Cover: The opioid crisis
What physicians need to know to be in compliance with new laws
by Kate Alfano, CMS Communications Coordinator
Five bills that will change the way physicians treat acute pain passed the 2018 Colorado General Assembly and were signed into law by Gov. John Hickenlooper. Colorado, like virtually every state in the country, is struggling with ways to mitigate the medical and economic consequences of the opioid epidemic.
The suite of legislation – which included one additional bill that did not pass this session – was developed by the 2017 Opioid and Other Substance Use Disorders Interim Study Committee last summer with strong involvement and support by the Colorado Medical Society and many other stakeholders.
The bills include measures that increase funding for access to treatment, enhance misuse prevention, require health plans to cover certain FDA-approved drugs for medication-assisted opioid dependence treatment without prior authorization, and enact safer opioid prescribing.
“We tried to take on the opioid crisis as comprehensively as we could,” said Sen. Jack Tate, R-Centennial, who served on the interim study committee and sponsored Senate Bills 22, 24 and House Bill 1136. “There are limits as to what the state government can do and fund, and limits with regard to intervening in the clinician-patient relationship. Keeping all those things in mind we got a package of bills through that I think touches a lot of parts of the crisis where we can help.”
“Each of the bills doesn’t necessarily solve the problem of the opioid epidemic but for a crisis of this magnitude, a single piece of legislation can’t be expected to solve the problem,” said Rob Valuck, PhD, RPh, director of the Colorado Consortium for Prescription Drug Abuse Prevention and co-chair of the interim study committee stakeholder task force. “These five bills represent a meaningful step forward in the right direction by addressing a wide range of issues within the crisis, from prevention to recovery.”
Senate Bill 18-022: Clinical Measures for Safer Opioid Prescribing
Effectivel immediately, SB18-022 limits physician prescribing of opioid narcotics for certain patients. Patients within the following categories are exceptions and the new law does not apply to them:
- Chronic pain patients with a history of pain lasting more than 90 days or following transfer from another physician who prescribed an opioid,
- Cancer-related pain patients,
- Hospice and palliative care patients,
- Patients who undergo a surgical procedure with pain expected to last more than 14 days because of the nature of the procedure.
For all other patients, the prescribing physician must limit the initial prescription of an opioid narcotic to no more than a seven-day supply of the medication. For outpatient care, after issuing the first opioid narcotic prescription the prescribing physician must check the Prescription Drug Monitoring Program (PDMP) database before prescribing any further opioid narcotics for the patient. The prescribing physician may exercise discretion to prescribe a second additional seven-day supply of opioid narcotic medication to the patient.
After the second opioid narcotic prescription, the law no longer applies to any patient and further prescribing of opioid narcotics to the patient is guided by the physician’s judgment and medical indications for treatment of the patient.
“Prescribers at one point were a root problem [of the opioid crisis] – in part due to the active misrepresentations by a few drug manufacturers and the government’s establishment of pain as the fifth vital sign,” Tate said. “This situation has been reversed. Because of the concerted efforts of the health professions over the past five years to rethink and reeducate themselves, the prescribing of opioids in Colorado is now in a state of decline. As the health professions are the first to say that much more work needs to be done, they see SB 22 as affirming, buttressing, and accelerating this progress.”
“I think that physicians haven’t gotten enough credit for all the work they’ve done already at cutting back on the prescribing of opiates,” said Sen. Irene Aguilar, MD, D-Denver. “I’m sure the next steps won’t be very dramatic for most but for those physicians who may not realize how significant our opioid crisis is, I hope that the limit on initial prescriptions will help them rethink whether there might be a safer method of treating someone who has acute pain.”
House Bill 18-1003: Opioid Misuse Prevention
The most important actions of this broad-scoped bill are that it extends the work of the 2017 interim committee for two years by establishing the Opioid and Other Substance Use Disorders Study Committee and it directs the center for research into substance use disorder prevention, treatment and recovery to develop and implement continuing medical education activities to help prescribers of pain medication safely and effectively manage patients with chronic pain, and when appropriate, prescribe opioids.
