1. Presented to: Gaston Controlled Substances Coalition, October 22, 2016
NCMB opioid prescribing update
Debra A. Bolick, MD Board Member
Presented to: Gaston Controlled Substances Coalition, October 22, 2016

2. Overview Update on new CME requirement Mandatory CSRS registration
Update on Safe Opioid Prescribing Initiative
Disciplinary process overview
Resources
Q & A

3. New CME requirement
NCMB recently received final approval for a new requirement for physicians and PAs to earn CME in controlled substances prescribing
Primary objectives:
Reduce inappropriate opioid prescribing and associated patients deaths and harm
Improve quality of care
Effective date: July 1, 2017

4. What are qualifying education topics?
Controlled substances prescribing
Chronic pain management
Avoiding abuse/diversion
All three topics need not be covered in every course completed
However, all three topics must be covered at least 1X during three-year CME cycle

5. Who is subject?
Licensees who wrote ANY controlled substances (even non-opioids) during most recent CME cycle
This includes retirees; If you prescribed controlled substances, you must comply
Who is exempt?
Licensees who wrote NO controlled substances scripts in the prior CME cycle
Residents

6. Enforcing the new requirement
Licensees will NOT be routinely required to submit documentation of each course completed
NCMB will continue its established practice of random CME audits to determine compliance with overall CME requirement and controlled substances requirement
If audited, you will be expected to submit documentation

7. Where to find courses
Many existing CME courses will meet the requirement
NCMB does not maintain a comprehensive list of “approved” courses – if the education topic is covered and the course is appropriately certified, it will count
NCMB posts a limited number of high quality, free or very low cost CME opportunities on its website

8. Overview Update on new CME requirement Mandatory CSRS registration
Update on Safe Opioid Prescribing Initiative
Disciplinary process overview
Resources
Q & A

9. NC CSRS
2016 NC General Assembly passed a bill that will make NC CSRS registration mandatory
All DEA registration holders would be subject
Law requires registration only (regular use is urged for NC prescribers)
Requirement would not take effect until NC CSRS completes technical upgrades
NCMB encourages timely compliance Why wait?

10. Fifth bullet, under Resources (bottom left of home page)
Also, can access by clicking on the slideshow image (bullet number four in the slides)

12. Note the position of Training & CSRS on the navigation.
Users must scroll down to the CSRS portion of the page. Click on the blue “here” to load the registration form. Licensees need provide just three pieces of information to register: DEA number, their address and a proposed password for NCCSRS access.
For residents, the menu item is labeled Address & CSRS.

13. Objectives Update on new CME requirement Mandatory CSRS registration
Update on Safe Opioid Prescribing Initiative
Disciplinary process overview
Resources
Q & A

14. NCMB stance on opioid prescribing
Pain is a legitimate medical problem; Patients deserve safe, appropriate care
NCMB has an obligation to encourage and ensure responsible opioid prescribing
Board does this through enforcement, but also by providing resources, developing policy
Bottom line: NCMB’s message is NOT, “Don’t treat pain” – It’s “Treat pain appropriately”

15. Who is investigated?
Physicians and PAs who are managing large numbers of patients at high doses of opioids
Physicians with 2+ patients deaths due to opioid overdose
Top one percent prescribing 100 milligrams of morphine equivalents (MME) per patient per day.
Top one percent prescribing 100 MMEs per patient per day in combination with any benzodiazepine and within the top one percent of all controlled substance prescribers by volume.
Prescribers with two or more patient deaths within a 12–month period due to opioid poisoning.

16. SOPI by the numbers
Since April, when SOPI was implemented, NCMB has opened 55 cases based on data provided by NCDHHS
20 percent of cases based on high dose, high volume criteria; rest on patient deaths criteria
To date, SOPI has directly affected 0.2 percent of prescribers (99.8 percent of prescribers not directly affected)

17. Areas of practice represented
About 1/2 of licensee cases reviewed to date by Chief Medical Officer’s department practice either pain management OR physical medicine & rehab
Remainder of licensees reviewed by CMO department practice in one of the following areas: family/internal medicine, emergency medicine, psychiatry or orthopedic surgery
No hospice/palliative care professionals

18. Board actions so far
To date, 18 cases have been decided by the Board, with the following results:
22 percent Board voted to pursue public action against the licensee
33 percent Board voted to take private action
44 percent Board voted to close case with no formal action

19. SOPI impact
NCMB has received a significant volume of calls from patients who report apparently arbitrary prescriber decisions to reduce doses
Many patients contacting NCMB state that doses have been cut in half or more, with no tapering
NCMB has received reports from emergency room physicians that more patients are being seen in the ED with acute withdrawal

20. Key points about opioids
100 MMEs/day is NOT a limit; Some states have established legal limits on opioids – NC is not one of them.
Physicians and PAs should provide appropriate pain management to their patients, in accordance with current standards of care
Prescribing at or above 100 MMEs per patient, per day, by statute, cannot be a basis for discipline (e.g. if care is otherwise appropriate)

21. Objectives Update on new CME requirement Mandatory CSRS registration
Update on Safe Opioid Prescribing Initiative
Disciplinary process overview
Resources
Q & A

22. Disciplinary Process Information received Investigation
Senior Staff Review
Committee & Full Board

23. What is the Board looking for?
In any case reviewed, the Board will determine whether a licensee practiced within accepted standards of care.
Standard of care is established primarily through the use of independent expert medical reviewers
Opioid cases are reviewed by other opioid prescribers practicing in NC

24. Hallmarks of appropriate care
Patient records document an appropriately thorough new patient evaluation
A specific differential diagnosis is established
There is documented development of a meaningful treatment plan
There is periodic review of the patient’s current status with documentation of progress towards established treatment goals

25. Guarding against abuse, diversion
The Board expects prescribers to actively monitor for diversion, abuse and addiction (e.g. pain contracts, pill counts, UDS, use of NC CSRS)
Board does not expect UDS, CSRS profile check every visit; Let individual patient circumstances guide you
The Board considers the prescriber’s response in the face of evidence of possible abuse/addiction. Does prescribing continue? Is patient confronted?

26. Acute pain
In acute contexts, (ex: post surgical pain relief) prescribers must take care not to overprescribe.
Be alert to hallmark signs of drug seeking: losing or forgetting medicine, requests for early refills or for repeated refills, complaints of severe pain several days post procedure absent the signs of infection, etc.

27. Objectives Update on new CME requirement Mandatory CSRS registration
Update on Safe Opioid Prescribing Initiative
Disciplinary process overview
Resources
Q & A

29. CME resource page

31. Opioid prescribing information
Note: MUST use url to access pages. Pages cannot be found using NCMB website site search.

33. In summary
To meet obligations to patients and avoid problems with the Board, NCMB recommends licensees:
Review opioid prescribing resources to assist with complying with current standards of care
Review panel of pain patients and practice policies – consistent with current standards?
Questions or concerns? Contact the Board. We cannot give legal advice, but we can explain NCMB expectations, policies and practices

34. Thank you!
Questions?