Danielle Lee: … Jacksonville and happy Saturday. I am Danielle Lee and welcome to The Conversation with Dr. Ali Kasraeian. Just a heads up, we do have an active severe thunderstorm warning for Baker and Nassau county until 5:45. You’ll hear a “dong” every couple of minutes or so throughout the show. But speaking of the show, Dr. Ali, we have a pretty interesting one on tap for today.
Dr. Kasraeian: As always, as always. Today in studio, we have our good friend Dr. Brian Yorkgitis who’s an acute care trauma surgeon at UF Health and an expert on the topic that we’re gonna discuss today. Opioids.
Narcotic pain medications have gotten a lot of attention recently because of the spike in use, prescriptions that have written for them, and most importantly, the concern regarding overdoses and the deaths relating to narcotic pain medication. And secondarily, people going out and getting narcotic pain medication-type adjunct, such as heroin because they’re a cheaper alternative when they have reached the point of addiction.
In response to this in the state of Florida, legislation has come into play that has put on a lot of provisions on how physicians can prescribe and the logistics around the prescription of narcotic pain medication. Today we are gonna discuss what this means to physicians and most importantly what it means to physicians who are dealing with acute pain.
Acute pain is defined as a normal predicted physiologic and time limited response to an adverse chemical, thermal, or mechanical stimulus, which can be associated with surgery, trauma, or an acute illness, which is a short-term illness. To help navigate this conversation will be Dr. Yorkgitis. Welcome to The Conversation.
Dr. Yorkgitis: Thank you very much and thanks for having us in preparation for this increased regulation on opiod prescribing. I think it’s really important from the prescriber and the patient standpoint to know what’s gonna happen July 1st? It’s gonna change. Especially patients that have gotten a prescription before for an acute problem or going into surgery for you and I, these patients coming in.
Law does not address chronic pain. That’s different. Other than on a prescriber standpoint, but for our patient, chronic pain is treated separate. This really is a bill for acute pain on a patient. But providers, a lot more burden.
Dr. Kasraeian: Yeah. The concern with this from a provider’s standpoint is that we live in a medical world that you hear about burnout. Multiple studies over the past few years have come up and have been criticized that physicians are suffering from burnout at 40 to 60% rates. One in four physicians suffers from suicidal thoughts. One in five has been diagnosed or treated with depression. One in 50, unfortunately, have attempted suicide. June 1st was actually an interesting day. It is called Crazy Socks for Docs day. You can look this up all over the internet, Facebook, and Twitter and you can see a lot of small posts and memes and comments regarding this day on June 1st where we wear odd socks to raise awareness for our physician colleagues who are dealing with mental health issues.
Reason I bring this up, a lot of these days burnouts and, really as importantly, early retirement of physicians, at the time where we’re dealing with significant workforce shortages, deal with the logistics, the bureaucratic paperwork aspects that we have to do electronic medical records. So in our attempts to make sure we are doing better with our patients and this opioid epidemic, how do we balance the thing from a governmental and regime coming in not swinging a pendulum? And the other side, where now doctors afraid to prescribe pain medications for their patients who may need them for a period of time?
Dr. Yorkgitis: The practice of medicine is changed obviously since your dad has been a physician and then as you and I are in our early to mid careers. The paperwork burden is astronomical in the insurance industry. But this law really adds a layer of burden. And I think that the patients and providers have to understand it actually criminalizes from prescription writing if we don’t follow the letter of the law. In which you could take a physician that could have a 20 year career and ruin their career. Therefore, you think about if it’s a family doctor, family doctors see an average of 60 to 80 patients a week. If you do that 50 weeks a year with two weeks of vacation over 20 years, think about the patients that have lost. We really have to think about the application of this. Not only the short-term, but the long-term.
I think that one thing about this law is it was rather quickly passed through legislation. A more robust longitudinal data may have provided a little better.But it’s here. There are parts of it I think are great. But there are other parts where I have data to show that may not be the best.
Dr. Kasraeian: Let’s break into this law. What exactly does this show? What does it mean? And how is it different than the laws that we have? Basically, this is a law that was signed into law on March 19th with the idea that the provisions of this law really go into effect on July 1st.
One of the first things was Florida Prescription Drug Monitoring System where physicians and practitioners or anyone either writing for a medication or prescribing a medication is able to maintain an electrical system to collect and store data and control substance dispensing information. Here’s it’s called E-FORCSE. Very, very cleaver pneumonic for Electronic Florida Online Reporting of Controlled Substances Evaluation program.
One of the things we will talk about on this show is whether or not the timing of how long you can write prescriptions is an issue. However, one of the things that’s gonna be a big, big, I think, hurdle between physicians, the logistics of this law, and actually patients who are gonna be a little bit frustrated through this process is the fact that the practitioner now must consult this data base and review the patient’s controlled substance dispensing history. Meaning that, what kind of pain medications have you received? Do you have any outstanding prescriptions now? And you have to do that before prescribing controlled substance for every patient above 16 years of age. For us as surgeons, this could be a daunting undertaking during a surgical day.
Dr. Yorkgitis: I think that the use of E-FORCSE is important, but the way it’s mandated may not be the best way to implement it. Previous studies really have shown that prescription drug monitoring programs are effective. The state of Tennessee, when they enacted the law in 2012, they saw a 36% drop in patients who were seeking multiple prescribers. And then in New York they saw, again, passed the same law, 75% decrease. We know that using the prescription drug monitoring program will alter physician prescribing by 40, 42% in some studies, but the system is hard.
I think to use in every patient every time adds to the day and decreases the amount of patients we can see. Also, it may limit you. If it’s down, we’re limited by three days. We all know that computers go down all the time, so if it just so happens your computer of the system goes down, then we can’t prescribe for anymore. Even chronic pain patients. Three days. Some patients may travel for a long distance to see their chronic pain doctor, get there, the system down and they can only prescribe three days.
Dr. Kasraeian: Where that becomes important, most pain medications and narcotic pain medication these days are not things you can call in or e-prescribe. These have to be paper written, hand written prescriptions of some sort in some capacity where you have to be present. There has to be an exchange within the practitioner in terms of an evaluation and then you have some form of a paper prescription that you take with you to fill these prescriptions. How difficult is this gonna be to logistically undertake? Obviously we have to do it, but is it going to potentially translate into a lot of unhappy physicians? And importantly, a lot of unhappy patients?
Dr. Yorkgitis: I think both. I think one thing is especially those physicians that may be towards the end of their career, adding this layer of burden, they may to decide to retire. They plan to retire in 67, 68, and then they decide to retire at 65 just because with the added burden of electronic medical record on the practice on top of the [inaudible 00:09:00], they may find that physicians that we thought were gonna be in the workforce longer, aren’t.
The second thing is the patient. If you’re in the office waiting and then backlog of your patients. If you’re that 11:30 appointment, you’re usually backlogged by 11:30 and just add to that. Then the patients are waiting. Or patients needing to discharge from the hospital that are waiting for us to write the prescriptions if we have to go and find them.
I think there’s an opportunity though to make it smoother and I think it’s the integration into the AMR. The minute that I plug in that I wanna prescribe a controlled substance we should have an AMR that really integrates E-FORCSE and does that check rate there while you’re typing that. You type Oxycontin or any controlled substance and it pops up and says, “We got this. Here’s the list.” That’d be great. I think that-