New law effective Jan. 1 aims to curb opioid abuse in the Silver State

CARSON CITY — Gov. Brian Sandoval and the Nevada Department of Health and Human Services announced an important reminder Friday that the provisions of Assembly Bill 474, the Controlled Substance Abuse Prevention Act, will go into effect January 1, 2018.

This measure was introduced by the Governor during his 2017 State of the State address, unanimously passed through both houses of the Legislature, and was signed into law on June 16, 2017.

Assembly Bill 474 expands and updates state laws related to the reporting of drug overdoses, provides prescribing protocols for healthcare providers that are prescribing controlled substances for the treatment of pain, and enacts the Prescribe 365 initiative.

While the use of controlled substances for the treatment of pain can be highly effective and medically necessary, the current opioid epidemic and overdose rates associated with prescription drugs underscores that such medications are not without inherent risks. Nevada’s legislation does not tell prescribers when or how they can prescribe, instead AB474 establishes a standard of care for prescribers so that, when prescribing such medications is clinically indicated, the prescriber and patient have the needed information to move forward with that prescription with some degree of confidence that the benefits outweigh the risks.

The primary goals of this legislation are to:
— Prioritize patient safety and responsibility
— Preserve clinical decision-making
— Promote the patient-prescriber relationship
— Reduce the amount of inappropriate prescribing
— Prevent addiction to prescription drugs through monitoring and mitigating risk
— Enhance the quality of care for patients with acute and chronic pain

The key provisions in AB 474 are divided into six sections:
— Additional Requirements for all Controlled Substance Prescriptions (For all Controlled Substances): The law requires prescribers to include additional patient information in every controlled substance prescription. The new data required includes the patient's birthdate, the diagnosis code for the disease being treated, the least number of days necessary to consume the quantity of the controlled substance and the practitioner’s Drug Enforcement Administration number. Prescribers are also required to check the Prescription Drug Monitoring Program (PDMP) prior to issuing a prescription for a controlled substance.

— Factors to Consider Before Writing a Prescription for a Controlled Substance: The law includes a comprehensive list of factors that prescribers should consider prior to writing a prescription to ensure patient safety when making a clinical decision to prescribe.

The following additional provisions in this bill are specific to controlled substances (Schedule II, III, IV) prescribed for the treatment of pain. The following provisions do not apply to controlled substances that are prescribed for medical conditions that are not pain related.

— Rules for First-Time Prescriptions of Controlled Substances For The Treatment Of Pain: AB 474 includes guidelines that prescribers must follow prior to writing an initial prescription, which include having a bona fide relationship with the patient; establishing a preliminary diagnosis and treatment plan; obtaining and reviewing the patient’s Prescription Drug Monitoring Report; and discussing non-controlled substance treatment options with the patient. The practitioner must also perform a patient risk assessment, which consists of reviewing the patient’s medical history, conducting a physical examination and assessing the patient’s mental health and risk of abuse, addiction and dependency.

If after review and assessment of the patient, the prescriber writes a prescription it can be for no more than 14 days for acute pain, and no more than 90 morphine mili-equivalent for opiate-naïve patients. Also, the patient must complete a written informed consent form stating that, among other things, they understand the potential risks and benefits of using the controlled substance.

— Prescribing After 30 Days: A practitioner who prescribes a controlled substance to treat pain for more than 30 days must enter into a Prescription Medication Agreement with the patient. The agreement must be part of the patient’s record and must include goals of the treatment. Patients also must agree to use the controlled substance as prescribed, not to share the medication, and to inform the practitioner of other prescriptions or substance uses that may affect the prescription.

— Prescribing After 90 Days: A practitioner who prescribes a controlled substance to treat pain for more than 90 consecutive days must now determine an evidence-based diagnosis for the cause of the pain; complete a risk of abuse assessment; continue an ongoing discussion about the plan with the patient; and obtain and review the patient’s Prescription Drug Monitoring Program report at least every 90 days during treatment.

— Prescribing After 365 Days: A practitioner should not prescribe a controlled substance to a patient who has already received 365 days’ worth of that controlled substance for a particular diagnosis in any given 365-day rolling period. The practitioner may choose to prescribe a larger quantity than the patient needs for the treatment period, so long as the practitioner documents their rationale in the patient’s medical record.

The Prescribe 365 initiative is a unique solution to the prescription drug crisis and serves as a rational, common-sense approach to controlled substance prescribing while not restricting the prescriber in any way. This program will serve as a way to define and identify over-prescribing.

The Department of Health and Human Services has compiled a number of resources to help prescribers implement the necessary changes into their practices to comply with the bill. Those resources can be found at Prescribe365.nv.gov.

AB 474 complements Senate Bill 459, the Good Samaritan Drug Overdose Act, which was introduced by Governor Sandoval and passed unanimously in 2015. Among other things, SB 459 provides immunity to individuals who, acting in good faith and with reasonable care, administer an opioid antagonist to someone experiencing an opioid-related drug overdose. Good Samaritan immunity is provided to individuals who seek medical help for others, themselves, or are the subject of the help request. SB 459 also requires first-time prescribing physicians to obtain a patient utilization report from the Prescription Drug Monitoring Program before they initiate a prescription for a controlled schedule II, III or IV prescription drug. Prescribing physicians now must check the PDMP for new patients or if the prescription is part of a new course of treatment and is written for more than seven days.