Florida Senate - 2015                          SENATOR AMENDMENT
       Bill No. CS for SB 816
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                 Floor: NC/2R          .                                
             04/23/2015 10:50 AM       .                                

       Senator Bradley moved the following:
    1         Senate Amendment (with title amendment)
    3         Between lines 85 and 86
    4  insert:
    5         Section 3. Subsection (3) of section 456.44, Florida
    6  Statutes, is amended to read:
    7         456.44 Controlled substance prescribing.—
    8         (3) STANDARDS OF PRACTICE.—The standards of practice in
    9  this section do not supersede the level of care, skill, and
   10  treatment recognized in general law related to health care
   11  licensure.
   12         (a) A complete medical history and a physical examination
   13  must be conducted before beginning any treatment and must be
   14  documented in the medical record. The exact components of the
   15  physical examination shall be left to the judgment of the
   16  clinician who is expected to perform a physical examination
   17  proportionate to the diagnosis that justifies a treatment. The
   18  medical record must, at a minimum, document the nature and
   19  intensity of the pain, current and past treatments for pain,
   20  underlying or coexisting diseases or conditions, the effect of
   21  the pain on physical and psychological function, a review of
   22  previous medical records, previous diagnostic studies, and
   23  history of alcohol and substance abuse. The medical record shall
   24  also document the presence of one or more recognized medical
   25  indications for the use of a controlled substance. Each
   26  registrant must develop a written plan for assessing each
   27  patient’s risk of aberrant drug-related behavior, which may
   28  include patient drug testing. Registrants must assess each
   29  patient’s risk for aberrant drug-related behavior and monitor
   30  that risk on an ongoing basis in accordance with the plan.
   31         (b) Each registrant must develop a written individualized
   32  treatment plan for each patient. The treatment plan shall state
   33  objectives that will be used to determine treatment success,
   34  such as pain relief and improved physical and psychosocial
   35  function, and shall indicate if any further diagnostic
   36  evaluations or other treatments are planned. After treatment
   37  begins, the physician shall adjust drug therapy to the
   38  individual medical needs of each patient. Other treatment
   39  modalities, including a rehabilitation program, shall be
   40  considered depending on the etiology of the pain and the extent
   41  to which the pain is associated with physical and psychosocial
   42  impairment. The interdisciplinary nature of the treatment plan
   43  shall be documented.
   44         (c) The physician shall discuss the risks and benefits of
   45  the use of controlled substances, including the risks of abuse
   46  and addiction, as well as physical dependence and its
   47  consequences, with the patient, persons designated by the
   48  patient, or the patient’s surrogate or guardian if the patient
   49  is incompetent. The physician shall use a written controlled
   50  substance agreement between the physician and the patient
   51  outlining the patient’s responsibilities, including, but not
   52  limited to:
   53         1. Number and frequency of controlled substance
   54  prescriptions and refills.
   55         2. Patient compliance and reasons for which drug therapy
   56  may be discontinued, such as a violation of the agreement.
   57         3. An agreement that controlled substances for the
   58  treatment of chronic nonmalignant pain shall be prescribed by a
   59  single treating physician unless otherwise authorized by the
   60  treating physician and documented in the medical record.
   61         (d) The patient shall be seen by the physician at regular
   62  intervals, not to exceed 3 months, to assess the efficacy of
   63  treatment, ensure that controlled substance therapy remains
   64  indicated, evaluate the patient’s progress toward treatment
   65  objectives, consider adverse drug effects, and review the
   66  etiology of the pain. Continuation or modification of therapy
   67  shall depend on the physician’s evaluation of the patient’s
   68  progress. If treatment goals are not being achieved, despite
   69  medication adjustments, the physician shall reevaluate the
   70  appropriateness of continued treatment. The physician shall
   71  monitor patient compliance in medication usage, related
   72  treatment plans, controlled substance agreements, and
   73  indications of substance abuse or diversion at a minimum of 3
   74  month intervals.
