Subject: State of Ohio Board of Pharmacy Acute Prescribing Limits Update
Date: Fri, 18 Aug 2017 15:23:49 +0000

From: State of Ohio Board of Pharmacy <contact@pharmacy.ohio.gov>

Reply-To: PRX-noreply@pharmacy.ohio.gov

E-NEWS UPDATE
ACUTE PRESCRIBING LIMITS UPDATE

New Limits on Prescription Opioids for Acute Pain

Effective August 31, 2017, the State of Ohio will have new rules for prescribing opioid analgesics for the treatment of acute pain.

Please be advised, these rules DO NOT apply to the use of opioids for the treatment of chronic pain.

In general, the rules limit the prescribing of opioid analgesics for acute pain, as follows:
1. No more than seven days of opioids can be prescribed for adults.
2. No more than five days of opioids can be prescribed for minors and only after the written consent of the parent or guardian is obtained.
3. Health care providers may prescribe opioids in excess of the day supply limits only if they provide a specific reason in the patient’s medical record.
4. Except as provided for in the rules, the total morphine equivalent dose (MED) of a prescription for acute pain cannot exceed an average of 30 MED per day.
5. The new limits do not apply to opioids prescribed for cancer, palliative care, end-of-life/hospice care or medication-assisted treatment for addiction.
6. The rules apply to the first opioid analgesic prescription for the treatment of an episode of acute pain.
NOTE: These rules do not apply to veterinarians.

A guidance document and links to the rules for prescribers can be accessed here: www.pharmacy.ohio.gov/AcuteLimits.

Rule 4729-5-30 – Manner of Issuance
• Starting December 29, 2017, rule 4729-5-30 will require prescribers to include the first four characters (ex. M16.5) of the diagnosis code (ICD-10) or the full procedure code (Current Dental Terminology – CDT) on all opioid prescriptions, which will then be entered by the pharmacy into OARRS.
• Starting June 1, 2018, this requirement will take effect for all other controlled substance prescriptions.
• Starting December 29, 2017, rule 4729-5-30 will also require prescribers to indicate the days’ supply on all controlled substance and gabapentin prescriptions.
Effective December 29, 2017, rule 4729-37-05 requires the use of the ASAP Version 4.2A Standard for reporting dispensing information to OARRS. Pharmacies should begin contacting software vendors now to be able to implement this change by the effective date of the rule.

For additional questions regarding the proposed rules, please review frequently asked questions by visiting: www.pharmacy.ohio.gov/AcuteFAQ.

If you need additional information, the most expedient way to have your questions answered will be to e-mail the Board office by visiting: http://www.pharmacy.ohio.gov/contact.aspx.

State of Ohio Board of Pharmacy | 77 S. High Street, 17th Floor | Columbus, OH 43215-6126

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Heads In The Sand — The Real Cause Of Today’s Opioid Deaths

http://www.acsh.org/news/2017/08/16/heads-sand-%E2%80%94-real-cause-todays-opioid-deaths-11681

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As opioids hit the workforce, employers are forced to improvise

http://www.hrdive.com/news/as-opioids-hit-the-workforce-employers-are-forced-to-improvise/449471/

Filed under: General Problems | 5 Comments »

Alcohol use and high-risk drinking has increased among US adults

http://www.clinicaladvisor.com/psychiatry-information-center/alcohol-use-and-high-risk-drinking-has-increased-in-united-states/article/681115/?DCMP=EMC-CA_Update_20170817&cpn=&hmSubId=Cg22JPoLNCY1&hmEmail=Oa5UfbxYIUtfs9-6S0wYYOCqHv3nkrf00&NID=&dl=0&spMailingID=17905564&spUserID=MjY0MzY4MjQzNzc0S0&spJobID=1081150319&spReportId=MTA4MTE1MDMxOQS2

(HealthDay News) — From 2001-2002 to 2012-2013 there was an increase in alcohol use, high-risk drinking, and in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) alcohol use disorder (AUD), according to a study published in JAMA Psychiatry.

