Prescribing Opioids

Prescribing Opioids and AB 474

New prescribing requirements have been established from the 2017 legislative session (AB 474 and SB 59). Review the below reference guides for details.

AB 474 Chart (FINAL)-page-001

Having trouble viewing the above chart? Download the PDF here.

Having trouble viewing the above white paper? Download the PDF here.

The above documents are fully vetted by the Nevada State Medical Association, Governor’s Office, the medicine-related licensing boards, the Health Department, and others.


PMP button smaller

More information on the PMP and how to register here.


Frequently Asked Questions About AB474

  1. When does this bill take effect? AB474 goes into effect on January 1, 2018.
  1. Will this bill require additional Continuing Medical Education? Yes, AB474 requires that all physician or physician assistants who are registered to dispense controlled substances to complete at least 2 hours of training relating specifically to the misuse and abuse of controlled substances, the prescribing of opioids or addiction during each period of licensure. Any licensee may use such training to satisfy hours of any continuing education requirement established by the Board.
  1. I’ve known my patients for years; do I really have to check the PDMP? Yes, the PDMP must be checked before a new prescription for a controlled substance (schedule 2-4) and then every 90 days for on-going treatment.
  1. What is NSMA doing to improve PDMP? NSMA is actively involved with the Board of Pharmacy to reduce the number of user clicks in the PDMP.  Please feel free to forward us any observations to admin@nvdoctors.org
  1. What does “opiate naïve” mean? AB474 defines opiate naïve as a patient who has not had an opiate for eighteen (18) days.
  1. The logistics behind the written informed consent and patient treatment agreement forms are going to add to the burdens of my overworked office, ER, practice, what can be done to eliminate this burden? The written informed consent is designed to educate the patient and to protect the practitioner. The state’s chief medical officer, Dr. John DiMuro and Dr. Stephanie Woodard are creating streamlined forms that can be modified and uploaded into you EMR for ease.  NSMA will be providing feedback to these forms and process.  Physicians may use extenders to complete the informed consent.
  1. What did NSMA do to protect physicians during the discussions on new opiate legislation? In 2016, NSMA established an opiate task force of over 30 members of all different specialties including ER, surgical specialties, pain management and primary care.  NSMA worked with the Governor’s office and staff to secure a seat at the negotiations.  NSMA advocated for the preservation of clinical judgment and negotiate out more severe limits and caps, including a mandate that all patients receiving opiates be required to submit to a urine drug screen.
  1. The new law requires that initial prescriptions be for no more than fourteen (14) days and for opiate naïve patients no more than 90 MME, what do I do with patients I inherit that are already exceeding those dosages – am I required to start from zero? No, the new law is intended to preserve your clinical judgment.  If you inherit a patient, you should ensure that you have a proper diagnosis and you should treat and write for the appropriate medication based on your clinical judgment.
  1. If a check of the PDMP reveals that the patient is on a course of opiate treatment already, may I also prescribe an opiate? It depends.  The intent of AB474 (section 61) is to ensure the PDMP is used to monitor patient’s prescriptions and ensure they are not receiving duplicate/concurrent prescription.  This in no way is intended to interfere or impact continuity of care between prescribers.

The law prohibits you from writing the same prescription for the same substance for the same ailment unless you are assuming a course of treatment for another practitioner.  The law does not prevent you from writing a prescription for a different ailment.

Examples:

Scenario 1.  Dr. A and Dr. B are in an oncology practice together.  They co-treat the same patient X. Dr. A starts a course of treatment, Dr. B takes over for the patient’s care while Dr. A is out of town.  They write for the same on-going treatment however these are consecutive prescriptions not concurrent.  Is this permitted under AB474?

Yes.  The prescribers would be working together to manage the patient.  Again, the intent is not to limit in any way the continuity of care of a patient.  In the scenario above it would be assumed that they would be working off the same treatment plan in the collaborative care of the patient.

Scenario 2.  Dr. A is an ER doc who treats Patient X’s broken ankle with a 3-5 day prescription for a controlled substance.  Patient X does not need surgery and follows up with his primary care physician 1 week later.  Dr. B is the primary care physician who writes a prescription for the same controlled substance for on-going care.  Is this permitted under AB474?

Yes, these are consecutive not concurrent prescriptions and are permitted under AB474.

Scenario 3.  Dr. A is a primary care physician treating patient X with low dose of controlled substance for a chronic pain condition.  Patient X breaks his hip requiring surgery.  Dr. B the orthopedic surgeon performs the surgery and wants to prescribe a more powerful dose for a short-term period of recovery.  Here the prescriptions are concurrent but are for different ailments.  Is this permitted under AB474?

Yes, the treating physician, Dr. B, would treat based on the new presenting problem.  This is exactly why the PDMP is so important for both patient safety and communication between providers.  Dr. B will need to take the prescription from Dr. A into account when prescribing and providing instructions related to medications and follow-up.  The intent is to preserve clinical decision making to ensure patient safety and care.

Scenario 4.  Dr. A is a pain management doctor treating Patient X for chronic pain and has prescribed a controlled substance.  Patient X goes to Dr. B a primary care doctor complaining of chronic back pain.  Should Dr. B write the prescription for Patient X?

No.  Under AB474, concurrent prescription for the same diagnosis are prohibited under AB474. If a check of the PDMP reveals that Patient X is receiving an on-going prescription for the same problem, the second physician may no prescribe to Patient X.

  1. What do I do if I have more questions about the opiate bill? NSMA is currently working with regulatory boards and various stakeholders on the implementation of AB474.  If you have any questions or concerns or want to provide feedback on the process, please contact us at admin@nvdoctors.org