Dear NVOS Members,
I hope you recall that, at the Governor’s request, the 2017 Legislature passed AB 474. (See page 17 of our NVOS End of 2017 Session Report; the link to the bill is live.) This bill is designed to help curb the opioid misuse and abuse epidemic; details are outlined in the report. Note that the bill was effective upon the Governor’s signature for the purpose of promulgating regulations; all other provisions – including many that will impact your daily interactions with your patients and your practice protocols– are effective on January 1, 2018.
PLEASE INCLUDE YOUR PRACTICE ADMINISTRATORS IN A REVIEW OF THIS BILL, SPECIFICALLY SECTIONS 51- 58; this is where you will find the steps that you must take and document in the patient record.
Progress in preparing for implementation:
The Governor’s office worked closely with organized medicine throughout the development of this legislation to assure that the bill is both practical and implementable. They were also very cognizant of our repeated requests not to interfere with the doctor-patient relationship.
In late June, the Governor’s chief health policy advisor, Elyse Monroy, called a meeting of the medical licensing boards and several of the specialty societies to talk about educating physicians and other prescribers about the requirements of the bill. We attended, along with the boards from Pharmacy, Nursing, NBME, and the Board of Osteopathic Medicine.
- Because each of the boards will issue its own regulations – but Pharmacy’s regulations will impact all prescribers — the boards agreed to coordinate; their legal counsel will meet collectively and work through overlapping issues. Specifically, Pharmacy is responsible to outline processes for generating the PDMP reports that will go to the licensing boards to alert them about potential overprescribing by physicians. The licensing boards will each determine their own processes for dealing with infractions.
- Based on the bill, licensing boards will no longer need to wait for a formal complaint against a physician before taking action about potential overprescribing; if the prescriber appears to be an “outlier”, the board will be in contact to ask for details. There will, of course, be variables for oncology and palliative care, as well as for pain management.
- If there is an actual infraction, Pharmacy may pull a DEA license AFTER the prescriber’s licensing board has taken action.
- There will be refinements to the PDMP, which can already track patients who are doctor shopping. New processes will allow the PDMP to review a physician’s prescribing pattern per patient.
- Each prescriber will be required to take 2 hours of CME within your licensure renewal cycle, up from the current 1 hour requirement.
- Prescriptions must include the ICD-10 code; your DEA number; and the number of days for which the prescription is written, if the patient consumes the maximum dosage as prescribed.
The boards are collaborating to develop a white paper to educate all prescribers, which will hopefully be released by the end of August. The document will includes sample forms and checklists that you can use as templates to satisfy the requirements of the bill.
DHHS staff assumed responsibility for putting together a group to work on the patient risk assessments that can be used to satisfy the provisions of the bill. This effort will be coordinated with the licensing board so physicians input is included. They are also working with the University of Nevada School of Medicine to develop a CME course that can be offered statewide.
Eventually, all this info needs to make its way into your EMRs, so the checklists and protocols are easily accessible and documentable. Since Pharmacy has relationships with the EMR vendors, they will coordinate data collection with their vendor.
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The information below arrived Monday from the AAOS; as you can readily see, Nevada is one of many states grappling with the opioid epidemic. I am pleased to say that NVOS was at the table during numerous discussion throughout 2016 and that we often cited the AAOS information statement mentioned below as a guide to informing policy.
State Governments, Orthopaedic Societies Respond to Opioid Epidemic
Though many benefit from opioid medications, abuse of prescription opioids is a serious problem, causing nearly 50 deaths a day and thousands of emergency room visits a year. In context, the number of emergencies related to nonmedical use of opioids increased 183% from 2004 to 2011. State governments have responded to this crisis in different ways, with nearly 80 laws passed in 2015-2016. Many of these laws, according to a study published in Practical Pain Management, have resulted “in an increasing proportion of legitimate chronic pain patients unable to fill their prescriptions.”
State laws with specific-mandates that impact orthopaedic surgeons generally fit within three large buckets: continuing medical education (CME) requirements, querying prescription drug monitoring programs, and quantitative limits to prescriptions.
Currently, 15 states have CME requirements for opioid prescribers. Though many of these laws vary, with some impacting only pain management clinics, many impact AAOS members. For instance, the New York law requires prescribers who hold a DEA license to take a three hour course on pain management, palliative care and addiction. The New York State Orthopaedic Society has responded to this mandate by creating a webpage at http://www.nyssos.org/education/pmc.html. The information page helps navigate the requirement for orthopaedic surgeons and steers members towards online modules created by the Boston University School of Medicine Safe and Competent Opioid Prescribing Education (SCOPE) and the New York Chapter American College of Physicians to meet requirements.
