New state laws let patients refuse opioid prescriptions

Four states have passed laws allowing patients to insert directives into their medical records saying they refuse their physicians’ prescriptions for opioids. But not all experts are convinced that such laws are needed.

Last year, a rule known as the voluntary non-opioid directive was included as part of Massachusetts Gov. Charlie Baker’s opioid legislation. A copy of the directive goes into the patient’s medical record and requires any treating physician to follow the non-prescribing instructions even if the patient is incapacitated, says James Gessner, MD, a past president of the Massachusetts Medical Society. It can be withdrawn only if a patient’s healthcare proxy is present or is otherwise available to medical personnel on site, he adds. 

Three other states-Alaska, Connecticut, and Pennsylvania-enacted legislation allowing the creation of voluntary non-opioid directives last year.

Directives such as these encourage discussions between physicians and patients about the risks of opioids and promote education about inappropriate use of such medications, Gessner says. By reducing the number of opioid prescriptions physicians write, the directives could limit the diversion of drugs, which occurs when people other than patients acquire these medications. Diversion is a key driver of the opioid crisis, he adds.

The Massachusetts law also called for educating medical students and doctors on how to prevent opioid abuse and establishing a seven-day limit on first-time opioid prescriptions. 

“This directive allows patients to sign a form saying they can refuse and they want to refuse any opioid prescription,” Gessner says. By promoting the kinds of conversations physicians should have with patients, the directive fosters shared medical decision making, and thus enhances the patient-physician relationship, says Gessner, an anesthesiologist. 

But David J. Tauben, MD, chief of pain medicine and director of medical student education in pain medicine at the University of Washington, says such laws are unneeded and burdensome for physicians. 

Most patients already refuse opioids because about 80% of them will stop taking the medications after a single dose due to unpleasant side effects, Tauben says. Moreover, many physicians welcome patients’ requests not to prescribe opioids, because some states make prescribing difficult by requiring physicians to comply with prescription monitoring programs and complete forms that state officials collect and review, he says. 

Silvia S. Martins, MD, Ph.D., a researcher specializing in addiction treatment at Columbia University, says such laws may be needed because some patients feel powerless to speak up when a physician recommends a treatment, even one the patient may fear is detrimental. 

“Without laws like this, a patient might want to decline but some doctors will say, ‘This is the best treatment for you,’” she says. 

Martins thinks that physicians and patients need more education.  “Sometimes, particularly in primary care, physicians will resort to opioids because of a lack of training about alternative medications,” she says. 

Joseph Burns is an journalist in Falmouth, Massachusetts. Do you think this bill would help your patients? Tell us at medec@ubm.com.