Recommending Repeal

HB 333, the three-day supply bill, targets the wrong person

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In an effort to curb the nation’s opioid crisis, US state legislators have recently passed a series of laws to limit the prescribing of such medications. State officials promote these laws as a way to prevent “overly generous” prescribing that might lead to opioid or heroin addiction. The Kentucky version of this law is HB 333, which was passed by our legislators on March 30, 2017 and signed by Gov. Matt Bevin on April 10, 2017. HB 333 limits the prescribing of Schedule II drugs to a three-day supply if intended to treat pain as an acute medical condition. Schedule II pain relief drugs include oxycodone, hydrocodone, and fentanyl. Fortunately, the limitation is subject to certain exceptions, such as if the practitioner believes that more than a three-day supply is medically necessary, the prescription is for chronic rather than acute pain, or pain associated with a cancer diagnosis, hospice, or end-of-life treatment, the drug is dispensed in an in-house setting, or the prescription is for pain following major surgery or trauma.

However, HB 333 will not minimize the ongoing opioid epidemic in our Commonwealth. Meara and colleagues provide the relevant empirical evidence in an article titled “State Legal Restrictions and Prescription-Opioid Use among Disabled Adults” published in the July 07, 2016 edition of The New England Journal of Medicine. The investigators evaluated the associations between negative opioid outcomes and state controlled substances laws. Using Medicare administrative data for fee-for-service persons 21–64 years of age in states that added 81 controlled substance laws (including laws similar to HB 333) from 2006–2012, they concluded that state laws restricting the prescribing and dispensing of controlled substances ARE NOT associated with reductions in potentially hazardous use of opioids or overdose.

In addition, HB 333 will hurt a number of our patients with acute pain. A three-day pain medicine prescription limit is not sufficient for all acute pain patients, a scientific fact acknowledged by the Centers for Disease Control (CDC). In an article titled “CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016” published in the March 18, 2016 edition of Morbidity and Mortality Weekly Report (MMWR), Dowell and colleagues note that “… because some types of acute pain might require more than 3 days of opioid treatment, it would be appropriate to recommend a range of <= 3–5 days or <= 3–7 days when opioids are needed.”

Finally, HB 333 targets the wrong people, for the long-term use of opioids after initial opioid treatment for acute pain is associated with only a 0.27 percent risk of opioid addiction.
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For all these reasons, Kentucky HB 333 should be immediately repealed and replaced by a bill that WILL decrease the impact of the opioid epidemic in the Commonwealth. Passage of a law that eliminates criminal sanctions for the medical use of cannabis is the ideal replacement for HB 333, for it would lead to an approximately 11 percent decrease in the annual number of daily opioid doses prescribed per physician
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, an approximately 25 percent lower average opioid overdose death rate
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, and decreased use of opiates and alcohol
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The Alliance for Innovative Medicine (AIM) is a nonprofit 501c(4) organization for physicians (and other professionals) fighting for the legalization of medical cannabis in Kentucky. For the past year, Founder and Executive Director Shannon Stacy has been actively advising Kentucky legislators about the risks and benefits of various medical cannabis-related legislative proposals. Recently, we have added an expert in cannabis legislation to our board, who has worked on dozens of pieces of legislation around the nation. In addition, AIM has been aggressively working to build our professional base of support. Our next educational event is a September 29, 2017 seminar that we are co-sponsoring with the Kentucky Nurses Association titled “The Endocannabinoid System and Cannabis: What Nurses Need to Know.” Nurses who attend this event at the Holiday Inn Louisville East – Hurstbourne will earn 6.6 contact hours and gain invaluable knowledge about the scientific rationale for medical cannabis. Anyone interested, inside or outside of the healthcare profession, may register to attend but will not receive contact hours. Registration and additional information can be accessed at www.kentucky-nurses.org. Join the movement!

1 Noble et al., “Long-term opioid management for chronic noncancer patients,” Cochrane Database of Systemic Reviews 2010, Issue 1.

2 Bradford, A. and Bradford W., “Medical Marijuana Laws Reduce Prescription Medication Use in Medicare Part D,” Health Affairs 35, 2016: 1230–1236.

3 Bachhuber, M. et al., “Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999–2010,” JAMA Internal Medicine 174(10), 2014: 1668–1673.

4 Lucas, P. et al., “Cannabis as a Substitute for Alcohol and Other Drugs: A Dispensary-Based Survey of Substitution Effect in Canadian Medical Cannabis Patients,” Addiction Research and Theory 21(5), 2013: 435–442.

Don Stacy, MD, dABR, cBioethics, is a physician-activist. He practices radiation oncology in Louisville and Indiana. He can be reached at 606.369.4246. AIM Executive Director Shannon Stacy, RN, can be contacted at director@aimky.org or 502.991.2713.