A new opioid control law in North Carolina brings a nearly immediate effect on physicians and health care providers. Signed by Gov. Roy Cooper on June 29, the Strengthen Opioid Abuse Prevention (STOP) Act has major provisions that went into effect just two days later, on July 1.
The legislation applies to providers, prescribers, and their clinical and non-clinical team members, as well as dispensers. The key points for private practice providers who prescribe “target controlled substances” (Schedule II and III opioids and narcotics listed in NC Gen. Stat. § 90-90(1), (2) or 90-91(d)) to patients in North Carolina are as follows:
- Consultation Requirements for NPs and PAs. As of July 1, 2017, nurse practitioners and physician assistants must personally consult with their supervising physician if the patient is being treated at a facility that primarily engages in the treatment of pain by prescribing narcotic medications or advertises for any type of pain management services, and the therapeutic use of the prescription will, or is expected to, exceed 30 days. When continually prescribing the targeted controlled substance to the same patient in accordance with the above, the NP/PA must consult with the supervising physician at least once every 90 days to verify that the prescription remains medically appropriate.
- CSRS Not Yet Mandatory, but Should Be Used. Though the law does not make controlled substance reporting system (CSRS) use mandatory immediately (and does not provide a date for when it will be), Medical Mutual’s advice is that providers should not put off registering for and using CSRS for North Carolina patients. It is expected that, after confirming technical upgrades to CSRS, the North Carolina Department of Health and Human Services (NC DHHS) and the North Carolina Medical Board (NCMB) will broadcast when mandatory registration must occur, and that this likely will take place in early 2018.
- A patient’s data in CSRS for the prior 12 months must be reviewed before an initial prescription to that patient.
- For every three-month period of continued prescription, the practitioner must review the patient’s prior twelve-month history in CSRS and document the results in the EHR.
- If CSRS cannot be reviewed because of some technological failure, that inability should be documented in the patient’s chart, and the review should occur as soon as the systems problem is fixed.
- CSRS review is not mandatory for certain patients, including but not limited to those receiving the prescription as part of cancer treatment, or those in hospice or receiving palliative care.
- Clinical and Non-Clinical Delegates May Be Used to Query CSRS for Physicians. Prescribers may continue to use “delegates” to query the North Carolina Controlled Substance Reporting System. Delegates must work under the physician’s direction and supervision, and the delegation must be approved by NC DHHS. To register delegates, the licensee must register a master account first. The easiest way for a physician licensee to register his or her own account is through the NCMB’s website: https://wwwapps.ncmedboard.org/Clients/NCBOM/Private/MDProfileUpdate/MDProfile_Login.aspx. Delegates may include office nurses and non-clinical staff. The master registrant is responsible for each of his or her delegates. Delegate accounts must be updated annually, or they will become inactive.
- Limitations on Prescriptions for Acute Pain. As of January 1, 2018, practitioners must not prescribe more than a five-day supply upon initial consultation and treatment of a patient for acute pain, unlessthe prescription is for post-operative acute pain relief for immediate use following a surgical procedure, in which case the prescription cannot exceed a seven-day supply.
- Acute pain is defined as pain, whether resulting from disease, accident, intentional trauma, or other cause, that the practitioner reasonably expects to last for three months or less. It does not include chronic pain or pain being treated as part of cancer care, hospice care, palliative care, or medication-assisted treatment for substance use disorder.
- Chronic pain is defined as pain that typically lasts for longer than three months or that lasts beyond the time of normal tissue healing.
- Electronic Prescribing Required as of January 1, 2020. As a general rule, practitioners must electronically prescribe all targeted controlled substances.
- Hospice and Palliative Care Instructions. Effective July 1, 2017, Hospice and palliative care providers must share information regarding proper disposal of medications with patients and their families.
As a result of the above, Curi recommends that practitioners take the following steps:
- Enroll in CSRS, read the act, and immediately adopt the prescribing limitations in the act
- Choose delegates carefully, ensuring delegates understand that they must only query CSRS upon the licensee’s request for a patient whose prescription options are being considered by the practitioner
- Set up a process to revoke delegates’ access if those employees leave the practice
- Update delegates’ accounts annually to maintain their access
- Personally document (in the patient’s EHR) that CSRS was queried, what the results were (the prescription history should be added to the EHR), what prescribing decisions were made, and why they were made
- Regularly audit their personal controlled substances prescribing history to ensure its accuracy
- Understand that the DHHS likely will flag unusual prescribing habits evidenced by CSRS activity and share them with the NCMB
- Ask for help with CSRS if needed (CSRS questions should be directed to the Division of Mental Health, Developmental Disabilities and Substance Abuse at  733-7011)
The following resources may be helpful for those seeking more information about the new law:
- STOP Act text: https://www.ncmedboard.org/images/uploads/article_images/H243v7.pdf
- North Carolina Medical Board’s STOP Act summary: https://www.ncmedboard.org/images/uploads/article_images/The_STOP_Act_summary.6.30.2017.pdf
- North Carolina Medical Board’s STOP Act FAQs: https://www.ncmedboard.org/images/uploads/article_images/STOPAct-FAQs-7112017.pdf
- North Carolina Medical Board’s Step by Step Guide to Registering for NC CSRS: https://www.ncmedboard.org/images/uploads/article_images/NC_CSRS_RegistrationGuide.pdf
- North Carolina Department of Health and Human Services site for the CSRS (including FAQs): https://www.ncdhhs.gov/divisions/mhddsas/ncdcu/csrs
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