Florida Senate - 2013 COMMITTEE AMENDMENT
Bill No. CS for CS for SB 1192
Senate . House
Comm: RCS .
The Committee on Appropriations (Grimsley) recommended the
1 Senate Amendment (with title amendment)
3 Delete lines 58 - 223
4 and insert:
5 Section 1. Section 456.44, Florida Statutes, is amended to
7 456.44 Controlled substance prescribing.—
8 (1) DEFINITIONS.—
9 (a) “Addiction medicine specialist” means a board-certified
10 psychiatrist with a subspecialty certification in addiction
11 medicine or who is eligible for such subspecialty certification
12 in addiction medicine, an addiction medicine physician certified
13 or eligible for certification by the American Society of
14 Addiction Medicine, or an osteopathic physician who holds a
15 certificate of added qualification in Addiction Medicine through
16 the American Osteopathic Association.
17 (b) “Adverse incident” means any incident set forth in s.
18 458.351(4)(a)-(e) or s. 459.026(4)(a)-(e).
19 (c) “Board-certified pain management physician” means a
20 physician who possesses board certification in pain medicine by
21 the American Board of Pain Medicine, board certification by the
22 American Board of Interventional Pain Physicians, or board
23 certification or subcertification in pain management or pain
24 medicine by a specialty board recognized by the American
25 Association of Physician Specialists or the American Board of
26 Medical Specialties or an osteopathic physician who holds a
27 certificate in Pain Management by the American Osteopathic
29 (d) “Board eligible” means successful completion of an
30 anesthesia, physical medicine and rehabilitation, rheumatology,
31 or neurology residency program approved by the Accreditation
32 Council for Graduate Medical Education or the American
33 Osteopathic Association for a period of 6 years from successful
34 completion of such residency program.
35 (e) “Chronic nonmalignant pain” means pain unrelated to
36 cancer which persists beyond the usual course of disease or the
37 injury that is the cause of the pain or more than 90 days after
39 (f) “Mental health addiction facility” means a facility
40 licensed under chapter 394 or chapter 397.
41 (2) REGISTRATION.—
Effective January 1, 2012, A physician
42 licensed under chapter 458, chapter 459, chapter 461, or chapter
43 466 who prescribes more than a 30-day supply of any controlled
44 substance, listed in Schedule II, Schedule III, or Schedule IV
45 as defined in s. 893.03, over a 6-month period to any one
46 patient for the treatment of chronic nonmalignant pain, must:
47 (a) Designate himself or herself as a controlled substance
48 prescribing practitioner on the physician’s practitioner
50 (b) Comply with the requirements of this section and
51 applicable board rules.
52 (3) STANDARDS OF PRACTICE.—The standards of practice in
53 this section do not supersede the level of care, skill, and
54 treatment recognized in general law related to health care
56 (a) A complete medical history and a physical examination
57 must be conducted before beginning any treatment and must be
58 documented in the medical record. The exact components of the
59 physical examination shall be left to the judgment of the
60 clinician who is expected to perform a physical examination
61 proportionate to the diagnosis that justifies a treatment. The
62 medical record must, at a minimum, document the nature and
63 intensity of the pain, current and past treatments for pain,
64 underlying or coexisting diseases or conditions, the effect of
65 the pain on physical and psychological function, a review of
66 previous medical records, previous diagnostic studies, and
67 history of alcohol and substance abuse. The medical record shall
68 also document the presence of one or more recognized medical
69 indications for the use of a controlled substance. Each
70 registrant must develop a written plan for assessing each
71 patient’s risk of aberrant drug-related behavior, which may
72 include patient drug testing. Registrants must assess each
73 patient’s risk for aberrant drug-related behavior and monitor
74 that risk on an ongoing basis in accordance with the plan.
75 (b) Before or during a new patient’s visit for services for
76 the treatment of pain at a pain-management clinic registered
77 under s. 458.3265 or s. 459.0137, a physician shall consult the
78 prescription drug monitoring program database provided under s.
79 893.055(2)(a) before prescribing a controlled substance listed
80 in Schedule II or Schedule III in s. 893.03. The physician may
81 designate an agent under his or her supervision to consult the
82 database. The Board of Medicine under chapter 458 and the Board
83 of Osteopathic Medicine under chapter 459 shall adopt rules to
84 establish a penalty for a physician who does not comply with
85 this subsection.
86 (c) (b) Each registrant must develop a written
87 individualized treatment plan for each patient. The treatment
88 plan shall state objectives that will be used to determine
89 treatment success, such as pain relief and improved physical and
90 psychosocial function, and shall indicate if any further
91 diagnostic evaluations or other treatments are planned. After
92 treatment begins, the physician shall adjust drug therapy to the
93 individual medical needs of each patient. Other treatment
94 modalities, including a rehabilitation program, shall be
95 considered depending on the etiology of the pain and the extent
96 to which the pain is associated with physical and psychosocial
97 impairment. The interdisciplinary nature of the treatment plan
98 shall be documented.
