2021 -- H 5242

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2021

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A N   A C T

RELATING TO HEALTH AND SAFETY -- OPIOID ALTERNATIVES

     Introduced By: Representatives Edwards, and Caldwell

     Date Introduced: January 29, 2021

     Referred To: House Health & Human Services

     It is enacted by the General Assembly as follows:

     SECTION 1. The general assembly finds that:

     Every competent adult has the fundamental right to self-determination regarding decisions

pertaining to his or her own health, including the right to refuse an opioid drug listed as a Schedule

II controlled substance pursuant to the provisions of § 21-28-2.02.

     SECTION 2. Title 23 of the General Laws entitled "HEALTH AND SAFETY" is hereby

amended by adding thereto the following chapter:

CHAPTER 1.12

OPIOID ALTERNATIVES

     23-1.12-1. Educational pamphlet.

     (a) The department shall develop and publish on its website an educational pamphlet

regarding the use of opioid alternatives for the treatment of pain. The pamphlet shall, at a minimum,

include:

     (1) Information on available opioid alternatives for the treatment of pain, including non-

opioid medicinal drugs or drug products and nonpharmacological therapies.

     (2) The advantages and disadvantages of the use of opioid alternatives.

     23-1.12-2. Rules and regulations.

     The department may adopt rules and regulations requiring health care practitioners to post

or disseminate the information contained in the educational pamphlet developed and published

pursuant to the provisions of § 23-2.12-1.

     SECTION 3. 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 his or her 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 the 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

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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 healthcare 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 healthcare 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 therapy

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

     (3) Under any other circumstances in which a healthcare 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

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     (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.

     (i) Except in the provision of emergency services and care, before providing anesthesia or

prescribing, ordering, dispensing, or administering an opioid drug listed as a Schedule II controlled

substance pursuant to the provisions of chapter 28 of title 21, for the treatment of pain, a health care

practitioner, excluding those licensed under chapter 19.1 of title 5, shall:

     (A) Inform the patient of available opioid alternatives for the treatment of pain, which may

include non-opioid medicinal drugs or drug products, interventional procedures or treatments,

acupuncture, chiropractic treatments, massage therapy, physical therapy, occupational therapy,

osteopathic care or any other appropriate therapy as determined by the health care practitioner.

     (B) Discuss the advantages and disadvantages of the use of opioid alternatives, including

whether the patient is at a high risk of, or has a history of, controlled substance abuse or misuse and

the patient's personal preferences.

     (C) Provide the patient with the educational pamphlet developed and published pursuant

to § 23-1.12-1.

     (D) Document the opioid alternatives considered in the patient's record.

     SECTION 4. Section 5-19.1-34 of the General Laws in Chapter 5-19.1 entitled

"Pharmacies" is hereby amended to read as follows:

     5-19.1-34. Notice of warning regarding use of Schedule II controlled substances to be

posted.

     (a) The director of the department of health shall compile a list of at least the ten (10) most

prescribed drugs containing opioids and/or other Schedule II controlled substances as listed in §

21-28-2.08 and forward it to the board of pharmacy which shall distribute that list to all pharmacies

in the state. The list shall also contain warnings relating to the overuse, misuse, and mixing of those

drugs with other drugs, specifically benzodiazepines, and/or alcohol, including, but not limited to,

dependence, addiction, or death.

     (b) Each pharmacy shall conspicuously display the list at or adjacent to the place in the

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pharmacy where prescriptions are presented for compounding and dispensing, and shall display

with the list the information contained in the educational pamphlet developed and published

pursuant to § 23-1.12-1.

     (c) The pharmacist shall also inform the patient that the pharmacist may dispense a partial

fill of the prescription if requested by the patient and the procedure for other partial fills until the

full prescription is dispensed within thirty (30) days of the date on which the prescription was

written.

     SECTION 5. This act shall take effect on September 13, 2021.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HEALTH AND SAFETY -- OPIOID ALTERNATIVES

***

     This act would provide that the department of health is to develop and publish an

educational pamphlet regarding opioid alternatives. The department may adopt rules for the posting

of the information by health care practitioners. The act would further provide that the information

is to be posted at pharmacy locations.

     This act would take effect on September 13, 2021.

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