Florida Senate - 2013                        COMMITTEE AMENDMENT
       Bill No. CS for CS for SB 1192
                                Barcode 978416                          
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                  Comm: RCS            .                                
                  04/23/2013           .                                

       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
    6  read:
    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
   28  Association.
   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
   38  surgery.
   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
   49  profile.
   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
   55  licensure.
   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
  154  prescribed.
  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
  159  identification.
  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
  163  manner.
  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