Tackling the Opioid Epidemic: Wisconsin Legislators, Governor, Agencies and Practitioners Team Up to Prevent Abuse

The opioid epidemic has garnered widespread attention and action both nationally and at the state level. The Wisconsin Legislature, Governor and administrative agencies continue to take actions to address the significant challenges of opioid overdose, misuse and abuse in Wisconsin. A number of the state initiatives aimed at combating these problems focus on the practices of health care practitioners authorized to prescribe controlled substances under their Wisconsin licenses.

Wisconsin’s Medical Examining Board (“MEB”) and Board of Nursing (“BON”) have issued guidelines regarding best practices in prescribing opioids, as authorized by 2015 Wisconsin Act 269. The MEB and BON have also added continuing education requirements for practitioners authorized to prescribe controlled substances. Below is an overview of the guidelines, with a focus on the guidelines recently approved by the BON, and brief summary of the continuing education requirements.

These steps come in advance of the requirement, effective on April 1, 2017, that prescribers review patient information from the Wisconsin enhanced Prescription Drug Monitoring Program (“ePDMP”) prior to prescribing any controlled substance for a supply greater than three days, as described in more detail below.

BON Guidelines

Overview

The BON’s Best Practices for Prescribing Controlled Substance Guidelines (“BON Guidelines”), which the BON approved on January 2, 2017 and are available here, are clinical practice guidance for APNPs prescribing controlled substances. An APNP is a nurse practitioner, nurse-midwife, certified registered nurse anesthetist or clinical nurse specialist who has been granted a certificate by the BON to issue prescription orders in compliance with Wisconsin Administrative Code N 8 (“N8”). The BON’s Controlled Substances Committee developed the guidance after researching both state and national guidelines and receiving input from various stakeholders and the public. The Centers for Disease Control Guideline for Prescribing Opioids for Chronic Pain (“CDC Guidelines”) is specifically cited as a resource.¹

The BON makes clear that this guidance is meant to serve as a supplement to, and not as a replacement for, an APNP’s clinical judgment. The scope of the BON Guidelines is not limited by setting (such as inpatient or outpatient) or by patient population, except that the guidance does not apply to patients who are in active cancer treatment, palliative care or end-of-life care. The BON includes general best practices for prescribing controlled substances as well as specific guidance for the most commonly misused and abused categories of prescription drugs: opioids; stimulants; and benzodiazepines.

General Guidelines

According to the BON Guidelines, APNPs should perform and thoroughly document an evaluation of the patient before prescribing controlled substances. The evaluation should include the reason to treat as well as a history and physical examination. The BON Guidelines also stress the importance of routinely discussing with a patient the effects controlled substances may have on the patient, the risks and benefits of the drugs, the prohibition on sharing these drugs with others and how to properly dispose of controlled substances.

The BON Guidelines include a number of recommendations to follow when prescribing the most commonly misused and abused categories of prescriptions drugs, including:

Establishing treatment goals before initiating treatment and considering the use of a controlled substances agreement when prescribing such drugs;
Reviewing the patient’s history of controlled substance prescriptions through the ePDMP;
Using pill counts and/or urine drug testing at a frequency based upon a patient’s risk factors; and
In general, not prescribing benzodiazepines and opioids concurrently.

Opioid Prescribing

In Wisconsin, opioids such hydrocodone/acteminophen, continue to be the most commonly prescribed drugs of those monitored by the PDMP, but recent data suggests prescribers are adjusting their prescriptive practices. Data compiled from the PDMP indicates a nearly 10 percent drop in the number of opioid prescriptions written from the third quarter 2015 to the third quarter 2016.² The BON Guidelines include a number of recommendations for prescribing opioids, such as APNPs should:

Strongly consider non-pharmacologic and/or non-opioid therapy before prescribing opioids;
Consider ordering naloxone in individual cases and based upon the APNP’s clinical judgment;
For acute pain, do not prescribe extended-release or long-acting opioids, quantities that exceed the anticipated duration of acute pain or additional opioids without re-evaluating the patient or referring the patient to a pain management specialist; and
Re-evaluate patients prior to opioid dose changes and also at least every three months.