Bridget F. Grant, PhD, from the National Institute on Alcohol Abuse and Alcoholism in Rockville, Maryland, and colleagues collected data from face-to-face interviews of US adults to examine the changes in alcohol use behaviors between 2001-2002 and 2012-2013. Data were included for 43,093 participants in the National Epidemiologic Survey on Alcohol and Related Conditions and for 36,309 participants in the National Epidemiologic Survey on Alcohol and Related Conditions III.

The researchers observed increases of 11.2%, 29.9%, and 49.4% in 12-month alcohol use, high-risk drinking, and DSM-IV AUD, respectively, between 2001-2002 and 2012-2013. Increases in alcohol use, high-risk drinking, and DSM-IV AUD were statistically significant across sociodemographic groups with few exceptions. The greatest increases were seen among women, older adults, racial/ethnic minorities, and individuals with lower educational level and family income. For the total sample and most sociodemographic subgroups, increases were also seen in the prevalence of 12-month DSM-IV AUD among 12-month alcohol users (from 12.9% to 17.5%) and among 12-month high-risk drinkers (from 46.5% to 54.5%).

“These findings portend increases in many chronic comorbidities in which alcohol use has a substantial role,” the authors write.

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FDA Warns About Dangers of Epidural Steroid Injections for Back Pain. Must Read Before Taking These Steroid

www.uspainclinic.com/2017/08/15/fda-warns-about-dangers-of-epidural-steroid-injections-for-back-pain-must-read-before-taking-these-steroid/

The Food and Drug Administration has just issued what’s called a “Medwatch Alert” warning that Epidural steroid injections or “ESIs” for back and neck pain can be extremely dangerous. The alert says: “Injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death.”

Epidural steroid injections – and catastrophic injuries from them – were the subject of my debut investigation for The Dr. Oz Show almost exactly a year ago. (You can watch the video here and read the web article here.) The epidural space is an area between the spinal cord and the bony structure of the spine.

Our investigation revealed that the steroids – called corticosteroids – used for epidural injections are not even FDA approved for this purpose and yet ESIs are done nearly 9 million times a year, according to an analysis by Dr. Laxmaiah Manchikanti.

In addition to informing the public via its Medwatch Alert, the FDA said, “We are requiring the addition of a Warning to the drug labels of injectable corticosteroids to describe these risks.”  Injectable corticosteroids include methylprednisolone, hydrocortisone, triamcinolone, betamethasone, and dexamethasone.

The new warning will be a more prominent reminder to doctors that injecting steroids into the epidural space, just outside the spinal cord, has risks. But the warning failed to list all of the possible adverse reactions. Those reactions are named in the fine print of current drug labels, and include: “arachnoiditis, bowel/bladder dysfunction, headache, meningitis, parapareisis/paraplegia, seizures, sensory disturbances.”

In 2009, the FDA convened a group to study the safety of some types of epidural steroid injections. In its new notice, the FDA said that group’s recommendations still are not ready and will be released when they are.

Dennis Capolongo of the EDNC, a group that has been campaigning against epidural steroid injections for years, called the FDA’s new warning “bitter sweet” because it did not go further.  Capolongo wants the FDA to go beyond telling doctors that injecting steroids into the epidural space COULD have severe side effects and instead state that they MUST NOT do it.

In February of this year, Australian and New Zealand health authorities came out with exactly that stronger language, stating that steroids like this, “MUST NOT be used by the intrathecal, epidural, intravenous or any other unspecified routes.” The South African government issued similar warnings, according to Capolongo.

Since the FDA is still actively studying these procedures, it will be interesting to see if the agency takes any further steps. If and when it does, you can bet I’ll pass the information along.

When your “pain doc” claims that YOU MUST HAVE ESI’s or they will not write any oral opiate pain meds… present them with this information.. what is more dangerous and presents the possibility of irreversible side effects …  opiates or ESI’s ?

Could the continued use of injecting these “dangerous medications” as ESI’s when there is strong evidence of pt harm be considered INSURANCE FRAUD ?… by providing services/procedures that are neither recommended nor approved by the FDA and the manufacturer of the medication.

Providing services/procedures that are NOT MEDICALLY NECESSARY… and charging from them is INSURANCE FRAUD.

