeking a fix. To be clear, I am not suggesting that we not address the opioid crisis as a serious epidemic. I am suggesting that politicians leave the guidelines to the physicians. Most of us will do the right thing, given clear evidence without the risk of handcuffs.
Also, given that our physicians are already over-burdened and burned out, why are we not considering other options for the naloxone question? Given that pharmacies are the entities filling a prescription, wouldn’t it make sense for the pharmacy to offer the naloxone? It’s over-the-counter in 45 states. And given that we have AEDs in almost every public venue, could we (or, should we) add a naloxone canister to the AED kit? And given that we’re offering naloxone, shouldn’t we consider public education on overdoses? Shouldn’t we make naloxone readily available and understood? As physicians, we should discuss the risks and benefits of everything we prescribe. We don’t need laws for that.
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