Benzodiazepine Prescribing

For prescribing benzodiazepines, which include drugs such as alprazolam, lorazepam and clonazepam, the BON Guidelines include the following recommendations:

An APNP should not prescribe benzodiazepines until the patient completes a trial of non-pharmacologic therapy; and
An APNP should prescribe short-acting benzodiazepines when starting drug therapy instead of long-acting benzodiazepines.

Stimulant Prescribing

The BON Guidelines recommend that an APNP ensure that a patient has undergone adequate testing, assessment and diagnosis before the APNP prescribes a stimulant.

BON Continuing Education Requirements

The BON revised N8, effective October 1, 2016, to require APNPs to complete 16 hours per biennium, rather than the original required 8 hours per year, of continuing education in clinical pharmacology or therapeutics related to the APNP’s area of practice. As part of the effort to address the current public health crisis related to prescription drug addiction, the BON is requiring that 2 of the 16 continuing education hours be in responsible prescribing of controlled substances.³

MEB Guidelines

The MEB issued Opioid Prescribing Guidelines (“MEB Guidelines”) on July 20, 2016 that are available here. The MEB Guidelines focus on opioid prescriptions for acute and chronic pain management but state that they do not apply to patients who are in active cancer treatment, palliative care or end-of-life care.

MEB Continuing Medical Education

In November 2016, the MEB issued an emergency rule, available here, requiring physicians (medical doctors and doctors of osteopathy) to complete two continuing medical education credits based upon the MEB Opioid Prescribing Guidelines (“OPG CME”). Physicians must complete the two OPG CME credits for each of the next two license renewal periods. The new two-credit OPG CME will satisfy two credits of the physician’s current thirty-credit CME requirement. The OPG CME requirement does not apply to physicians who do not have a DEA number for prescribing controlled substances. Also, fellows, residents and other license holders currently in postgraduate training are exempt from CME requirements, including the OPG CME requirement, for renewal as long as they have satisfactorily completed three or more consecutive months of postgraduate training during the biennium.

ePDMP

The ePDMP is a new system that contains data about schedule II-V controlled substance prescriptions reported by pharmacies dispensing in Wisconsin. Beginning April 1, 2017, a “practitioner” is required to review a patient’s ePDMP records before issuing a prescription order for that patient for a monitored drug.⁴ A practitioner, which is defined as a person licensed in Wisconsin to prescribe and administer drugs or licensed in another state and recognized by Wisconsin as a person authorized to prescribe and administer drugs, includes physicians and APNPs. Such practitioners must register for a new account prior to accessing the ePDMP.

The requirement for a practitioner to review a patient’s ePDMP records before prescribing a monitored drug does not apply in the following circumstances:

The patient is receiving hospice care;
The prescription order is for a number of doses that is intended to last the patient three days or less and is not subject to refill;
The drug is lawfully administered to the patient;
Due to emergency, it is not possible for the practitioner to review the patient’s ePDMP records before issuing a prescription order for the patient; or
The practitioner is unable to review the patient’s ePDMP records because the ePDMP digital platform is not operational or because of another technological failure, if the practitioner reports that failure to the Controlled Substance Board.

Practical Takeaways

APNPs and physicians should consider taking the following steps to help ensure their opioid and other identified prescriptive practices are appropriate:

Review the BON and MEB guidelines and modify prescriptive practices, as appropriate;
Identify and complete approved BON continuing education/OPG CMEs to comply with the new requirements;
Complete registration to access the ePDMP; and
Review policies and procedures and modify, as appropriate in light of the BON and MEB guidelines, and to comply with the ePDMP requirements.

If you would like further guidance, please contact:

Robin Sheridan at (414) 721-0469 or rsheridan@hallrender.com;
Laura Leitch at (608) 770-9496 or lleitch@hallrender.com;
Carrie Joshi at (414) 721-0489 or cjoshi@hallrender.com; or
Your regular Hall Render attorney.

¹ CDC, CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016, March 15, 2016, https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.
² Controlled Substances Board, WI Prescription Drug Monitoring Program, July 1 – September 30, 2016, available at https://content.govdelivery.com/attachments/WIGOV/2016/11/01/file_attachments/650010/PDMP%2BReport.pdf.
³ Wis. Admin. Code N 8.05
⁴ Wis. Stat. 961.385

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