Starting October 2, 2018, prescribers in California will be required to check the state’s prescription monitoring database, Controlled Substance Utilization Review and Evaluation System (CURES), before prescribing Schedule II, III, or IV drugs. California is one of 39 states that mandate prescribers to check prescription monitoring databases in an effort to combat the opioid epidemic. By checking a database before prescribing, prescribers can identify “doctor shoppers” who go from doctor to doctor to obtain multiple prescriptions.

Prescribers will now be required to check CURES if it is the first time prescribing the scheduled drug for the patient or if it has been four months since the last time they checked the database for the patient. The check must be completed no earlier than 24 hours or the previous business day prior to the prescribing, ordering, administering or furnishing of a controlled substance to the patient.

All prescribers who were authorized to prescribe or dispense Schedule II-IV controlled substances were originally required to just register to use CURES by July 1, 2016. The requirement to check the database was to start six months after the state certified the database was ready. The California Department of Justice (DOJ) certified CURES was ready for statewide use on April 2, 2018.

If prescribers do not comply, it could result in disciplinary proceedings against a practitioner’s license. The Medical Board of California states in their CURES Mandatory Use FAQs¹, “Failing to consult CURES is a violation of the law and it could result in the issuance of a citation and fine, or could be a cause of action In an accusation that leads to disciplinary action. Disciplinary action could be a public reprimand, suspension, probation, or revocation. Each violation of the law is reviewed on a case-by-case basis.”

The Medical Board of California also recommends that prescribers either note in the patient’s chart that they checked the CURES database or print the report and put it in the patient’s file to document that the check was completed.

MDToolbox makes it convenient for prescribers to check CURES by providing a link directly to the database from within the prescription writer. The system also automatically makes note that the database was checked for the prescriber. For more information and to request a free trial, see California E-Prescribing or contact us at info@mdtoolbox.com.

1. Medical Board of California CURES Mandatory Use FAQs http://www.mbc.ca.gov/Licensees/Prescribing/CURES/CURES_FAQ.pdf?utm_source=link&utm_medium=email&utm_campaign=CURES&utm_content=faq

President Donald Trump declared the opioid epidemic a national public health emergency on October 26, 2017. In his address, Trump called opioids the “worst drug crisis in American history.”

After the President’s declaration, the President’s Commission on Combating Drug Addiction and the Opioid Crisis issued its final report¹. In the Chairman’s letter written by Governor Chris Christie, he points out that 175 Americans are dying a day from this epidemic. The 131-page report goes on to include more than 50 recommendations.

One of the most prudent recommendations is that the Office of National Drug Control Policy (ONDCP) and the DEA increase electronic prescribing to prevent diversion and forgery. They also recommend that the DEA revise the Interim Final Rule which lays out the requirements for electronically prescribing controlled substances in order to make registration and using EPCS easier.

Other recommendations include mandatory PDMP checks, the creation of a Department of Justice-led data-sharing hub, and integrated PDMP data in EHRs. The report suggests passing the Prescription Drug Monitoring (PDMP) Act of 2017 which mandates using PDMPs in states that receive federal funding. This Act also directs the Department of Justice (DOJ) to fund the establishment and maintenance of a data-sharing hub so information could be shared across states. The Commission points out that many providers resist using PDMPs because they don’t integrate well into EHRs, so they believe improving these integrations is necessary to increase effectiveness.

While these are great strides in the right direction, there is still a huge issue at hand. Trump did not mention any specific actions the administration will take or how they will be funded. With only declaring it a national public health emergency as opposed to a national emergency, there is not much more funding available. The commission’s report urges Congress and the Administration to block grant federal funding for opioid-related and SUD-related activities to the states. However, the report does not address the amount of funding needed for their recommendations.

1. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf

In a draft report, the Commission on Combating Drug Addiction and the Opioid Crisis proposed that state and federal prescription drug monitoring programs (PDMPs) should be completely interoperable by July 1, 2018¹. The White House-appointed commission is led by New Jersey Governor Chris Christie and is tasked with addressing the national opioid crisis.