99 (d) (c) The physician shall discuss the risks and benefits
100 of the use of controlled substances, including the risks of
101 abuse and addiction, as well as physical dependence and its
102 consequences, with the patient, persons designated by the
103 patient, or the patient’s surrogate or guardian if the patient
104 is incompetent. The physician shall use a written controlled
105 substance agreement between the physician and the patient
106 outlining the patient’s responsibilities, including, but not
107 limited to:
108 1. Number and frequency of controlled substance
109 prescriptions and refills.
110 2. Patient compliance and reasons for which drug therapy
111 may be discontinued, such as a violation of the agreement.
112 3. An agreement that controlled substances for the
113 treatment of chronic nonmalignant pain shall be prescribed by a
114 single treating physician unless otherwise authorized by the
115 treating physician and documented in the medical record.
116 (e) (d) The patient shall be seen by the physician at
117 regular intervals, not to exceed 3 months, to assess the
118 efficacy of treatment, ensure that controlled substance therapy
119 remains indicated, evaluate the patient’s progress toward
120 treatment objectives, consider adverse drug effects, and review
121 the etiology of the pain. Continuation or modification of
122 therapy shall depend on the physician’s evaluation of the
123 patient’s progress. If treatment goals are not being achieved,
124 despite medication adjustments, the physician shall reevaluate
125 the appropriateness of continued treatment. The physician shall
126 monitor patient compliance in medication usage, related
127 treatment plans, controlled substance agreements, and
128 indications of substance abuse or diversion at a minimum of 3
129 month intervals.
130 (f) (e) The physician shall refer the patient as necessary
131 for additional evaluation and treatment in order to achieve
132 treatment objectives. Special attention shall be given to those
133 patients who are at risk for misusing their medications and
134 those whose living arrangements pose a risk for medication
135 misuse or diversion. The management of pain in patients with a
136 history of substance abuse or with a comorbid psychiatric
137 disorder requires extra care, monitoring, and documentation and
138 requires consultation with or referral to an addiction medicine
139 specialist or psychiatrist.
140 (g) (f) A physician registered under this section must
141 maintain accurate, current, and complete records that are
142 accessible and readily available for review and comply with the
143 requirements of this section, the applicable practice act, and
144 applicable board rules. The medical records must include, but
145 are not limited to:
146 1. The complete medical history and a physical examination,
147 including history of drug abuse or dependence.
148 2. Diagnostic, therapeutic, and laboratory results.
149 3. Evaluations and consultations.
150 4. Treatment objectives.
151 5. Discussion of risks and benefits.
152 6. Treatments.
153 7. Medications, including date, type, dosage, and quantity
155 8. Instructions and agreements.
156 9. Periodic reviews.
157 10. Results of any drug testing.
158 11. A photocopy of the patient’s government-issued photo
160 12. If a written prescription for a controlled substance is
161 given to the patient, a duplicate of the prescription.
162 13. The physician’s full name presented in a legible
164 (h) (g) Patients with signs or symptoms of substance abuse
165 shall be immediately referred to a board-certified pain
166 management physician, an addiction medicine specialist, or a
167 mental health addiction facility as it pertains to drug abuse or
168 addiction unless the physician is board-certified or board
169 eligible in pain management. Throughout the period of time
170 before receiving the consultant’s report, a prescribing
171 physician shall clearly and completely document medical
172 justification for continued treatment with controlled substances
173 and those steps taken to ensure medically appropriate use of
174 controlled substances by the patient. Upon receipt of the
175 consultant’s written report, the prescribing physician shall
176 incorporate the consultant’s recommendations for continuing,
177 modifying, or discontinuing controlled substance therapy. The
178 resulting changes in treatment shall be specifically documented
179 in the patient’s medical record. Evidence or behavioral
180 indications of diversion shall be followed by discontinuation of
181 controlled substance therapy, and the patient shall be
182 discharged, and all results of testing and actions taken by the
183 physician shall be documented in the patient’s medical record.
185 This section subsection does not apply to a board-eligible or
186 board-certified anesthesiologist, physiatrist, rheumatologist,
187 or neurologist, or to a board-certified physician who has
188 surgical privileges at a hospital or ambulatory surgery center
189 and primarily provides surgical services. This section
190 subsection does not apply to a board-eligible or board-certified
191 medical specialist who has also completed a fellowship in pain
192 medicine approved by the Accreditation Council for Graduate
193 Medical Education or the American Osteopathic Association, or
194 who is board eligible or board certified in pain medicine by the
195 American Board of Pain Medicine or a board approved by the
196 American Board of Medical Specialties or the American
197 Osteopathic Association and performs interventional pain
198 procedures of the type routinely billed using surgical codes.
199 This section subsection does not apply to a physician who
200 prescribes medically necessary controlled substances for a
201 patient during an inpatient stay in a hospital licensed under
202 chapter 395 or to a resident in a facility licensed under part
203 II of chapter 400. This section does not apply to a physician
204 licensed under chapter 458 or chapter 459 who writes fewer than
205 50 prescriptions for a controlled substance for all of his or
206 her patients during a 1-year period.
208 ================= T I T L E A M E N D M E N T ================
209 And the title is amended as follows:
210 Delete line 8
211 and insert:
212 substances; authorizing the the Board of Medicine and
213 the Board of Osteopathic Medicine to adopt