“We’re glad the committee will be around for two more years so they can keep doing this job for a meaningful length of time,” Valuck said. “We expect they’ll be able to figure out virtually everything the state could do and try to do it.”
“We’re looking for even more engagement, especially from the physician community,” he continued. “CMS has been involved since the beginning. We’re hoping to see even more engagement from the component societies of CMS and the specialty societies. The more doctors step up in leadership positions and help lead the solution, the more successful we’ll be.”
Of the need for medical society involvement, Rep. Brittany Pettersen, D-Jefferson, said “We need them at the table so legislation isn’t passed that has unintended consequences. We also need their help with outreach and education about the bills passed during this last session. There is a lot of misinformation out there and the medical societies can help inform physicians.”
HB18-1003 also establishes the following specific measures to combat opioid misuse in Colorado:
- Requires the governor to direct the Colorado Consortium for Prescription Drug Abuse Prevention to report to the General Assembly on recovery services and approaches in other states;
- Authorizes school-based health centers to apply for grants to expand behavioral health services to include substance use disorder treatment and requires the Department of Public Health and Environment to prioritize funding to the centers that serve communities with high-risk factors;
- Directs the Department of Health Care Policy and Financing to award grants supporting substance abuse screening, brief intervention and referral programs; and
- Establishes programs to prevent youth addiction and support youth whose family members experience addiction.
The law takes effect July 1.
HB18-1007: Substance Use Disorder Payment and Coverage
This legislation requires all individual and group health benefit plans to provide coverage without prior authorization for a five-day supply of at least one FDA-approved drug for medication-assisted opioid dependence treatment for the first request within a 12-month period.
Under the bill, insurers cannot take adverse action against a provider based solely on a patient satisfaction survey relating to the patient’s satisfaction with pain treatment.
The law takes effect Jan. 1, 2019.
HB18-1136: Substance Use Disorder Treatment
This bill adds residential and inpatient treatment coverage as well as medical detoxification services to Colorado Medicaid to serve individuals with substance use disorders, including those with co-occurring mental health disorders. The State Department has to seek federal approval no later than Oct. 1, 2018.
SB18-024: Expand Access Behavioral Health Care Providers
The final bill introduced from the 2017 interim study, it amends the Colorado service corps program by expanding the availability of behavioral health care providers in shortage areas in the state by establishing a system for school loan repayment and a scholarship for providers trained in addiction counseling.
“Behavioral health care providers” comprises licensed and certified addiction counselors; licensed professional counselors; licensed clinical social workers; licensed marriage and family therapists; licensed psychologists; licensed physician assistants with specific training in substance use disorders; advanced practice nurses; physicians certified or trained in addiction medicine, pain management or psychiatry; and candidates for licensure as an addiction counselor, professional counselor, clinical social worker, marriage and family therapist or psychologist.
“We know that the opioid epidemic reaches into all areas of Colorado, both urban and rural, and across all socio-economic classes,” Tate said. “Unfortunately, treatment for mental health and substance use disorders is not as widespread. With SB 24, the state will devote $2.5 million toward incentivizing behavioral health care providers to go into areas of the state where care is not readily available and also toward funding important addiction treatment training.”
The law takes effect July 1.
“I’m pleased with the progress we made passing five bills in our opioid package and securing funding increases for treatment in the budget,” said Rep. Chris Kennedy, D-Lakewood, who sponsored or co-sponsored each of the opioid bills. “The steps we’ve taken will reduce overprescribing and increase access to treatment and recovery services across Colorado.”
The interim study committee has been authorized to operate for two more years. “I think we have a huge opportunity to set the groundwork to be a leader nationally in the way we address the epidemic,” said Pettersen, who also said she is chairing the committee for a second year. “I am really proud of what we’ve been able to accomplish but it is just the first step and I am committed to having doctors at the table as we continue the conversation.”
“The opioid crisis is very much one of those issues that thankfully isn’t partisan at all,” Aguilar said. “I hope going into the next session that more focus is put on treatment and looking at some of the social determinants that contribute to this issue.”
Posted in: Colorado Medicine | Cover Story | Practice Management | Legal and Ethics | Initiatives | Prescription Drug Abuse