The commission proposed several recommendations to President Trump in the report including declaring the opioid epidemic a national emergency. Specifically relating to the PDMPs it states, “Provide federal funding and technical support to states to enhance interstate data sharing among state-based prescription drug monitoring programs (PDMPs) to better track patient-specific prescription data and support regional law enforcement in cases of controlled substance diversion. Ensure federal health care systems, including Veteran’s Hospitals, participate in state-based data sharing.”

The report states that currently 49 states have PDMPs but many do not share data. As we wrote about earlier, 37 states are connected to NABP PMP InterConnect which is run by the National Association of Boards of Pharmacy. The commission urged that the VA and HHS should lead the effort to have all state and federal PDMP systems share information.

The report went on to state that PDMPs need to be easy to use and include other data to assist prescribing doctors. Interestingly, the commission said that “ideally, clinician should check their state PDMP before making the decision to prescribe either an opioid or benzodiazepine” but there was no recommendation to make it mandatory for prescribers to check.

The commission’s final report is due in just a couple weeks on October 1^st and it’s expected to include several other recommendations related to health IT.

1.  https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf

Missouri Governor Eric Greitens recently signed Executive Order (EO) 17-18¹ directing the Missouri Department of Health and Senior Services (DHSS) to create a statewide Prescription Drug Monitoring Program (PDMP). Despite legislative efforts for more than a decade, Missouri is currently the only state lacking such a program.

The governor’s announcement of the statewide PDMP said that it will utilize de-identified data from private sector partners to target “pill mills” that pump out prescription drugs at dangerous and unlawful levels. It will monitor both prescribers and dispensers of Schedule II through Schedule IV controlled substances in an effort to go directly to the source of drug shoppers. Opioids are the main focus as the national plague is hitting hard in Missouri with over 900 deaths in 2016 being due to opioid overdoses.

The executive order received national praise. Richard Baum, Acting Director of National Drug Control Policy stated, “In the context of both the ongoing opioid epidemic and the health of Missourians, it’s vital to have safeguards in place to make sure that doctors aren’t overprescribing opioids that can be misused and patients aren’t doctor-shopping for multiple prescriptions that could be misused or diverted.” Secretary Tom Price of the U.S. Department of Health and Human Services also praised the Governor stating, “I commend Missouri Governor Eric Greitens for taking a strong step in fighting the opioid epidemic by joining other states in establishing a Prescription Drug Monitoring Program (PDMP). I commend Governor Greitens for his leadership in Missouri as we all work to detect and deter the abuse of prescription drugs.”

State statute prevents Missouri from identifying patients, so they will be focusing on the prescribers and the dispensers with data from pharmacy benefit management organizations. They plan to be live with data from Express Scripts Holding Co. later this summer and hope to contract with two additional pharmacy benefit management organizations as well.

Due to the lack of a statewide program, local counties, led by St. Louis County, took it upon themselves earlier this year to create a prescription monitoring program. The St. Louis County PDMP focuses at the patient level instead of on prescribers and dispensers. The county program has three goals listed on its website²:

   1) Improve controlled substance prescribing by providing critical information regarding a patient’s controlled substance prescription history
   2) Inform clinical practice by identifying patients at high-risk who would benefit from early interventions
   3) Reduce the number of people who misuse, abuse, or overdose while making sure patients have access to safe, effective treatment

The new statewide PDMP is hoped to be a companion to the county program which covers the majority of the state, not a replacement, as the two systems take different approaches to combating the opioid epidemic.

1.https://governor.mo.gov/news/archive/governor-eric-greitens-announces-statewide-prescription-drug-monitoring-program

2. http://www.stlouisco.com/HealthandWellness/PDMP

New York State Attorney General Eric Schneiderman’s office sent a letter¹ September 20th asking Governor Andrew Cuomo to veto two bills seen as loopholes to the newly implemented Internet System for Tracking Over-Prescribing (I-STOP) laws. I-STOP mandates electronic prescribing in New York and requires prescribers to check the state Prescription Monitoring Progarm (PMP) before prescribing controlled substances.  The goal is to prevent drug abuse and drug seeking and increase patient safety. Read more about I-STOP here.