At least 26 states have some form of mandatory querying of prescription drug monitoring programs (PDMP) before prescribing an opioid. PDMPs are state electronic databases that track prescriptions of controlled substances, including opioids. These requirements significantly vary by state; Some states require prescribers to check the PDMP before writing the majority of opioid prescriptions; Others mandate checking the PDMP only for certain providers or under certain circumstances, such as when a provider has a reasonable belief of inappropriate use or if the prescription is for chronic pain. Recently, the Texas Orthoapedic Society has created a page for orthopaedic surgeons to advocate for proven, patient-centered solutions at http://www.stateortho.com/txpdmp/. According to the grassroots page, “TOA has indicated to lawmakers that the PDMP is an appropriate tool that physicians will utilize when it is necessary. However, as TOA has pointed out to lawmakers in a recent hearing, ‘doctor shoppers’ are not going to have a knee replacement surgery or purposely break their arm to access prescription drugs.” The TOA is advocating for policies that utilize data from PDMPs to flag “doctor shoppers” — the practice of visiting numerous physicians to obtain several prescriptions for prescription drugs.
Quantitative limits to opioid prescriptions are becoming a popular solution for politicians desperately seeking answers to the opioid epidemic. With little scientific research on limiting opioid prescriptions to certain-day supplies actually working, state medical societies have sought to mediate a popular idea’s impact to the patient-physician relationship. The Ohio State Medical Association in March 2017 worked with their governor, John Kasich, to announce new rules that will create prescription limits of up to seven days of painkillers for adults and five days for kids and teens with limits only applying to acute pain patients, with exceptions for cancer, hospice or medication-assisted addiction patients. Prescribers in Ohio can override the limits if they provide a specific reason in the patient’s medical record.
In February, New Jersey Governor Chris Christie signed a bill into law that sets a five-day limit on initial prescriptions for pain-killing opioids with little exemptions. Christie declared the law, “the toughest in the country in the fight against heroin and opioid addiction.” Though Governor Christie says, “we are taking action to save lives,” his administration gave little proof of the efficacy of the law while patient groups decried the potentially dangerous approach. The physicians of New Jersey nearly unanimously called the law “cruel” to patients and opposed the “one-size fit all” approach.
Last year, the National Governors Association (NGA) secured 46 Governors (including Gov Sandoval) in a Compact to Fight Opioid Addiction. To address the growing heroin and opioid situation, the NGA Center for Best Practices developed a road map to help states prevent, respond and treat opioid misuse as well as strengthen law enforcement efforts to address illegal supply chain activity. According to the NGA, “It is designed as a policy development tool, allowing a state to use all or portions of the road map as it applies to their unique situation.” The Compact says that, “Although there has been progress in recent years, inappropriate opioid prescribing continues to fuel one of the deadliest drug epidemics in our nation’s history… [The Compact] sends a clear signal to opioid prescribers and others whose leadership is critical to saving lives.” The compact has three distinctive portions. First, to reduce inappropriate opioid prescribing. Second, changing the public’s understanding of opioids and addiction. Last, creating pathways to recovery for individuals with addictions.
In November 2015, the American Academy of Orthopaedic Surgeons released an information statement titled “Opioid Use, Misuse, and Abuse in Orthopaedic Practice.” The document said, in part, “The AAOS believes that a comprehensive opioid program is necessary to decrease opioid use, misuse, and abuse in the United States. New, effective education programs for physicians, caregivers, and patients; improvements in physician monitoring of opioid prescription use; increased research funding for effective alternative pain management and coping strategies; and support for more effective opioid abuse treatment programs are needed.” To read the statement, visit: http://www.aaos.org/uploadedFiles/PreProduction/About/Opinion_Statements/advistmt/1045%20Opioid%20Use,%20Misuse,%20and%20Abuse%20in%20Practice.pdf
To highlight the potential dangers of opioids, the AAOS created a multimedia public service campaign that was released at the 2017 Annual Meeting. The campaign includes display and radio ads, urging doctors and patients to exercise caution in prescribing and taking opioids. Visit for more information http://orthoInfo.org/PrescriptionSafety.
Despite legislative and other efforts to stem the tide of opioid abuse, the crisis still affects many Americans. The National Safety Council provides toolkits and resources for addressing substance abuse in the home and workplace. To learn more, visit: http://safety.nsc.org/rxemployerkit
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There will be much more information to share in the coming weeks and months, but your government affairs team wanted to make sure that this issue is high on your radar screens NOW.
Cordailly, Kathleen |