This spring, Oklahoma joined several states in the nationwide movement to restrict opioid prescriptions. Generally, Senate Bill 1446 places limits on the number of opioid pills that practitioners can prescribe and puts in place safeguards to help curb the potential for opioid abuse.

Acute pain

Starting on November 1, practitioners will only be able to initially prescribe a week’s worth of opioid drugs to manage acute pain and must limit the dosage to the lowest effective dose. Prior to issuing the initial prescription of a Schedule II controlled dangerous substance or any opioid drug to manage acute pain, the practitioner must discuss with the patient (or the parent or guardian if the patient is under age 18) the risks associated with the drugs, including the risks of addiction and overdose and the dangers of taking opioid drugs with alcohol, benzodiazepines and other central nervous system depressants, the reasons why the prescription is necessary, and alternative treatments that may be available.

Before renewing the prescription for up to seven more days, the law requires a consultation with the patient to determine that the patient needs the prescription and that the prescription does not present a risk for abuse, addiction, or diversion. If after the initial 14 days the practitioner determines that the patient still needs opioids to manage acute pain, the practitioner must again discuss the risks associated with the drugs, the reasons why the prescription is necessary, and alternative treatments that may be available. The practitioner must also enter into a patient-provider agreement with the patient.

Chronic pain

In addition to restricting certain prescriptions for acute pain, the law implements increased safeguards for patients who are prescribed opioids or other Schedule II controlled dangerous substances for chronic pain. For instance, practitioners are now required to enter into a patient-provider agreement with the patient that explains the risk of dependence on opioids and documents the mutual understanding of the plan between the practitioner and patient. The law also requires a practitioner to review the treatment plan progress at a minimum of every three months and to assess the patient before each renewal to determine if the patient is experiencing dependence problems.

Patients who are prescribed a Schedule II controlled dangerous substance or any opioid drug for cancer treatment, hospice, or palliative care or who are residents in a long-term care facility are exempted from these requirements.

Additional requirements

The law also requires physicians to participate in one hour of continuing education in pain management or opioid abuse and addiction each year before the physician renews his or her license to practice. As written, the law only amends the CME requirements for MDs, but we expect the Oklahoma State Board of Osteopathic Examiners to follow suit. Notably, the law provides for disciplinary action if a practitioner fails to check the Oklahoma Prescription Monitoring Program (PMP) database as required by statute.

Attorney General guidance

The changes to opioid prescribing requirements have given rise to a number of questions from healthcare providers, including questions about the ability of mid-level providers and other staff to perform the required visits and consultations and the necessity of face-to-face visits for each required discussion with the patient.

The Oklahoma Office of Attorney General recently addressed some of these questions in a letter to the Oklahoma Board of Medical Licensure and Supervision. The letter clarified that the initial seven-day prescription for a Schedule II controlled dangerous substance or any opioid drug for patients suffering from acute pain requires a physician to have a face-to-face encounter with the patient. However, the consultation required to issue a subsequent seven-day prescription may be performed by any “practitioner,” which includes a physician assistant under the supervision of a physician, or “any other person licensed, registered, or otherwise permitted to prescribe, distribute, dispense … or administer a controlled dangerous substance in the course of professional practice or research in this state,” which would include an Advanced Practice Registered Nurse (APRN) with prescriptive authority. If the practitioner determines through the consultation that the subsequent prescription is necessary, appropriate, and does not present a risk of abuse, then the practitioner would consult with his or her supervising physician, who would then issue the subsequent prescription. Similarly, any “practitioner” may conduct the required three-month assessment for patients suffering from chronic pain.

It is important to note that the AG’s interpretation appears to assume that the particular drug being prescribed is one that only physicians can legally prescribe, but keep in mind that there are certain opioids that are not classified as Schedule II controlled dangerous substances that physician assistants and APRNs with prescriptive authority can legally prescribe, and they will continue to be permitted to prescribe those drugs after November 1, provided that they adhere to the new procedures described above. Additionally, there appears to be some differences of opinion among state licensing boards on these issues involving mid-level providers and the necessity of face-to-face visits, so be on the lookout for further guidance.

Physicians, mid-level providers, hospitals, and other healthcare providers will all be impacted by these new opioid prescribing requirements.