Controlled Substance Prescriptions
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 are a grim reminder
that such medications are not without inherent risks.
During the 2017 session, the Nevada Legislature passed
Assembly Bill 474, the Controlled Substance Abuse Prevention Act. This legislation does
not tell prescribers when or how they can prescribe. Instead, it establishes
a standard of care for prescribers so that when such medications are clinically
indicated, the prescriber and the patient have the information they need
to move forward with confidence, knowing that the benefits of a controlled
substance prescription outweigh the risks.
The primary goals of Assembly Bill 474 are:
- 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
- Enhance the quality of care for patients with acute and chronic pain.
In order to accomplish these goals, AB 474 is divided into six sections.
1) Additional requirements for all controlled substance prescriptions. The law requires prescribers to include additional patient information
in every controlled substance prescription, such as the patient's
birthdate, the diagnosis code for the disease being treated, the minimum
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.
2) Factors to consider before writing a prescription for a controlled substance. The law includes a comprehensive list of factors that prescribers should
consider before writing a prescription to ensure patient safety.
The following additional provisions in the bill are specific to controlled
substances (Schedule II, III, IV) prescribed for the treatment of pain.
However, the following provisions do not apply to controlled substances
that are prescribed for medical conditions that are not pain related.
3) 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, including 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, he or she understands
the potential risks and benefits of using the controlled substance.
4) 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.
5) 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.
6) Prescribing after 365 days. A practitioner should not prescribe a controlled substance to a patient
who has already received 365 days 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 his or her rationale in
the patient’s medical record.