January 2017 Opioid Update
This announcement has 3 attachments:
Reminder January 1st, 2017 Opioid Rule are effective
Overview of the Final NH Board of Nursing Opioid Prescribing Rules
Adapted from the New Hampshire Medical Society
After being approved by the Joint Legislative Committee on Administrative Rules (JLCAR), the New Hampshire Board of Nursing (BON) adopted at their December board meeting, the final rules for opioid prescribing for the management or treatment of non-cancer and non-terminal pain, as well as requirements to use the state prescription drug monitoring program (PDMP) based on the adoption of HB 1423 in late June.
Going into effect January 1, 2017, the new BON rules apply to initial Schedule II, III and IV opioid prescriptions that are self-administered by an individual patient for the management or treatment of pain. Excluded from the new rule is the supervised administration of opioids in a health care setting.
JLCAR also conditionally approved parallel administrative rules for the boards of medicine, nursing, dentistry, podiatry, optometry, and naturopathy that are patterned on the Board of Medicine rules. The Board of Veterinary Medicine rules are still to be formulated for review by JLCAR in December. Each of the impacted health professional boards will meet to finalize and adopt their rules in November and December with an effective date of January 1, 2017.
The NH Board of Nursing adopted nearly a year ago its first set of administrative rules as emergency rules, that covered various aspects of opioid prescribing in response to a 13-page proposal offered by Governor Hassan’s administration.
The BON then replaced the emergency rules with an updated version that went into effect in June and took into account opioid prescribing changes outlined in SB 576, which was signed by Governor Hassan in January 2016.
In June, the Governor signed into law HB 1423 – an act relative to rulemaking for prescribing controlled drugs that applies to the licensees of all health professional boards prescribing Schedule II, III and IV opioids for the treatment and management of pain.
The NH Board of Nursing opioid prescribing rules included several key items incorporated from HB 1423:
-Health Care Setting Administration Exclusion: The Applicability statement (Med 502.01) clarified the scope of the prescribing rules by adding the clause: “...and shall not apply to the supervised administration
of opioids in a health care setting.” This means the requirements outlined in the rules will not apply to patients that receive administered opioids in hospitals, ambulatory care, urgent care, etc.
-Prescription Means Self-Administered by Patient: The definition of “Prescription” was added and carefully worded to ensure that orders that are given for the administration of opioids in a health care setting are not considered a prescription for the purposes of this rule. Only opioids that are prescribed for an individual patient that are to be self-administered would require the following of these rules.
-Apply Only to Opioids for Pain: Acute and Chronic Pain (Med 502.04 and 502.05) have been clarified to relate to opioid prescriptions only for acute and chronic pain. The wording “any other acute medical condition” has been removed. These rules do not apply to other controlled prescription drugs.
-Chronic Pain Patients: The rule has opioid prescribers query the PDMP and re-evaluate treatment plans at least twice a year, as well as document the consideration of a specialist consultation when a patient receives 100 mg morphine equivalent dose for longer than 90 days.
-ED Prescription Limits: A new provision required by HB 1423 is for acute pain in an emergency department, urgent care setting or walk-in clinic. The rule states that licensees shall not prescribe for more than 7 days, unless the medical condition is documented and appropriate clinical rationale is included in the patient’s medical record.
-PDMP Exceptions: The final rule provides exceptions for PDMP queries for administration in a health care setting, technological problems, and in an emergency department that would materially delay care.
BEST PRACTICE RECOMMENDATIONS
-Coordination of Care: Share these materials with APRNs, physicians, and PAs who prescribe opioid medications, as well as medical assistants, nurses and practice managers involved in the process of prescribing opioids.
-Patient Check List: Utilize the checklist as a tool to assist with evaluating the steps necessary to work with patients who are being prescribed Schedule II, III and IV opioids.
-Process Effectiveness: Evaluate current work flows to determine if any changes are needed to ensure compliance with the new rules, including appropriate PDMP delegation policies and procedures. Evaluate EMRs to determine if changes are needed to accommodate work flow updates.
-Patient Education: Review patient materials including treatment plans, treatment agreements,
informed consent documents, and other patient educational materials to ensure compliance and completeness.
-Patient Check List: In recognition of the complexity of trying to implement these regulations, the Governor’s Healthcare Task Force, NH Medical Society and NH Hospital Association have developed an updated “Patient Check List for Opioid Prescribing Rules” based on the final rules for licensees to utilize to ensure that they are following all of the components required for all pain, acute pain and chronic pain. Please note that this checklist is meant to be a tool only and should not replace your responsibility for reviewing and understanding the complete set of rules.
-Other Opioid Prescribing Tools Online: To assist with opioid prescribing requirements, other resources such as sample treatment agreements, risk assessment tools and clinical guidelines can be found under Prescribing Opioids safely on the NHNPA website https://nhnpa.enpnetwork.com/page/22411-nh-opioid-prescribing-resource
-CME Competency for Opioid Prescribing: 3 hours of NH BON approved CME are required every two years relating to opioid prescribing, including medicated assisted treatment (MAT). The listing of approved CME courses can be found on the NH BON and NHNPA websites.
-PDMP: NH Prescription Drug Monitoring Program became live two years ago as the 49th state program implemented with the legislature adding this year several requirements and funding for enhancements, including daily dispenser uploads and multi-state query access (including NH, CT, MA, RI, VT and NY, with ME and NJ slated to be added soon).
In brief, prescribers are required to review the PDMP for Schedule II, III and IV opioids before the initial prescription for acute pain, and at least twice a year for patients prescribed opioids for chronic pain care. The PDMP home is located at http://www.newhampshirepdmp.com/.