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Division of Professions and Occupations (DPO): Opioid Guidelines - Under Review and Pending Update

Highlights

Overview

On March 14, 2019, the revised Guidelines for Prescribing and Dispensing Opioids were adopted by all six of Colorado's prescribing and dispensing Boards: the Colorado Dental Board, the Colorado Medical Board, the State Board of Nursing, the State Board of Optometry, the Colorado Podiatry Board, and the State Board of Pharmacy, and endorsed by the State Board of Veterinary Medicine.

Revisions were necessary due to the new requirements in Senate Bill 18-22 Clinical Practice for Opioid Prescribing. This new state law went into effect on May 21, 2018, immediately upon the Governor's signature. The law sets forth prescribing requirements, such as the number of opioids to be prescribed and required Prescription Drug Monitoring Program checks in certain clinical situations. The law also provides specific exemptions to these requirements.

The Boards will continue to evaluate the Policy, incorporating new legislation and collaborating with other state agencies, researchers, practitioners, patients, the Colorado Consortium for Prescription Drug Abuse Prevention, and other stakeholders to identify and evaluate outcomes. The Boards remain committed to this Policy as a living document, reflective of the evolving science, technology, policy and law in their ongoing efforts to address Colorado's opioid crisis.

New Law Affects Colorado Prescribers, Limits Opioid Prescriptions

Note: The prescribing and dispensing Boards are reviewing Senate Bill 18-22 Clinical Practice for Opioid Prescribing, and considering its impact, if any, on the Guidelines for Prescribing and Dispensing Opioids. Please check back for updates.

On Monday, May 21, 2018, Governor John Hickenlooper signed Senate Bill 18-22 Clinical Practice for Opioid Prescribing. The bill went into effect immediately upon the Governor's signature. This new state law limits the number of opioid pills a healthcare provider can prescribe and affects physicians, physician assistants, advanced practice registered nurses with prescriptive authority, dentists, optometrists, podiatrists, and veterinarians.

Under the new law, a prescriber must limit a patient's initial prescription of an opioid to a seven-day supply, if the prescriber has not written an opioid prescription for the patient in the last 12 months. The prescriber may exercise discretion in including a second fill for a seven-day supply. These limits do not apply, if, in the judgment of the prescriber, the patient:

  • Has chronic pain that typically lasts longer than 90 days or past the time of normal healing, as determined by the prescriber, or following transfer of care from another prescriber who prescribed an opioid to the patient,
  • Has been diagnosed with cancer and is experiencing cancer-related pain, or
  • Is experiencing post-surgical pain, that, because of the nature of the procedure, is expected to last more than 14 days.
  • Is undergoing palliative care or hospice care focused on providing the patient with relief from symptoms, pain and stress resulting from a serious illness in order to improve quality of life. (This exemption is allowed for physicians, physician assistants and advanced practice registered nurses only.)

After the first prescription, the prescriber is required to check the Prescription Drug Monitoring Program (PDMP) database before prescribing any additional opioids for the same patient. Failure to check the PDMP constitutes unprofessional conduct if the prescriber repeatedly fails to comply with this new requirement. The second fill requirement to check the PDMP does not apply when a patient:

  • Is receiving the opioid in a hospital, skilled nursing facility, residential facility, or correctional facility,
  • Has been diagnosed with cancer and is experiencing cancer-related pain, or
  • Is undergoing palliative care or hospice care,
  • Is experiencing post-surgical pain, that, because of the nature of the procedure, is expected to last more than 14 days,
  • Is receiving treatment during a natural disaster or during an incident where mass casualties have taken place or has received only a single dose to relieve pain for a single test or procedure.

After the second opioid prescription, the law has no further restrictions on the healthcare provider's prescribing practices. The new law does require a healthcare provider, or the provider's designee, to specify the provider's specialty upon the initial query of the PDMP. It also states a violation of the new requirements does not constitute negligence or contributory negligence per se and does not create a private right of action or serve as the basis of a cause of action.

Key Points and Recommendations

  • These guidelines do not have the force of law, but instead are intended to assist practitioners evaluate and make informed decisions about the safe prescribing and dispensing of opioids.
  • Collaboration with Mental and Behavioral Health.
  • Consideration of alternatives to opioids.
  • Partnership with the patient to develop a treatment plan, including functional goals and an exit strategy.
  • Patient education, including the risks and benefits of opioid therapy, which is crucial prior to initiating therapy, before increasing the dosage and upon meeting the "bright line" safe prescribing thresholds.
  • Reduction in days of treatment for acute pain.
  • Assessment of patient functionality early and often.
  • Frequent re-balancing of the risks and benefits of continued opioid therapy.
  • Incorporation of three "bright line" safe prescribing thresholds upon which the prescriber should re-evaluate the patient and the effectiveness of the opioid treatment and employ risk mitigation strategies, including prescriptions for Naloxone, if opioid treatment is to continue:
    • Dosage: 50 mme/day
    • Formulation: Long-acting or extended-relief formulation
    • Duration:
      • 3-7 days for acute, non-traumatic or non-surgical pain
      • 30 days for sub-acute pain
      • 90 days for chronic, non-cancer pain

Q&A Webinar

The Division of Professions and Occupations held an informational session on April 20, 2018, to educate stakeholders on the new Guidelines for Prescribing and Dispensing Opioids.

More information clarifying and explaining core aspects of the Guidelines will be available in the coming weeks. Written questions may be provided at any time to holli.weaver@state.co.us. Questions received in person, via webinar or in writing will help the Division develop a Frequently Asked Questions (FAQ) document, which will be posted on the prescribing and dispensing Board's websites at a later date.

Prior Opioid Policy Stakeholder Recordings

The Division hosted several stakeholder meetings in Denver prior to the adoption of the Guidelines for Prescribing and Dispensing Opioids. The following recordings are available on YouTube.

August 30, 2017 | October 27, 2017 | November 14, 2017 | December 28, 2017

Streamlined Veterinary Opioid Policy adopted

On December 14, 2017, the State Board of Veterinary Medicine updated its policy for the prescribing and dispensing of opioids to reflect changes from SB 17-146 Access to Prescription Drug Monitoring Program, signed into law on April 6, 2017. This policy was originally adopted in an effort to provide guidelines to veterinarians. Opioid use in the practice of veterinary medicine requires a unique policy to address the nuances of practice that involves the animals and the owner. Download the updated Veterinary Opioid Prescribing and Dispensing Policy.