The New Opioid Prescribing Law (AB474)

 By: Daniel Burkhead, M.D. President-Elect Clark County Medical Society

By: Daniel Burkhead, M.D.
President-Elect
Clark County Medical Society

What we’ve learned, and what we’ve accomplished.

  Sandy Reed, Dr. Daniel Burkhead, and Ed Cousineau ran a panel discussion on AB474

Sandy Reed, Dr. Daniel Burkhead, and Ed Cousineau ran a panel discussion on AB474

Well, it’s been over eight months since the new opioid law went into effect, and I think it’s safe to say that the dust has settled to some extent. Most practitioners have a good understanding of the reasoning behind the law, and the intent of the laws in an effort to battle the opioid crisis. Unfortunately, however, when the new law took effect January 1st, many prescribers were taken by surprise due to the numerous procedural changes that the new law required. Uncertainty about the law created significant confusion and heightened anxiety for those who prescribe controlled substances.

Recognizing this concern, the leadership at Clark County Medical Society (CCMS) and Nevada State Medical Association (NSMA) organized a number of educational opportunities and resources to help practitioners understand the law. CCMS organized a Town Hall Meeting in December connecting physicians and patients with policy-makers, regulators, and administrative representatives responsible for the law’s implementation. The Town Hall Meeting was very well attended, and it helped to clear up some of the mystery surrounding the wording of the new law. NSMA developed a comprehensive provider tool kit, which is still available on the NSMA website (nvdoctors.org). In addition, CCMS/NSMA members Don Havins M.D., J.D., and Senator Joe Hardy held several informative CME conferences and I teamed up with NSMA Executive Director Cat O’Mara to hold CME meetings in an effort to educate physicians and practice groups about the law. Through these forums, further questions were raised, including the question of how the State Regulatory Agencies were planning to enforce the new law, and what punitive measures may be implemented.

As a pain management physician, my clinic experienced one of the unintended consequences of the new law: that many practitioners in Southern Nevada simply stopped prescribing controlled substances, making access to care more difficult for those patients with a legitimate need for such medications. Most providers, however, reluctantly “hung in there” and did the right thing for their patients by continuing to provide the care they needed. Compliance with the new law required some major changes to many practices, and those that persevered should be congratulated!

  Physician Members of the Clark County Medical Society participating in a Town Hall discussion on AB474

Physician Members of the Clark County Medical Society participating in a Town Hall discussion on AB474

By the same token, those practices that decided to “opt out” of prescribing controlled substances should not bear any shame. At the beginning of 2018, the potential risk to a well-meaning physician’s license seemed to outweigh the benefit of being able to provide pain medications to legitimate patients. While the Osteopathic, Dental, and Nursing Boards seemed to take a more comprehensive approach to the law, the Nevada State Board of Medical Examiners provided notice of a potential disciplinary regulation that came to be known as the “five strikes and you’re out” policy. This regulation caused great concern to many physicians as it could’ve potentially imposed significant punishment for simple clerical errors. Due to the lobbying efforts of NSMA and the engagement of the entire Nevada medical community, including several CCMS trustees, the Board decided to withdraw the disciplinary regulation and form a subcommittee to examine the interpretation of the law and to determine appropriate regulatory measures.

This NSBME subcommittee included physician representatives from CCMS, NSMA, NSBME, and the Board of Pharmacy and was chaired by Dr. Victor Muro. Through a series of meetings from February through May of 2018, this subcommittee worked to develop recommendations to both the Board of Medical Examiners and Board of Pharmacy to clarify several items within the law. Some of the proposed regulations from the subcommittee include: a definition for acute pain (with exemptions for hospice, palliative, and cancer pain), clarification that a physician can change the treatment plan (i.e. change of pain medication) for a patient without requiring new documentation, allowance for multiple providers to share “informed consent” and “prescription agreements” within the same practice, clarification of what constitutes a reasonable effort to obtain prior medical records dependent upon the situation, and clarification of provisions relating to the Prescription Drug Monitoring Program, among others. More information regarding the status of the newly proposed regulations is available on the NSMA website (nvdoctors.org).

  Dr. Weldon Havins running a free CME for CCMS Members on compliance with AB474

Dr. Weldon Havins running a free CME for CCMS Members on compliance with AB474

One of the most important accomplishments of this NSBME subcommittee included a strong recommendation to the Board of Medical Examiners for regulatory measures to include less punitive approaches to enforcement. This approach will allow for the Board to follow its usual course of action for violations of the law, and will, importantly, allow for a stronger sense of “due process.” This is very good news for prescribers in Nevada and demonstrates the power of organized medicine.

We have certainly gone through the toughest part of this transition into the new law, and I applaud those of you who have stuck it out. It is my personal belief that the law has provided reason to make prescribers think more carefully about the overall treatment plan for a patient who requires controlled substances, and it has also had some impact on patient’s expectations with regards to opioid prescriptions for pain. Hugh Bassewitz, an orthopedic spine surgeon and CCMS Trustee commented that he has seen a “significant decrease in the number of patients that are already on opiates at the time of the initial consultation and far fewer patients expecting or requesting opiate medication.”

I want to extend my sincere gratitude to the members of Clark County Medical Society and Nevada State Medical Association for all of the hard work in fighting for the rights of physicians to treat their patients with fairness. As the 2019 legislative session approaches, CCMS and NSMA will be working with legislators to improve several aspects of the current law. I encourage you to stay engaged in these organizations to ensure that your voice is heard throughout this process.