I suspect that most docs providing ESI’s are aware or should be aware of the potential problems and by sharing this information with them… will make them aware of the hazards to their pts and will make the monetary awards that much greater when a pt is harmed and they end up suing the doc… because the doc ignored the warnings.

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Coroner: 1-year-old died of drug overdose

http://www.fox19.com/story/36149619/coroner-1-year-old-died-of-drug-overdose

HAMILTON, OH (FOX19) –

A toddler died of a drug overdose, according to the Butler County Coroner’s Office.

The coroner’s report shows Dorrico Dawaun Brown Jr. died due to toxicity of a combination of drugs, including oxycodone. 

Officials said the 1-year-old’s father reportedly found the child not breathing, lying on a bed on May 17. 911 was called and the child was taken to Ft. Hamilton Hospital where he was pronounced dead.

“My son is just freezing cold and I don’t think he’s even breathing,” said the man who called 911. “He was taking a nap and I came in here and he’s just cold.” 

The dispatcher then gave instructions to the father on how to do CPR until rescue crews arrived.

The coroner said the manner of death could not be determined.

Wednesday, Dorrico Dawaun Brown was indicted by a grand jury on charges of endangering children and involuntary manslaughter. A warrant has been issued for his arrest.

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Energy drinks: A gateway to drug use?

http://www.medicalnewstoday.com/articles/318889.php

Energy drinks are an increasingly popular beverage among teenagers and young adults in the United States. According to the National Center for Complementary and Integrative Health, in the adult population, energy drink consumption is most common among males aged between 18 and 34.

The U.S. Food and Drug Administration (FDA) have not yet regulated energy drinks and are continuously researching their effects on health. Some adverse events owed to energy drink consumption reported by the FDA include flushing, headaches, abnormal heart rates, nausea, lethargy, loss of consciousness, and, in the most severe cases, death.

A new study led by Dr. Amelia Arria, from the Center on Young Adult Health and Development at the University of Maryland in College Park, has now uncovered strong links between the regular consumption of energy drinks among young adults and their risk of developing substance use disorders.

Dr. Arria and her colleagues conducted their study on a population of 1,099 young adults. The participants were recruited in their first year of college, at which point most of them were age 18, but the study itself was conducted when the participants were aged between 21 and 25 years.

The researchers’ findings were published in the journal Drug and Alcohol Dependence.

‘Energy drink users at risk of substance use’

Previous research published by Dr. Arria had already shown a correlation between energy drink consumption and alcohol dependence, as well as the use of nonmedical prescription stimulants (NPS), or illegal drugs.

However, this is the first cohort study to take into account potential correlations between energy drink consumption and substance use, differentiating between distinct patterns of energy drink ingestion.

These different patterns of energy drink consumption were referred to as “trajectories,” and the researchers identified four: “persistent trajectory,” “non-use trajectory,” “intermediate trajectory,” and “desisting trajectory.”

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The trajectory groups were defined according to how many energy drinks the participants were likely to have consumed year by year during the first 4 years of the study. The substance use outcomes at age 25 were then compared among the four groups.

Of all participants, 51.4 percent had a persistent trajectory of energy drink consumption, 20.6 percent were non-users, 17.4 percent had an intermediate trajectory, and 10.6 percent were desisting, or cutting down on energy drinks over time.

The researchers found that participants with a persistent trajectory of energy drink consumption were at a much higher risk of using NPS and stimulant drugs, and being diagnosed with an alcohol use disorder at age 25.

“The results suggest that energy drink users might be at heightened risk for other substance use, particularly stimulants,” says Dr. Arria.

Results remained consistent even after the researchers had controlled for possible confounding factors, such as demographic information, sensation-seeking intent, consumption of other caffeinated beverages, and substance use habits at age 21.

Participants who reported an intermediate level of energy drink consumption were also at a much higher risk of using cocaine and NPS, as well as developing alcohol use disorder, at age 25 than their peers with non-use and desisting trajectories.

Further research encouraged

The team acknowledges that the biological factors behind both frequent energy drink consumption and a predisposition for substance use remain unclear for the time being, but they insist that the correlation between those two behaviors warrants further research.

Dr. Arria argues that specialists should now aim to discover whether teenagers consuming energy drinks are at a similar risk of being diagnosed with a substance use disorder in adulthood. This danger may well be present; around one third of U.S. adolescents aged 12 to 17 drink this type of beverage.

