What the new opioid prescribing law means for Emergency Departments
While many emergency physicians are aware of the new prescribing law, NJACEP continues to receive questions and requests for clarification. There are conflicts in the law that we knew about and were not permitted to amend. We are continuing to work on changes in regulation or by legislation, if necessary, to address these problems, specifically as it relates to emergency medicine.
As of March 2, 2017:
When issuing an initial opioid prescription for a patient, it cannot exceed a five-day supply. The law does not define what a five-day supply is nor does it discuss the MME. It does, however, require that the prescription be written for the lowest effective dose of immediate-release opioid drug.
The law does not apply to a prescription for a patient who is currently in active treatment for cancer, receiving hospice care from a licensed hospice or palliative care, or is a resident of a long term care facility, or to any medications that prescribed in the treatment of substance abuse or opioid dependence (medication assisted treatment).
Determining whether it is an initial prescription
If a patient HAS NOT been prescribed that medication (or its pharmaceutical equivalent) in the last year from ANY prescriber, then it IS deemed “initial” and the 5-day supply limit is in play.
If the patient HAS been prescribed that medication (or its pharmaceutical equivalent) in the last year from ANY prescriber, then it is NOT an initial prescription and the 5-day limit does not apply. While it is not necessarily relevant to ED, if this is not an initial prescription, you can write up to 25-day supply if it is the 2nd prescription within the same month as the 5-day, otherwise you can write as much as 30-days going forward.
If it is an initial prescription the emergency regulations are requiring that “initial” be written on the prescription. This is solely for the pharmacy’s benefit to help calculate the patients copay or coinsurance. We are working to change this since the pharmacy can find this out on their own, but for now, you will need to make this notation on the script.
Even though the ED is exempt from checking the PMP when prescribing less than a 5-day supply, practically speaking, you are going to have to check the PMP to determine if you are writing an initial script even when you are writing less than a 5-day supply. This is for two reasons: (1) to write that it is “initial” and (2) to make sure the patient isn’t coming prematurely after their initial 5-day was prescribed.
Prior to prescribing the initial 5-days
· Take and document the results of a thorough medical history, including the patient’s experience with non-opioid medication and non-pharmacological pain management approaches and substance abuse history;
· Develop a treatment plan, with particular attention focused on determining the cause of the patient’s pain; and
· Access relevant prescription monitoring information under the Prescription Monitoring Program
· Make a notation in the patient’s medical record that there was a discussion with the patient or the patient’s parent or guardian, about the risks of developing a physical or psychological dependence on the controlled substance and alternative treatments that may be available. While the law requires this discussion by the same doctor/patient/treatment plan at the 1st and 3rd script, in the ED it is easy to just have this discussion every time you prescribe these medications.
Pain agreements required for the treatment of chronic pain
While the use of pain contracts for chronic pain patients has been a BME guideline in current regulation, this new law codifies that regulation and makes the use of pain management agreements mandatory when treating chronic pain, defined as the continuous treatment for pain for three months or more.
It was not intended for EDs to enter into pain contracts with patients. However, there is a conflict in the law as it defines the 3rd prescription that triggers the pain agreement. For now, no pain agreements are intended for use in the ED, unless you are treating the same person for chronic pain as part of a regular and ongoing course of treatment. This will be fixed by regulation.
Update on PDMP Registrations and Mobile App
The NJPMP converted to a new platform, Appriss AWARxE, in November 2016. At that time, any prescriber who had not accessed the old system through Optimum/O-Tech at least once since October 2015 or who did not have an unique email address associated with their old registration, was not migrated over to the new system and those prescribers need to re-register since the registration process utilizes an unique email address. The new registration process uses a validation process to check a prescriber’s professio nal license, DEA and State CDS Registration numbers and if it matches the State’s file, the prescriber will be automatically approved for access to the NJPMP. The NJPMP’s mobile app for Android and Apple iOS had to be temporarily disabled due to the platform conversion with the new vendor. The state is working to re-deploy the mobile app. If you do not have a login for the PDMP, please visit: http://www.njconsumeraffairs.gov/pmp/Pages/register.aspx