When the time came for the 2019 Texas Legislature to tackle opioids, Rep. J.D. Sheffield, DO (R-Gatesville), says lawmakers did it the right way: By listening to physicians.
“The legislature allowed the doctors and the medical profession to take the lead in writing [the] legislation,” Representative Sheffield told Texas Medicine. “At no point did I feel a lot of pushback from other legislators or other groups. They realized that we were the ones who knew the problem best, and [we] also were able to show them that we wanted to solve these problems and were very committed to solving those problems.”
Several new laws will affect how physicians practice and how they prescribe controlled substances, including a delay on required checks of the state’s prescription monitoring program (PMP); a limit on opioid prescriptions for acute pain; and a new electronic prescribing requirement coming in 2021.
Six more months
Physician-legislators drove much of the action at the Capitol to combat opioid addiction and drug diversion. For his part, Representative Sheffield authored a key bill that gave physicians more time to comply with a mandate to use PMP Aware, the state’s prescription monitoring database.
A mandate passed in 2017 to check the PMP before issuing any prescriptions for opioids, barbiturates, benzodiazepines, or carisoprodol originally was supposed to take effect this month. But thanks to this year’s House Bill 3284 by Representative Sheffield, physicians and other prescribers have another six months to get ready and integrate their electronic health record (EHR) systems with PMP Aware. The mandate will now go into effect on March 1, 2020.
That measure and Senate Bill 500 by Sen. Jane Nelson (R-Flower Mound) will collectively ease the transition. Already in effect, SB 500 provides the funds for the Texas State Board of Pharmacy (TSBP) to upgrade PMP to a more integration-ready software and to purchase user licenses for every prescriber in the state. Some prescribers were purchasing the user licenses for $50 per year to connect their EHRs to the PMP, but now, SB 500 will cover the cost of those licenses for all prescribers in Texas.
“I use the PMP myself,” Representative Sheffield said, “and for physicians who’ve never used it, if they can find themselves using it just a few times, I think they’ll be as amazed as I was when I started using it how much information it gives you about opioid prescribing, drug-diverters, or drug-seekers. It’s just become an invaluable tool in the clinic where I work [to deal with] this problem.”
HB 3284 also gives physicians a greater voice in the use of the PMP, requiring TSBP to establish an advisory committee on PMP issues that will include both physicians and pharmacists.
E-prescribing and a new opioid limit
While HB 3284 was focused on making the PMP mandate realistic, House Bill 2174 by Rep. John Zerwas, MD (R-Richmond), was a broader measure, with implications for opioid prescriptions, electronic prescribing, and Medicaid coverage for substance abuse treatment.
Effective this month, HB 2174 establishes a 10-day limit on prescribing opioids for acute pain, with no refills allowed. The bill includes exceptions for chronic pain, and pain treated as part of cancer care, hospice and end-of-life care, or palliative care. The “no-refill” provision contains an exception for treatment of substance addiction.
“Most minor injuries we see, we should be able to handle with 10 days of opioids, or not need opioids at all,” said Houston family physician Troy Fiesinger, MD. “For me as a family doctor, as much as I don’t like arbitrary limits, it does remind me, ‘Do you really need to give them X amount of pain medication?’”
Surgical specialists, on the other hand, have valid concerns about properly treating post-operative pain under the limit, Dr. Fiesinger says. And he adds the bill isn’t specific about what a 10-day limit really means: A 10-day supply could mean a prescription for one pill a day, for example, or for patients to take one every four hours.
HB 2174 also requires electronic prescribing of all controlled substances beginning in 2021, the year in which Medicare rolls out the same requirement. The bill includes a number of exceptions for electronic prescribing, such as lack of availability because of a temporary technological or electronic failure. It allows for a one-year renewable waiver for physicians to be exempt from electronic prescribing. An interagency workgroup will establish recommendations and standards for receiving a waiver, which will include economic hardship and technological limitations.
Beginning Nov. 1, the bill also mandates Medicaid coverage of medication-assisted opioid or substance abuse treatment without preauthorization, except to minimize waste, fraud, or abuse. It requires physicians to take two hours of CME related to prescribing and monitoring controlled substances before Sept. 1, 2021.
Tex Med. 2019;115(9):26-28
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