Prescribing

In response to the epidemic, CDC released the Guideline for Prescribing Opioids for Chronic Pain in March 2016. The guideline offers primary care providers a set of voluntary, evidence-based recommendations for prescribing opioids to patients 18 years or older in primary care settings. It focuses on chronic pain treatment, and does not apply to patients in active cancer treatment, palliative care or end-of-life care.

A variety of legal and regulatory strategies have been adopted by individual states, more or less following the spirit of the Guideline.

Prescribing Limits

  • The National Conference of State Legislatures (NCSL) published an analysis of the state-level legislative strategies addressing prescribing opioids. According to the analysis, the most common state-level response is to limit first-time opioid prescriptions to a certain number of days’ supply – most common being seven days, though some laws set limits at three, five or 14 days. In a few cases, states also set dosage limits (morphine milligram equivalents, or MMEs). Nearly half the states with limits specify that they apply to treating acute pain, and most states set exceptions for chronic pain treatment. Some states also set limits specifically for minors. Most laws, however, specify exceptions for chronic pain, some also for cancer, hospice and/or palliative care. Many also allow exceptions for the treatment of substance use disorder or medication-assisted treatment (MAT), or for the professional judgment of the provider prescribing the opioid. Many laws stipulate that any exceptions must be documented in the patient’s medical record.[1] We recommend referring to NCSL’s website for more information on individual state legislation.


Authority to Prescribe Controlled Substances

  • Independent prescribing (also called “prescriptive authority”) is the ability of advanced practice registered nurses (APRNs) to prescribe, without limitation, legend (prescription) and controlled drugs, devices, adjunct health/medical services, durable medical goods, and other equipment and supplies. Independent prescribing does not require collaboration with a physician and is a key element of scope of practice for APRNs, as well as being part of the APRN Consensus Model, which seeks to achieve uniformity of state regulation of APRN practice.

  • Many states have made, and many are considering making, changes to existing laws that regulate scope of practice for APRNs, including independent prescribing privileges. Despite the existence of the consensus model, there are extensive disparities among the states with respect to prescriptive authority. In some states, prescriptive authority is granted at the time of APRN licensure; in others, the APRN must apply separately for these privileges. Differences exist in how much and what type of advanced pharmacology and pharmacotherapeutics education is required, and whether and how much supervision of prescribing practice must take place before independent prescriptive authority is granted. Variation in prescribing laws also include whether all, or only some, APRN roles can be granted prescriptive authority; restrictions on prescribing controlled substances or the schedules of controlled drugs included; and the requirements for collaboration with a physician.  A comprehensive review of nurse practitioner prescribing laws in a particular state or Washington, DC, is available.

  • Physician assistants are also authorized to prescribe medications in all jurisdictions where they are licensed. That authority includes controlled medications in every jurisdiction except Kentucky.  Prescribing authority of physician assistants of controlled substances differs in each state. Visit aapa.org to view up-to-date prescribing authority for physician assistants (on the website’s search box, type in PA opioid prescribing authority.

  • Forty-one states and the District of Columbia have one or more laws that require a prescriber or dispenser to ensure that prescriptions for medications are based on an examination of the patient. States with these laws may require a physical examination as part of prescribing regulations, or may prohibit pharmacists and physicians from dispensing certain types of drugs if there is doubt the drugs were prescribed following a physical exam. Some states limit the applicability of the laws to certain drug types, apply laws only in certain circumstances, or contain exceptions to examination requirements. Most states and the District of Columbia have multiple physical examination laws and thus fall under multiple categories.

Paper/Electronic Prescribing

  • Electronic prescribing of controlled substances (EPCS) is legal in all 50 states. It helps to reduce fraud and abuse of controlled substances like prescription opioids. Moving from paper-based prescribing to EPCS enables providers to make use of enhanced security features that technology affords. Prescribers can be authenticated before prescribing a controlled substance and prescriptions may be transmitted to pharmacies securely without risk of alteration or diversion. Utilization of EPCS:

    1. Enhances Patient Safety by providing alerts to prevent drug-to-drug and drug-to-allergy interactions, inappropriate dosing, and duplicate therapies and patient status — such as pregnancy or breast-feeding.
    2. Improves Accuracy by reducing errors inherent in paper-based prescribing, including illegible handwriting, misinterpreted abbreviations, and unclear dosages.
    3. Reduces Fraud and Drug Diversion by ensuring the safe transmission of opioids and other prescription drugs from clinician to pharmacy without the risk of forgery or alteration.
    4. Reduces Drug Misuse and Abuse by allowing clinicians to view patients’ medication histories at the point of care, which helps them determine if patients are “doctor shopping” or are exhibiting other behaviors associated with drug abuse.
    5. Improves Workflow Efficiencies by streamlining all prescribing into a single workflow, eliminating the need to switch between workflows (electronic for some medications and paper for others).

  • Although the majority of providers are sending electronic prescriptions, far fewer prescribers are using this capability for prescribing prescription opioids.[2]

  • National EPCS availability is a key step in combating prescription drug fraud and abuse and some states, are taking legislative action to mandate electronic prescribing

Learn More Here.

Prescription Drug Monitoring Programs (PDMP)

  • Forty-nine states, the District of Columbia and Guam currently operate PDMPs, but vary in how quickly dispensers must submit data to the PDMP—within 24 hours, one week or one month.

  • According to NCSL, at least 26 states and Guam require prescribers to check the PDMP before writing opioid prescriptions, sometimes called mandated or universal use. The criteria for checking the PDMP varies, with some states requiring prescribers to check it before writing the majority of opioid prescriptions. Others mandate checking the PDMP only for certain providers or under certain circumstances, such as when a provider has a reasonable belief of inappropriate use or if the prescription is for chronic pain. At least 15 states also require prescribers to recheck the PDMP within a certain time period, such as within three months, 180 days or one year of writing the initial prescription.[3]

Learn More:

Taxes

This area of the law is dynamic and changing quickly, and while we endeavor to keep this toolkit updated, we make no guarantees about the completeness, accuracy, reliability, suitability or availability of the information referenced within. We highly suggest that you use this toolkit as your basic guide, and check with the institutions linked here to obtain their most recent updates.

[1] K. Blackman, “Prescribing Policies: States Confront Opioid Overdose Epidemic,” National Conference of State Legislatures, Aug 2017, p. 3, http://www.ncsl.org/Portals/1/Documents/Health/prescribingOpioids_final01-web.pdf.

[2] Health IT, “Electronic Prescribing of Controlled Substances (EPCS)” (Washington, DC, Nov 4, 2016), https://www.healthit.gov/opioids/epcs.

[3] National Conference of State Legislatures, “Prescription Drug Monitoring Programs” (Washington, DC, Jun 1, 2016), http://www.ncsl.org/research/health/prescription-drug-monitoring-programs-postcard.aspx.