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 risk; and,
  • 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.