Dr. Leslie Greenberg's Blog

Nevada has instituted a new controlled substance law for prescribers to follow…. or else!

I recently attended a 2-hour evening session informing me of the details of the new Nevada AB474, Nevada’s opioid prescribing law.  Unless your head has been in the sand, you must know that there is an opioid crisis.  Nevada’s government has decided that to decrease the abuse, they should make the prescribing cumbersome and onerous.  I have had patients ask me for a benzodiazepine to take before a flight.  This now requires an online data search of the patient’s PMP, risk factors, alternatives, evaluation, and a signed informed consent form.  I took notes at my meeting and have included them below…

AB474. This is the Nevada law that was enacted January 1, 2018 and it has turned controlled substance prescribing on its head.

Here are the following requirements…

Controlled prescriptions needs to have four components written on the prescription.

1. Patient date of birth,
2. Patient diagnosis with specific ICD10 code
3. Lowest number of days the medication is intended for,
4. Prescriber’s name and DEA number

As a physician, we are required to have 2 hours of continuing medical education per year specifically about opioid prescribing.  This evening met that requirement for this year.  Hooray!

The office note needs to document the following.

1. The patient needs to be a “bonafide” (meaning you’ve seen them in the last 6 months) patient of the prescriber.
2. The physician is expected to consider alternatives to the controlled substances.
3. Patient’s previous medical records need to be obtained. Good faith is a reasonable standard meaning the patient has signed consent for records to be transferred.

“Informed consent” form needs to be obtained from the patient.  The informed consent must contain

1. potential risks  and benefits of controlled substance treatment
2. Proper use of controlled substance
3. Alternative treatments instead of controlled substances
4. Provisions of the treatment plan
5. Risks of dependence, addiction, overdose during treatment
6. Methods to safely store and legally dispose of controlled substance
7. How refill requests will be addressed
8. Risks to fetus (for women of childbearing age) and availability of antagonist of substance for overdoses
9. If a minor, the risks of abuse, misuse and ways to detect.

How many days of medication can be prescribed for the first prescription?  14 day maximum for pain relief.  Some pharmacies only fill 7 days worth of pain medicine (this is the rule of those specific pharmacies).

Risk factors.  There are 16 risk factors to review with each patient before a prescription is written.

1. Any other drugs illicit being used?
2. Is the patient using prescription inappropriately?
3. Is patient suspected of diverting prescription?
4. PMP (Prescription Monitoring Program—a patient-specific online database of controlled substance use) indicates regular (and not excessive) behavior
5. “Irregular” blood or urine screen
6. Test negative for drugs that should be present.
7. Current prescription ineffective
8. Patient using drugs or alcohol
9. # of patient’s refill requests?
10. # of patient claims prescription lost/stolen?
11. Patient has strange behavior or intoxication
12. Patient reluctant to reduce or stop prescription
13. Patient change in physician health
14. Does the physician suspect chronic-use opioids, abuse, illegal drug use or diversion suspected?
15. Patient not cooperative with exam, analysis or text?
16. Patient increased dosage without physician authorization?

Prescription Medication Agreement (must be completed on all patients on controlled substances for more than 30 days) include

1. Goals of treatment
2. Consent to testing to monitor use
3. Requirements that this controlled substance is only taken as prescribed
4. Patient admits they are prohibited to share
5. The patient is required to inform the doctor when other controlled substances are prescribed or taken
6. Use of alcohol or marijuana
7. Previous treatment for side effects or complications related to the use of controlled substance
8. Each state previously resided in or that has a controlled prescription filled
9. Authorization for doctor to conduct random inventory of controlled substance (this means the doctor can count your number of pills to confirm that it correlates with the number that should be remaining.
10. Reasons doctor may change or discontinue controlled substance treatment.
11. Any other requirements determined by doctor

The patient must perform a urine drug screen, if the physician asks for it.

The patient needs to inform the physician if they use any other drugs (including marijuana) and if they are having any side effects.

At 90 days, an evidence-based work up of the medical condition has been initiated.  For instance, if the pain medicine is being used for back pain, has the back pain been worked up appropriately?  Have non-controlled substances be tried and failed?

It the patient is taking more than 90 MME (morphine equivalents)? if so consider sending them to pain management physician as this falls outside the normal dosage range.

“Prescribe 365” This refers to the patients only receiving one years supply of rx in one year to help decrease duplicative rx. Or doctor shopping.

Long-term management of patients with controlled substance prescriptions. 

Must be seen every 3 months for long-term pain management. Three prescriptions, each for one month, can be given to the patient at one visit (as long as the physician feels comfortable doing this.)

Controlled substance agreement needs to be signed by the patient once a year.

Resources  www.nvdoctors.org or www.prescribe365nv.gov or http://bop.nv.gov/links/PMP/ or https://knowyourpainmeds.com is geared toward patients.