   75         (e) The physician shall refer the patient as necessary for
   76  additional evaluation and treatment in order to achieve
   77  treatment objectives. Special attention shall be given to those
   78  patients who are at risk for misusing their medications and
   79  those whose living arrangements pose a risk for medication
   80  misuse or diversion. The management of pain in patients with a
   81  history of substance abuse or with a comorbid psychiatric
   82  disorder requires extra care, monitoring, and documentation and
   83  requires consultation with or referral to an addiction medicine
   84  specialist or psychiatrist.
   85         (f) A physician registered under this section must maintain
   86  accurate, current, and complete records that are accessible and
   87  readily available for review and comply with the requirements of
   88  this section, the applicable practice act, and applicable board
   89  rules. The medical records must include, but are not limited to:
   90         1. The complete medical history and a physical examination,
   91  including history of drug abuse or dependence.
   92         2. Diagnostic, therapeutic, and laboratory results.
   93         3. Evaluations and consultations.
   94         4. Treatment objectives.
   95         5. Discussion of risks and benefits.
   96         6. Treatments.
   97         7. Medications, including date, type, dosage, and quantity
   98  prescribed.
   99         8. Instructions and agreements.
  100         9. Periodic reviews.
  101         10. Results of any drug testing.
  102         11. A photocopy of the patient’s government-issued photo
  103  identification.
  104         12. If a written prescription for a controlled substance is
  105  given to the patient, a duplicate of the prescription.
  106         13. The physician’s full name presented in a legible
  107  manner.
  108         (g) Patients with signs or symptoms of substance abuse
  109  shall be immediately referred to a board-certified pain
  110  management physician, an addiction medicine specialist, or a
  111  mental health addiction facility as it pertains to drug abuse or
  112  addiction unless the physician is board-certified or board
  113  eligible in pain management. Throughout the period of time
  114  before receiving the consultant’s report, a prescribing
  115  physician shall clearly and completely document medical
  116  justification for continued treatment with controlled substances
  117  and those steps taken to ensure medically appropriate use of
  118  controlled substances by the patient. Upon receipt of the
  119  consultant’s written report, the prescribing physician shall
  120  incorporate the consultant’s recommendations for continuing,
  121  modifying, or discontinuing controlled substance therapy. The
  122  resulting changes in treatment shall be specifically documented
  123  in the patient’s medical record. Evidence or behavioral
  124  indications of diversion shall be followed by discontinuation of
  125  controlled substance therapy, and the patient shall be
  126  discharged, and all results of testing and actions taken by the
  127  physician shall be documented in the patient’s medical record.
  129  This subsection does not apply to a board-eligible or board
  130  certified anesthesiologist, physiatrist, rheumatologist, or
  131  neurologist, or to a board-certified physician who has surgical
  132  privileges at a hospital or ambulatory surgery center and
  133  primarily provides surgical services. This subsection does not
  134  apply to a board-eligible or board-certified medical specialist
  135  who has also completed a fellowship in pain medicine approved by
  136  the Accreditation Council for Graduate Medical Education or the
  137  American Osteopathic Association, or who is board eligible or
  138  board certified in pain medicine by the American Board of Pain
  139  Medicine or a board approved by the American Board of Medical
  140  Specialties or the American Osteopathic Association and performs
  141  interventional pain procedures of the type routinely billed
  142  using surgical codes. This subsection does not apply to a
  143  physician who prescribes medically necessary controlled
  144  substances for a patient during an inpatient stay in a hospital
  145  licensed under chapter 395 or for a resident in a facility
  146  licensed under part II of chapter 400.
  148  ================= T I T L E  A M E N D M E N T ================
  149  And the title is amended as follows:
  150         Delete line 15
  151  and insert:
  152         the review; amending s. 456.44, F.S.; revising the
  153         application of provisions specifying requirements for
  154         standards of practice for certain controlled substance
  155         prescribing; providing an effective date.