Indiana’s new opioid prescribing rule went into effect Nov. 6, 2014. (See the previous article here.) As a reminder, tramadol (trade names include Ultram® and Ultracet®) is not yet addressed by the rule. Although tramadol became a federally scheduled drug on Aug. 18, 2014, the prescribing rule specifically states that tramadol has to be classified as a controlled substance under Indiana law before it will fall under the rule.
At present, Indiana law does not specifically classify tramadol as a controlled substance. So, the tramadol threshold in the rule does not currently have to be followed for purposes of compliance with the rule.
“Although doctors always have to comply with both state and federal law and be mindful of the standard of care in all prescribing, this rule is one of those rare instances where the federal law doesn’t automatically trump state law,” said Julie Reed, ISMA general counsel.
A bill to schedule tramadol has been introduced again in the Indiana General Assembly (HB 1184). Passage would make tramadol a schedule IV controlled substance under Indiana law and thus place it within the scope of the new opioid prescribing rule. If passed, the law would become effective immediately upon passage, which could occur as early as April.
If tramadol becomes scheduled as a controlled substance by Indiana, the new prescribing rule will apply to tramadol when a patient reaches a 60 mg. morphine equivalent dose (MED) of tramadol per day. At the urging of the ISMA during the rulemaking process, those thresholds were raised from the original proposed number of 15 mg. MED.
“We are aware that the morphine equivalent conversions have been challenging to determine since the Medical Licensing Board of Indiana declined requests to adopt a conversion table and some conversion charts do not include tramadol,” noted Reed.
At the ISMA’s request, the publisher of one of the morphine equivalent conversion websites agreed to add tramadol. That website is here. The ISMA is not permitted to publish information from that website or interpret its results.
Other conversion references are available and can be used. The rule merely requires the use of “accepted conversion tables.” The ISMA does not endorse any particular publisher, table or figures, and the publication of the above website should not be viewed as an endorsement.
NOTE: Tramadol became a Schedule IV controlled substance in Indiana as of 04/23/15 (HB 1184).