Texas physicians need to prepare for changes in state law tied to opioid prescribing in the coming months, according to the three-physician panel that addressed "Responding to the Opioid Epidemic" at the 2019 Texas Medical Association Fall Conference.
"The devil is in the details when you're in your offices trying to make all this work," said Troy Fiesinger, MD, a Sugar Land family physician and the panel's moderator.
The 2019 Texas Legislature approved several bills tied to opioid prescriptions, including:
- House Bill 3284 by Rep. J.D. Sheffield, DO (R-Gatesville), which extended the deadline from September to March 2020 for physicians to check the state’s prescription monitoring program (PMP) before issuing any prescription for opioids, benzodiazepines, barbiturates, or carisoprodol.
- House Bill 2174 by Rep. John Zerwas, MD (R-Richmond), which established a 10-day limit for opioid prescriptions for acute conditions. The bill as originally filed set a seven-day limit, but Dr. Zerwas accepted the 10-day provision based on physician input. The bill requires electronic prescribing for opioids beginning in 2021 (to coincide with a Medicare requirement) plus two hours of CME for opioid-prescribing. It also generally prohibits prior authorization requirements for medication-assisted treatment for opioid use disorder.
Several provisions in the new bills still have to be ironed out by the Texas Medical Board (TMB), says Dr. Fiesinger, who serves on TMA's Council on Legislation. For instance, the 10-day limit on opioids does not spell out acceptable dosages or other important factors in prescribing. Likewise, although there are now different requirements for prescribing for "acute pain" and "chronic pain," there are no clear definitions of either term, he says.
"There's obviously a lot we have to work out, so stay tuned," Dr. Fiesinger said.
Also, the legislature approved three separate bills requiring opioid CME, each with different requirements for hours and deadlines. The TMB is aware of the discrepancy and is scheduled to meet in October to reconcile the three bills and further clarify "acute" and "chronic" pain, Dr. Fiesinger says. He also pointed out that TMA provides CME on opioids.
Lindsay Botsford, MD, a family physician from Sugar Land, addressed best practices on opioids, pointing out that prescription pain relievers outrank all the other causes of illicit drug use among adults in Texas, according to the 2016-2017 National Survey on Drug Use and Health. Also, 15% of Texas high school students have used prescription pain medication without a prescription, according to the 2017 Youth Risk Behavior Study.
Many practices have patients sign a controlled-substance agreement (also called a pain management contract) that says they will follow the physician's prescription instructions. But "a pain contract by itself is not going to fix your problem," Dr. Botsford told the Fall Conference general session.
Practices need to make sure their policies are uniformly carried out, especially when they have multiple physicians. That starts with defining what triggers an agreement – the medications covered and under what conditions they'll be prescribed. Practices also need to specify how refill requests and exceptions will be handled, and create standards for when urine tests will take place, among other matters.
"Whatever you decide, make sure everyone in your office is on the same page with it," she said.
The language in controlled-substance agreements can vary, depending upon the physician's and patient's needs, but many contracts are chock full of legalese that confuse patients, Dr. Botsford says. Though there's little evidence that a controlled substance agreement improves patient outcomes, it is considered a best practice. It's also a chance to discuss a potentially serious problem with patients, and the best way to make it effective is to avoid making it a legal document, she says.
"Trying to shoot for something that has a sixth-grade reading level and something the patient understands makes it more valuable," she said.
Physicians need to have a clear understanding about why all the limits on opioids are needed, says San Antonio orthopedic surgeon Adam Bruggeman, MD, president of the Texas Orthopaedic Association. Evidence shows that the fewer pills that are prescribed, the less likely patients are to develop drug dependence.
"If we allow traditional prescribing habits to prevail, which is, 'I'm not going to see you for another 30 days and give you 30 days' worth of tablets. Take this Tramadol three times a day, 90 tablets, and come see me in a month and let's see how things are coming,'" Dr. Bruggeman told the audience. "If you practiced that … the chances of the patient still being on the Tramadol in three years is over 20%, and the chances of them being on it beyond a year is over 40%."
Physicians should watch for several red flags in prescribing any opioid to avoid TMB sanctions, Dr. Bruggeman says. They include people traveling from long distances to obtain an opioid prescription, or if more than one person from the same address receives an opioid prescription from one physician.
Physicians can avoid these and other problems by using electronic prescribing for opioids, he says. Physicians also must check the PMP to make sure they aren't prescribing an opioid to a patient who already is receiving benzodiazepines, barbiturates, or carisoprodol.
"Please recognize, if there are two [physicians] writing for a drug, one writing for the benzo and one writing for the opiate in combination with each other, both of you are responsible," Dr. Bruggeman said. "Please, please, please – look before you write any of these medications."
For resources on these and other best practices, Dr. Botsford recommended the American Academy of Family Physicians Chronic Pain Management Toolkit; the American Medical Association Opioid Task Force Recommendations to Physicians; and sample forms for controlled substance agreements at the American Academy of Pain Medicine and the National Institute on Drug Abuse. Physicians also can contact the TMA Knowledge Center at (800) 880-7955 or by email.