“Future studies should focus on younger people, because we know that they too are regularly consuming energy drinks. We want to know whether or not adolescents are similarly at risk for future substance use.”

Dr. Amelia Arria

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Largest Ever Study on Marijuana Reveals Smoking It does not Damage the Lungs, Rather Improves It

http://anonhq.com/largest-ever-study-marijuana-reveals-smoking-not-damage-lungs-rather-improves/

We have said in the past, and still stand by it, that our goal is to promote medical use of marijuana, similar to the ones on CBD UK. We are not just an advocate of the plant just for smoking sake. We want people to benefit from it.

But across the world, there are many negative stereotypes and false mythologies about the plant. Especially in some countries in the global south; it is believed the mere smoking of marijuana irrespective of the quantity and the strength, can cause mental illness, the worst of it being madness.

However, over the years, as proponents of the plant gain momentum on its medical benefits, many researchers are using their own resources to conduct studies on the plant. Although research on the plant is still low, the little studies conducted are showing that some of the negative stereotypes against the plant aren’t true.

In the study we have come across on marijuana, it revealed that smoking the plant does not hurt the capacity of the lung, as previously suspected by medical experts. The study was conducted in 2012. It is said to be the largest ever study conducted on marijuana smoking. The study has been accepted in the Journal of the American Medical Association.

According to the study, even though most marijuana smokers tend to inhale deeply and hold the smoke in for as long as they can before exhaling, the lung capacity didn’t deteriorate, even among those who smoked a joint a day for seven years, or once a week for 20 years.

The study was conducted by researchers from the University of California, San Francisco, and University of Alabama at Birmingham, all in the United States.

The researchers said they knew tobacco smoking causes lung damage, leading to respiratory issues such as chronic obstructive pulmonary disease. However, they wanted to be clear whether smoking marijuana can also have similar effects as tobacco.

The researchers carried out their research by measuring lung function multiple times in more than 5,100 men and women during a 20-year period.

The data used in the study was from the Coronary Artery Risk Development in Young Adults. The researchers collected repeated measurements of lung function and smoking from March 1985 to August 2006. More than half of the participants, about 54%, said they were current marijuana smokers, cigarette smokers or both when the study began. The average marijuana use was only a joint or two a few times a month.

The researchers then calculated the effects of tobacco and marijuana separately, both in people who used only one or the other, and in people who used both. The researchers also considered other factors that could influence lung function, like air pollution in cities.

To know the healthiness of the lung of participants, the researchers measured how well participants could blow air in and out. It is said healthy adult can exhale about a gallon of air in one second.

Although the study focused on lighter smokers of marijuana and tobacco, the result showed that some participants who smoked more than a joint a day of marijuana for seven years could exhale even more than a gallon of air a second.

On the other hand, cigarette smokers struggled to exhale half a gallon, highlighting how cigarette smoking damages lung function, unlike marijuana smoking which has been shown to improve it. For those looking to quit smoking, you can find effective support at sites like https://heysnus.com/el.

However, the researchers warned that people should not simply take the findings of the study as a green light to smoke marijuana. They recommended that other factors should be considered before the plant is smoked.

“Marijuana is a complicated substance, and for people who are thinking about what they’ve done in the past or are thinking about using marijuana or believing it can help medically, their decision should not be based on lung consideration. It’s not a decision about lung health, it’s all the other issues: the risk of addiction, an increase in the chance of having accidents and social functioning,” co-author of the study, Dr Stefan Kertesz said. Dr Kertesz is also a researcher and primary care doctor at University of Alabama at Birmingham and the Birmingham Veterans Affairs Medical Center.

Dr Kertesz also added that the extra strength of the lung of marijuana smokers may come from the habit of deeply inhaling, holding and slowly exhaling the marijuana smoke. He said: “It’s a tiny increase; it’s not a big increase to lung health. So be careful not to say that, ‘Oh, wow! Lungs work better on marijuana.’ That would be totally inaccurate.”

Commenting on the study, Dr. Donald Tashkin, who has studied the relationship between marijuana smoking and lung function for more than 30 years as a professor of medicine at University of California Los Angeles said the study has confirmed what other research has also concluded on marijuana.