The first bill (S.6778/A.9334)² relates to nursing homes. It would provide an exception to the requirement to e-Prescribe for prescribers in nursing homes. The reasoning behind the bill is that prescribers are not in nursing homes 24 hours a day and patients need to get their medications in a timely manner. The letter requesting the veto points out that oral prescription orders are already allowed in emergency situations which should suffice any true needs and the bill would only serve to weaken I-STOP. The Deputy Attorney General, Brian Mahanna, stated in the letter that healthcare errors and drug diversion are particularly problematic in nursing homes and electronic prescribing has proven to reduce them. Not only does electronic prescribing reduce errors such as illegible handwriting and increase patient safety, it offers the ability for an on-call Long Term Care prescriber to approve and send medications even when they are away from the facility. Many software systems (including MDToolbox) have easy to use mobile apps and web versions that can be securely accessed from wherever the prescriber is.

The second bill (S.6779-B/A.9335-B)³ would provide an exception to prescribers who write paper prescriptions from having to report them to the state Department of Health. I-STOP requires all prescriptions to be sent electronically, but there are three statutory exemptions. These include a temporary electrical or technical failure, if e-Prescribing would result in a delay that would adversely impact a patient’s health, or if the prescription is to be filled out-of-state.  Currently, if a prescriber writes a paper prescription because of one of these exemptions they are required to file a report with the Department of Health. The bill removes this requirement and only calls for a notation in the patient’s record. Mahanna states in his letter this bill would “create a gaping loophole in ISTOP’s universal e-Prescribing reporting requirements.” He points out that prescribers could avoid compliance with I-STOP and “doctor shopping” patients could lie about a prescription being filled out of state.

The two bills passed the NYS legislature earlier this year and were just delivered to the Governor.

1.https://www.scribd.com/document/324826179/2016-9-20-Ltr-to-a-David-Re-ISTOP#from_embed

2.  An act to amend the public health law and the education law, in relation to exceptions to requirements for electronic prescriptions 

3. An act to amend the public health law and the education law, in relation to electronic prescriptions 

All eyes have been on New York State as their I-STOP law requiring prescriptions to be sent electronically went into effect in March. Electronic Prescribing of Controlled Substances (EPCS) and non-controlled substances is mandatory across the state. Due to this mandate, New York leads the nation with the highest percentage of e-Prescribing pharmacies and prescribers. Other states are looking to New York to see how successful their mandate is and some have started to follow suit.

Maine is following New York by requiring controlled substance prescriptions to be sent electronically by July 2017. However, Maine is not requiring non-controlled substances to be prescribed electronically. It would follow that if prescribers are sending controlled substances electronically, they will most likely prescribe non-controlled substances through the same route though. Their law is in combination with required use of their state Prescription Monitoring Program (PMP) in an effort to combat opiate abuse. Read more about it in our post Maine to Require e-Prescribing of Controlled Substances.

Minnesota was actually the first state to require electronic prescribing. However, there are no penalties for writing paper prescriptions so many prescribers still pick up their paper pad when they need to prescribe. According to Surescripts’ National Progress Report¹, in 2015 Minnesota ranked 24^th compared with other states with less than 3% of their prescribers enabled for EPCS.

Massachusetts just launched an updated version of their state PMP to the tune of $6.2 million. They updated it with the aim of making it easier and faster for prescribers to use, as the old system was said to be very difficult to navigate and severely underutilized. The system now also offers interstate operability by giving Massachusetts prescribers access to data from other states. Currently, the number of other states’ data available is limited but the system has the potential to connect with up to 45 other states. Other updates include the ability to sync with EMRs, the ability to easily assign delegates to check the system on the prescriber’s behalf, and allowing for easy reporting to compare prescribing practices with other physicians. Starting October 15^th, prescribers will be required to check the state PMP any time they prescribe a schedule II or schedule III drug, as opposed to the current requirement of only checking the first time they prescribe one of these drugs.

Now that Massachusetts has their new PMP in place, it is rumored they may be the next state to require EPCS. They ranked number 9 in Surescripts’ National Progress Report with over 90% of their pharmacies enabled for EPCS, but the percent of prescribers with EPCS capabilities was only 4%. As of last week, 63% of their prescribers who had prescribed opioids were registered with the PMP but the number is growing daily.

At MDToolbox, we are watching closely in anticipation to see which state will be the next to take this important step in combating drug fraud and abuse.

1. 2015 National Progress Report http://surescripts.com/news-center/national-progress-report-2015/