Not just this area, in case you haven’t heard it is a nationwide problem and frankly the US is about the only place it is happening in the world.
New practice guidelines were instituted regarding the use of opiods and particularly
Bupreophine on March 14, 2017 and again updated April 17, 2017, and again May 3, 2017 that apply specifically to their use for non malignant or acute pain situations. While these regulations apply most specifically to prescribing physicians, they have a strong effect on Formularies. there are lot of states whose “laws” are changing. But irregardless of what a states law may be individual states practice guidelines (the rules doctors have to abide by) almost always are ahead of state law as a majority of states still operate on biennium or annual legislative process. Title 21 Code of Federal Regulations > Part 1306 > 1306.07 has detoxification dispensing under clinical supervision only since 2005. For example the cardiologist requirement for non malignant pain is a practice requirement, while it may not in every case be legislative requirement the physician can and is (finally) liable both civilly and criminally if something goes wrong and it is only going to get stricter as practice guidelines are the standard. The idea is simply that doctors regulate doctors better than state legislators.
The standard for dispensing methadone to a terminal cancer patient for example is different than acute pain or chronic pain. Thus the cardiologist for chronic pain patients. The feds say “shall require each patient to undergo a complete, fully documented physical evaluation by a program physician or a primary care physician, or an authorized healthcare professional under the supervision of a program physician” Under CFR 8.12, How that happens is determine by a state medical board’s practice guidleines and that for chronic pain now in 47 (soon to be 50 states) happens to include a cardiology consult.
The reason is prolonged QT interval preclude methadone use because patients die at an alarming rate using methadone if it is. But it isn’t a simple matter of looking at at ekg and determining the if the QT is within normal values for the QT interval which are between 0.30 and 0.44 (0.45 for women) seconds. Prolonged QT interval has been defined as > 450 milliseconds for men and > 460 – 470 milliseconds for women.
Obviously ones heart rate has bearing so the QT interval generally is corrected for its dependence on heart rate using Bazett’s formula:30 QTc = QT interval (in milliseconds) divided by the square root of the preceding RR interval (in seconds). But its not the only way of doing it (or the best) Nor is it it the only consideration for heart problems.
If you are interested about the physiology of al this: the problem is the causation of the prolonged QT interval involves the human ether-a-go-go-related gene (hERG) and the subunit of the voltage-gated potassium channels (found predominantly in the myocardium) for which it encodes. These channels are the predominant facilitators of the delayed-rectifier potassium ion currents, which cause repolarization. Abnormalities in these channels have been shown to lead to prolonged action potentials that are expressed as long QT intervals on the electrocardiogram. The health risks associated with a prolonged QT interval are not clear. Although individuals with a prolonged QT interval often usually asymptomatic, some may develop palpitations, syncope, seizures, or cardiac arrest. when sodium channel blockers are introduced.
Anesthetics are one of them (thus the required pre-op ekg) as are anti-seizure medicines often used for TN but the most potent of all are narcotics and especially methadone (its why all addicts and regular users of narcotic medications eventually die) QT interval prolongation can also lead to the potentially fatal reentrant arrhythmia known as Torsades de Pointes when potassium channel blockers are intoduced. Again its not a big deal for a cancer patient who’s going to die anyway, but important to those who aren’t.
The implementation of “First Fill” regulations under AB 1124 Drug Formulary regs that took effect In July of this year has closed up some of the sizable loop holes state agencies and Insurance company formularies operated under (soley to save money,) that were outside the intent practice guidelines (but within the "legal requirements.) Sure with a legal prescription all meds are available to all people all of the time, but Pharmacies are now held accountable to make sure they are legal prescriptions.
First fill requirements met and do meet the compassionate reasons. Obviously all the medical stuff takes time, so basically what has happened is for these scheduled meds, a 7 day prescription can be filled with little difficulty. subsequent prescriptions however have to meet all the rules.
TJ