Opioid Prescribing Update

From the Winter 2020 Journal of the Colorado Dental Association

In recent years, there has been significant legislative and policy attention around the issue of opioid prescribing, given the opioid epidemic gripping Colorado and the entire nation. Opioids, both prescription and illicit, have become the leading cause of accidental death in the U.S. for young adults.¹ Risks of opioid-related adverse drug events (including overdose), physical dependence and development of opioid use disorder have become an increasingly common consideration for medical and dental practices. The number of lives impacted by the opioid crisis is astonishing. The Centers for Disease Control and Prevention (CDC) reports that opioid overdose killed nearly 400,000 Americans between 2000 and 2017,² and currently 130 Americans die every day of opioid overdose.³

While opioid prescribing in medical settings is not the only contributing factor to address as advocates seek to end the opioid epidemic, reducing opioid prescribing is a key preventive intervention that can help make a difference to address this crisis.

Numerous interventions have already taken effect in recent years in the opioid prescribing space, with more anticipated, including policies that:

• Require all dentists with a DEA license to register for an account with Colorado’s Prescription Drug Monitoring Program (PDMP). This requirement has been in place since 2014. The Colorado Dental Board is able to monitor registration and usage information for Colorado dentists, and has indicated that some enforcement may soon be taken for dentists who are not in compliance with the registration requirement.
• Require dentists to notify any patient that is prescribed a controlled substance that the patient’s information will be entered into the PDMP if they fill the prescription. This requirement has been in place since 2011. A helpful tear-out flyer is included in this issue and can be posted in your office to satisfy the notification requirement.
• Limit initial opioid prescriptions to seven days and require all opioid prescribers to conduct a PDMP check for all “refills” (second script) of opioid prescriptions. This requirement has been in place since May 2018. Certain exemptions apply and more information can be found on the CDA website.
• Impose more aggressive limits on the drug quantities that will be paid for by insurance plans (both Medicaid and private carriers). Medicaid has restricted opioid prescriptions to four days (up to 24 pills) since 2018. Several private insurers have similar quantity restrictions.
• Require all opioid prescribers to complete training to ensure competency in opioid prescribing best practices (the Colorado Dental Board recently adopted a one-hour training requirement for dentists).
• Require e-prescribing for all opioid prescriptions by July 1, 2023, with limited exceptions for very low volume prescribers (less than 24 opioid scripts per year) and practices where implementation would pose a significant financial hardship (formal waiver required). E-prescribing of opioids may also be required for Medicare patients by July 1, 2021. Please keep these requirements in mind as you renew practice management subscriptions and upgrade software systems in the next few years. The CDA expects to offer some partner solutions for interested Colorado dentists before the 2023 enforcement date.
• Update the state’s PDMP to be more user-friendly in connection with a state sunset review of the program. CDA members will soon be surveyed for input on how the PDMP could be improved in connection with this statewide program review. Legislative efforts in 2020 may also expand drugs visible in the PDMP program to include benzodiazepines and other non-opioid medications.
• Encourage best practice opioid prescribing protocols for dental practice according to guidelines developed in connection with the Colorado CURE project.

Required Continuing Education

Another recent prescriber-facing intervention was the adoption of a 2019 state bill (SB19-228) that added a new training requirement for all prescribers of opioids, including dentists. The training seeks to help address Colorado’s opioid crisis by requiring all prescribers of opioids to complete training in four key areas:

• Best practices for opioid prescribing, according to the most recent version of the DORA Division Professions and Occupations’ Guidelines for the Safe Prescribing and Dispensing of Opioids;
• Recognition of substance abuse disorders;
• Referral of patients with substance use disorders for treatment; and
• Use of the PDMP.

Best practice protocols around opioid prescribing have shifted dramatically in the last decade and even the last few years. The legislature’s hope in adopting training requirements was to ensure that all providers were as up to date as possible on current recommendations and non-opioid pain management options.

In November 2019, the Colorado Dental Board adopted rules that require at least one hour of training (out of up to four possible hours) per license renewal cycle. The rule adopted by the board, which is still pending final state approvals, requires opioid training that addresses at least one of the four topics above and allows credits to be obtained through:

• Relevant continuing education (CE) courses;
• Self-study of relevant scholarly articles or relevant policies/guidelines;
• Peer review proceedings that involve opioid prescribing;
• Attendance at a relevant conference (or portion of a conference);
• Teaching a relevant class/course; or
• Participation in a relevant presentation, such as with your practice.

Dentists must maintain documentation of the training completed.  Dentists are responsible for ensuring that the training they complete follows the requirements of the rule. The Colorado Dental Board will not provide a list of courses or advanced approval for materials.

Opioid training may not be counted toward the 30 bi-annual continuing education credits required to renew a dental license unless the course also meets all requirements for CE credits (as outlined in Dental Board Rule 1.3 (G)—primarily that the course is ADA CERP, AGD PACE, AMA Category 1 or CODA recognized). If a given training would qualify for CE credit if taken independently and also addresses at least one of the four topical areas above, it may be counted for both CE credit and to satisfy the opioid training requirement.

The Colorado Department of Regulatory Agencies (DORA) has indicated that they plan to implement the attestation for the opioid training requirement during the February 2020 dentist license renewal cycle. However, given the less than two-month window between the rule’s effective date and the dental license renewal, DORA has indicated that no enforcement, audits or disciplinary actions related to the opioid training requirement will occur until the 2022 dental license renewal cycle. The attestation will operate like the check box dentists must click to attest to having completed continuing education credits required for each license renewal cycle. Simply check the box if you have completed the required opioid training when completing your February 2020 license renewal. Leave the box unchecked if you have not completed the opioid training (without penalty for the 2020 license renewal).

Complete exemptions from the opioid training requirements are provided for dentists who never prescribe opioids or those who have a national board certification that includes equivalent training to the Colorado Dental Board requirements (though no current board certifications in dentistry appear to meet these standards). If you qualify for an exemption, you should be able to check an exemption box under the attestation during license renewal.

There is a high likelihood that continued discussion of policy interventions to further address the opioid crisis will continue. There is a high degree of continued need around treatment for substance use disorders and community support. There may also be additional payer and provider interventions considered. The CDA will continue to participate in these discussions and focus on an appropriate balance between reducing potential risk for patients and managing regulatory hurdles for dental practices.

References:

1. Centers for Disease Control and Prevention. Ten Leading Causes of Death and Injury. https://www.cdc.gov/injury/wisqars/LeadingCauses.html. Published April 10, 2019. Accessed September 12, 2019.
2. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths – United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2018;67(5152):1419–1427. Published 2018 Jan 4.
3. Centers for Disease Control and Prevention. Understanding the Epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html. Published July 24, 2019. Accessed September 12, 2019.