“This is a well-done study involving more subjects than in the past. The public should take away it’s a confirmatory study, but larger and longer than previous studies demonstrating, once again, that smoking marijuana does not impair lung function, unlike tobacco,” Dr Tashkin said.

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How much would you pay to live pain-free?

https://www.washingtonpost.com/news/wonk/wp/2017/08/07/how-much-would-you-pay-to-live-pain-free/

What’s the dollar value of pain? Or more accurately: What’s the value of getting rid of it or avoiding it completely?

That’s the question posed by a team of Icelandic and American economists in a working paper published this week by the National Bureau of Economic Research. It’s not just an academic inquiry — the opiate epidemic currently ravaging many U.S. communities owes much of its existence to the more aggressive stance toward pain that pharmaceutical companies, doctors and patients started adopting in the 1990s.

The question of “how did we arrive at a place where 60,000 people a year die from drug overdose,” in other words, is at least partly a question of “how far would we go to avoid pain?”

But if you’re an economist, answering that question is surprisingly difficult. You can’t simply flat-out ask people how much they’d pay to avoid pain. Most people aren’t used to thinking of their suffering in dollar terms. People who haven’t experienced severe or chronic pain are likely to underestimate the value of being pain-free. There’s often a gap between what people say on questions like these, and what they actually do.

So for this paper, the researchers used a technique that’s been used to study the implicit “cost” of a number of different ailments, like migraines, cancer and arthritis. They analyzed data from over 22,000 Americans over the age of 50 who had taken part in the Health and Retirement Study, a federally-funded survey of older Americans, between 2008 and 2014.

That survey asked respondents three key questions. First, how satisfied they were with their life overall. Second, how much money they made in the past year. And third and most crucially: “Are you often troubled with pain?”

Triangulating a dollar value for pain from these three variables requires some statistical jiu-jitsu. To heavily oversimplify it, you can use the three numbers to estimate how much money it would take for a person currently suffering pain to rise to the same level of overall life satisfaction as somebody not experiencing pain. Conversely, for a person not experiencing pain you can estimate how much money you’d have to take away for them to have the same life satisfaction as a pain-sufferer.

As the study’s authors put it, you get an implicit answer to this question without having to actually pose it to people: “Consider your overall satisfaction with life being often troubled by pain, what would you be willing to pay to be just as happy but without pain?”

The answer: between $56 and $145. A day. Which works out to between $20,000 and $53,000 a year. Recall that the median household income is about $56,000, and the trade-off becomes stark: Some people would theoretically be willing to give up their entire livelihoods to be pain-free.

These results control for a number of other factors that could presumably influence this trade-off, like marital status, age, race, and various health conditions. The authors nonetheless found that two considerations have a lot of influence on the numbers: pain severity (the more pain you’re in, the more you’d pay to make it stop) and overall income (if you have more money to burn, you’d pay more to get rid of pain).

Still, the overall well-being cost of pain is staggering, particularly when you stack it against the cost of products designed to make pain go away: prescription opiates. At current prices, according to drug price aggregator GoodRX, you can purchase a 120-pill supply of Oxycodone for about $20 (without insurance). That works out to a generous day’s supply of four pills for a total of 68 cents. Insurance coverage would drive the price down to practically zero. All you need is a doctor’s prescription.

Imagine you’re a rational pain-sufferer, willing to pay upwards of $100 a day to ease your suffering. Along comes a product that offers the promise of doing that for less than 1/100th of that price. What are you going to do?

This new study has limitations, of course. It focused exclusively on older Americans — the math might be different for young folks. The pain price estimates are just that — estimates, based on survey data that may be subject to its own forms of error.

But it nevertheless underscores the huge gap between what people appear to be willing to pay to get rid of pain and the actual price dealing with pain via opiate painkillers.

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First-in-the-Nation Program Offers Co-Payment Assistance For Medicine to Reverse Opioid Overdoses Beginning August 9, 2017

https://www.governor.ny.gov/news/governor-cuomo-announces-no-cost-or-lower-cost-naloxone-available-pharmacies-across-new-york

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