2019 -- H 5537 SUBSTITUTE A

========

LC001484/SUB A/3

========

     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2019

____________

A N   A C T

RELATING TO FOOD AND DRUGS - UNIFORM CONTROLLED SUBSTANCES ACT

     Introduced By: Representatives Mattiello, Caldwell, Serpa, Alzate, and Bennett

     Date Introduced: February 27, 2019

     Referred To: House Health, Education & Welfare

     It is enacted by the General Assembly as follows:

     SECTION 1. Section 21-28-3.20 of the General Laws in Chapter 21-28 entitled "Uniform

Controlled Substances Act" is hereby amended to read as follows:

     21-28-3.20. Authority of practitioner to prescribe, administer, and dispense.

     (a)(1) A practitioner, in good faith and in the course of his or her professional practice

only, may prescribe, administer, and dispense controlled substances, or he or she may cause the

controlled substances to be administered by a nurse or intern under his or her direction and

supervision.

     (2) When issuing an initial prescription for an opiate to an adult patient, a practitioner

shall not exceed the maximum daily dose requirements established by the department of health.

     (3) Except as provided in subsection (a)(4) of this section, a practitioner shall not issue an

opiate prescription to a minor for more than twenty (20) doses at any time. Prior to issuing an

opiate prescription to a minor, a practitioner shall discuss with the parent or guardian of the minor

the risks associated with opiate use and the reasons why the prescription is necessary. The

practitioner shall document their discussion with the parent or guardian in the medical record.

     (4) Notwithstanding the limitations referenced in subsection (a)(3) of this section, if, in

the professional medical judgment of a practitioner, a greater dosage or supply of an opiate is

required to treat the minor patient's acute medical condition or is necessary for the treatment of

chronic pain management, sickle cell related pain, intractable pain treatment as defined in chapter

37.4 of title 5, pain associated with a cancer diagnosis or for palliative care, then the practitioner

may issue a prescription for the quantity needed to treat such acute medical condition, chronic

pain, sickle cell related pain, intractable pain, pain associated with a cancer diagnosis, or pain

experienced while the patient is in palliative care, provided that this dosage shall not exceed the

maximum daily dosage permitted for the treatment of this pain as set forth in the department of

health regulations. The condition triggering the prescription of an opiate shall be documented in

the minor patient's medical record, and the practitioner shall indicate that a non-opiate alternative

was not appropriate to address the medical condition.

     (5) Notwithstanding subsections (a)(2) and (a)(3) of this section, this section shall not

apply to medications designed for the treatment of substance abuse or opioid dependence.

     (b) The prescription-monitoring program shall be reviewed prior to starting any opioid. A

prescribing practitioner, or designee as authorized by § 21-28-3.32(a)(3), shall review the

prescription-monitoring program prior to refilling or initiating opioid therapy with an intrathecal

pump. For patients the prescribing practitioner is maintaining on continuous opioid therapy for

pain for three (3) months or longer, the prescribing practitioner shall review information from the

prescription-monitoring program at least every three (3) months. Documentation of that review

shall be noted in the patient's medical record.

     (c) The director of health shall develop regulations for prescribing practitioners on

appropriate limits of opioid use in acute pain management. Initial prescriptions of opioids for

acute pain management of outpatient adults shall not exceed thirty (30) morphine milligram

equivalents (MMEs) total daily dose per day for a maximum total of twenty (20) doses, and, for

pediatric patients, the appropriate opioid dosage maximum per the department of health.

     (d) For the purposes of this section, acute pain management shall not include chronic pain

management, pain associated with a cancer diagnosis, palliative or nursing home care, or other

exception in accordance with department of health regulations.

     (e) Subsection (c) shall not apply to medications designed for the treatment of substance

abuse or opioid dependence.

     (f) On or before September 1, 2018, the director of health shall develop, and make

available to health-care practitioners, information on best practices for co-prescribing opioid

antagonists to patients. The best practices information shall identify situations in which co-

prescribing an opioid antagonist may be appropriate, including, but not limited to:

     (1) In conjunction with a prescription for an opioid medication, under circumstances in

which the health-care practitioner determines the patient is at an elevated risk for an opioid drug

overdose;

     (2) In conjunction with medications prescribed pursuant to a course of medication

LC001484/SUB A/3 - Page 2 of 4

therapy management for the treatment of a substance use disorder involving opioids; or

     (3) Under any other circumstances in which a health-care practitioner identifies a patient

as being at an elevated risk for an opioid drug overdose.

     (g) The best practices information developed pursuant to subsection (f) of this section

shall include guidelines for determining when a patient is at an elevated risk for an opioid drug

overdose, including, but not limited to, situations in which the patient:

     (1) Meets the criteria provided in the opioid overdose toolkit published by the federal

substance abuse and mental health service administration;

     (2) Is receiving high-dose, extended-release, or long-acting opioid medications;

     (3) Has a documented history of an alcohol or substance use disorder, or a mental health

disorder;

     (4) Has a respiratory ailment or other co-morbidity that may be exacerbated by the use of

opioid medications;

     (5) Has a known history of intravenous drug use or misuse of prescription opioids;

     (6) Has received emergency medical care or been hospitalized for an opioid overdose; or

     (7) Uses opioids with antidepressants, benzodiazepines, alcohol, or other drugs.

     (h) On or before September 1, 2018, the director of health and the secretary of the

executive office of health and human services shall develop strategies that include:

     (1) Allowing practitioners in non-pharmacy settings to prescribe and dispense opioid

antagonists; and

     (2) Ensuring that opioid antagonists that are distributed in a non-pharmacy setting are

eligible for reimbursement from any health insurance carrier, as defined under chapters 18, 19,

20, and 41 of title 27, and the Rhode Island medical assistance program, as defined under chapter

7.2 of title 42.

     SECTION 2. This act shall take effect upon passage.

========

LC001484/SUB A/3

========

LC001484/SUB A/3 - Page 3 of 4

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO FOOD AND DRUGS - UNIFORM CONTROLLED SUBSTANCES ACT

***

     This act would restrict the initial prescription to an adult to the maximum daily dosage

established by the department of health. The act would also restrict all prescriptions to a minor

patient for an opiate to twenty (20) doses, with exceptions for certain conditions and medicines

designed for substance abuse or opioid dependence treatment.

     This act would take effect upon passage.

========

LC001484/SUB A/3

========

LC001484/SUB A/3 - Page 4 of 4