AB474: Is Your Practice Ready?

 By Catherine O'Mara, JD Executive Director Nevada State Medical Association

By Catherine O'Mara, JD
Executive Director
Nevada State Medical Association

New Controlled Substance Prescriber Law Effective January 1, 2018

Every Nevadan, whether physician, patient, or citizen, has been impacted by the prevalence of opioids in our community. In response to the nationwide opioid epidemic and the effects felt in Nevada, Governor Sandoval brought forth legislation known as the Prescription Drug Abuse Prevention Act (AB474). Passed unanimously by the legislature, AB474 goes into effect on January 1, 2018 and will impact all prescriptions for controlled substances, although most provisions of the law uniquely apply to controlled substances prescribed to treat pain.

As an advocate for physicians, the Nevada State Medical Association (NSMA) understands that there is much angst about how to comply with the new law. It is critical that physicians (including residents) and physician assistants take the time to understand these requirements so that you can best treat your patients within the confines of the law. The key to successfully complying with AB474 is to clearly understand what is required, focus on what you can do now to prepare, and to consider some best practices to assist your workflow.

Requirements of AB474
The law’s requirements are best understood broken down into five categories, with the most significant changes being the new provider guidelines found in sections 52-58 of AB474. The five categories are: (1) required reports of overdoses, (2) continuing medical education (CME) requirements; (3) mandated registry and use of the prescription monitoring program (PMP); (4) required prescription components; and (5) prescriber guidelines.

1. Providers Will Be Required to Report Cases of Overdose.
Under AB474, a physician, physician assistant, nurse or veterinarian licensed in accordance with Nevada state law will be required to report actual or suspected cases of drug overdoses to the State’s Chief Medical Officer (State of Nevada Division of Public and Behavioral Health - DPBH). DPBH is currently working on draft regulations, and the promulgation process on these regulations will begin in early 2018. While the law is effective on January 1, 2018, the overdose reporting requirement will not kick in until after the regulatory process is concluded.

What should you do now? Look for future updates on this requirement in 2018.  We expect emergency regulations to be issued the week of January 16, 2018.  Emergency regulations will be in place while the formal regulatory process continues.  

2. Providers Are Required to Obtain Two Units of Continuing Medical Education on the Topic of Misuse and Abuse of Controlled Substances, the Prescribing of Opioids or Addiction.
Under the new law, all licensed providers registered to dispense controlled substances will be required to complete two (2) units of CME each licensing cycle specifically to the misuse and abuse of controlled substances, the prescribing of opioids or addiction. The units may be substituted for ethics or any other general requirement.  Entities like NSMA and our county medical societies, Project ECHO and others frequently offer these CME opportunities, and many exist online.

What should you do now? Look for opportunities to fulfill these two units of CME. The first two units must be completed by the 2019 licensing cycle.

3.  Providers with Licenses to Prescribe Must Register for and Query the PMP.
The Prescription Drug Monitoring Program (PMP) is a computerized program that tracks prescriptions for controlled substances. It is housed by the Nevada State Board of Pharmacy (BOP) and is accessible at all hours through a secure website. According to data provided by the BOP, 83.5% of MD and 87.8% of DO prescribers are registered with the PMP, but only 10.7% of DOs and 15% of MDs queried the system in 2016. While we expect those numbers to be higher in 2017, the law now requires both registry and use. 

All prescribers of any controlled substance must check the patient’s utilization report in the PMP before issuing an initial prescription and at least once every 90 days for the duration of that course of treatment. The PMP is a tool to help the provider assess the medical necessity of prescribing the controlled substance for that patient. Providers may use extenders or agents to access the PMP but must review the information themselves. If the provider determines that the PMP does not support medical necessity or if the patient has already been issued a prescription for the same controlled substance to treat the same diagnosis for the same period of time, the provider must not issue an additional prescription

What should you do now? Register for the PMP at: https://nevada.pmpaware.net or call the Nevada Prescription Monitoring Program at 1-855-5NV-4PMP and begin checking the PMP before issuing an initial prescription and every 90 days for all controlled substances, including opioids for pain.

4.  To Be Valid, Prescriptions Must Contain the Patient’s Date of Birth, ICD-10 Code, the Fewest Number of Days Necessary to Consume the Medication, and the Prescriber’s Name and DEA License Number .
In addition to current requirements, all prescriptions must now contain four elements along with the medication being prescribed: (1) patient’s date of birth; (2) patient’s diagnosis through the ICD-10 code, (3) the lowest number of days the medication is intended for; and (4) the prescriber’s name and DEA number. Through regulations promulgated by the BOP, pharmacists working with prescriber offices can work to correct a lack of an ICD-10 code or a number of days dosage but cannot assign a DEA number to a prescription, even if the pharmacist personally knows the prescriber. If multiple practitioners’ names and DEA numbers are printed on the prescription form, the prescription cannot be filled unless the prescribing practitioner and DEA number are clearly indicated.

It is important to note that electronic prescriptions, electronic medical record/electronic health record (EMR/EHR) systems doing business in Nevada must offer the ability to transmit a legal prescription. If your practice is having any issues getting your EHR/EMR systems in place, the BOP or the NSMA can help intervene.

What should you do now? Ensure preprinted prescriptions and EMR/EHR system contain new requirement for legal prescriptions, including the ability to clearly delineate the DEA number of the prescriber.
5. All Prescribers of Controlled Substances Must Follow New Prescribing Guidelines.
The most substantive provisions of AB474 are the provider guidelines. Nevada policymakers approached this legislation with the stated objective to prioritize patient safety and responsibility and to preserve clinical judgment in the face of addressing a public health crisis. There are some requirements that apply to all prescriptions for controlled substances; however, most provisions apply only to those controlled substances prescribed to treat pain.

5a. Prescriptions for All Controlled Substances Require the Prescriber to Query the PMP, Consider Important Factors Prior To Prescribing and Write the Prescription in Accordance with the New Law.
For all prescriptions of controlled substances, the prescriber must query the PMP upon initial prescription and at least once every 90 days during the course of treatment. Here, the provider is using the PMP as a tool to consider medical necessity and must refrain from prescribing if the prescription is not medically necessary or if another prescription exists to cover that diagnosis and time.

Providers must also consider certain factors, if applicable, prior to prescribing. These factors are itemized in the law, and include considerations such as any history of aberrant behavior or public intoxication, unauthorized increase in dosage of controlled substance, or substance abuse, any evidence that the patient has been addicted to, misused, abused or diverted a controlled substance, reluctance to discontinue usage despite improvement, lack of cooperation, or discharge from other provider clinics, any changes in the patient’s health (such as pregnancy), or any other factors that may that may influence or affect the decision to prescribe.

In addition, the prescription for any controlled substance must contain the statutory requirements as explained above: current requirements plus patient’s date of birth, ICD-10 diagnosis, minimum number of days for the prescription and the prescriber’s name and DEA license number.