KDA Today
KDA Today
For Immediate Release
Date: Oct 19th, 2012
Contact: Mr. David Beyer
Phone: 800-292-1855
Email: info@kyda.org
House Bill 1 and What It Means to You
Introduction
In April of this year the Kentucky General Assembly passed legislation aimed at curbing prescription drug abuse. This legislation is commonly referred to as House Bill 1 (HB1). HB1 was signed into law by Governor Steve Beshear on April 24, 2012. HB1 required the five licensing Boards affected by the legislation to promigulate regulations concerning prescribing standards for certain controlled substances.1 These new regulations went into effect on July 20, 2012. The legislation has created much discussion among practitioners as to the efficacy of the legislation on addressing the perceived problem and the countervailing impact on patient care.
This article will attempt to explain the impact of HB1 on practitioners and provide guidance on navigating the mandates while ensuring practitioners are able to prescribe appropriate pain medications to their patients when indicated.
The Problem
Kentucky has experienced a substantial increase in prescription drug abuse. The number of prescriptions for drugs like Lortab and Vicodin has increased by 48 million doses over the past 5 years. Prescriptions for drugs containing oxycodone have increased even more dramatically from 31 million doses in 2006 to 79 million doses in 2011. That’s enough for 20 doses of oxycodone for each of the 4 million men, women and children living in the Commonwealth. Concomitantly, the number of deaths attributable to prescription drug abuse has increased. It is estimated that 95 Kentuckians die each month from prescription drug abuse or nearly 1000 per year. That’s more than the average of 700 people who die in traffic accidents each year. Similarly, the number of drug addicted newborns in Kentucky has increased from 29 in 2000 to 730 in 2011.2
There is anecdotal evidence of patients “doctor shopping” and prescribers not being aware of the amount and type of controlled substances previously prescribed to these patients by other practitioners. There have also been cases of patients actually physically harming themselves to convince prescribers to provide them with controlled substances. The Kentucky Board of Dentistry (KBD) has received calls from dentists in support of HB1 who have had patients needing multiple teeth extracted request only one tooth per visit be removed so that the patient can obtain a new prescription for pain medication at each visit.
Finally, it has been reported that treatment admissions for opiate dependence has increased by 900% in the past ten years.3 It is obvious Kentucky cannot continue on this path. Prescribers are the gate keepers to prescription drugs. They have been given great latitude in the past to use their sound judgment concerning when and in what amounts pain medicine should be prescribed. Unfortunately, this great latitude has resulted in the current epidemic of prescription drug abuse we have in Kentucky. Accordingly, the Legislature decided to step in and enact certain restrictions in an attempt to address this growing problem. Although HB1 will not completely solve the problem, it is a starting point to gain control of this ever increasing problem.
The Solution
The Legislature determined that part of the solution is to require prescribers to query the Kentucky All Schedule Prescriptions Electronic Report (KASPER) database before writing prescriptions for certain scheduled controlled substances. HB1 requires all dentists licensed in Kentucky who hold a DEA permit to register with KASPER at https://ekasper.chfs.ky.gov/accessrequest/activateaccount.aspx.
Section 3 of HB1 states that:
Prior to the initial prescribing or dispensing of any Schedule II controlled substance or a Schedule III controlled substance containing hydrocodone to a human patient, a practitioner shall:
- Obtain complete medical history
- Conduct physical exam
- Document above
- Query KASPER
- Make written treatment plan stating objectives of the treatment
- Discuss risks and benefits of the use of controlled substance(s)
- Obtain written consent for treatment
Most of the required documentation is simply what conscientious practitioners already record as part of their patients’ dental records.
HB1 lists six instances in which a practitioner does not have to conduct a KASPER query. Of these six exceptions, one specifically applies to dentists. Section 3 (3) exempts dentists from the requirements of HB1 for “the prescribing of a three (3) day supply of a schedule III controlled substance following the performance of oral surgery by a dentist…” 4
What This Means to You
If you are a dentist licensed by Kentucky and you hold a DEA permit to prescribe controlled substances you must:
- Register with the Cabinet for Health and Family Services to obtain a KASPER account;
- Query KASPER prior to the initial prescribing of a controlled substance;
- Document relevant information obtained from KASPER to determine if it is medically appropriate and safe to prescribe a controlled substance;
- Actually examine the patient, obtain a medical history and document this information; and
- Discuss the risks and benefits of the use of the controlled substance including the risk of tolerance and drug dependency.
You do not have to do steps 2 through 5 if you are prescribing a Schedule III or one of the listed Schedule IV controlled substances after the performance of oral surgery provided no more than a 72 hour supply of such controlled substance is prescribed.5 The fourteen Schedule IV controlled substances are footnoted below.6
KBD regulations also exempt the need to query KASPER if you are prescribing a “pre-appointment medication for the treatment of procedure anxiety provided the prescription is limited to a two day supply and has no refills.” 7
HB1 further requires practitioners to query KASPER no less than once every three (3) months for all available data on the patient and review that data before issuing any new prescriptions or refills for the patient for the listed scheduled controlled substances.8
However, KBD regulations permit a dentist to provide one (1) refill within 30 days of the initial prescription for the same controlled substance for the same amount or less or prescribe a lower schedule drug for the same amount without a clinical re-evaluation.9 A patient who requires an additional prescription of a controlled substance must be clinically re-evaluated.
The requirement for a patient to be clinically evaluated prior to the initial prescribing of a controlled substance as well as for refills beyond a thirty day period are to prevent patients from telephoning a dentist to request pain medications when it is not a true necessity. I have had dentists tell me this helps them decline such requests when they have concerns about the true need for pain medications.
Finally, HB1 and the KBD regulations require you to obtain three hours of continuing education (CE) related to KASPER, pain management, or addiction disorders during each two year license renewal cycle. These three hours of CE may be counted toward your required thirty (30) hours of CE.
Conclusion
Prescription drug abuse has become a significant problem in Kentucky. The Kentucky Legislature enacted HB1 in an effort to curb this problem. For dentists, the main impact is a requirement to register for a KASPER account, query KASPER before initially prescribing a controlled substance, and consider the merits of prescribing a controlled substance to a patient based on the results of the KASPER inquiry. In addition, dentists must document the results of the KASPER query as well as the results of their examination of the patient, medical history, and their discussion with the patient about the risks and benefits of the use of the controlled substance including the risk of tolerance and drug dependency. Most of this required documentation is simply what most conscientious practitioners already record as part of their patients’ dental records. Finally, the KBD has prepared a list of frequently asked questions regarding HB1 and KASPER which can be viewed on our website at http://dentistry.ky.gov/ .
References
[1] The five state licensing boards are the Kentucky Boards of: Medical Licensure; Nursing; Dentistry; Optometric Examiners; and, Podiatry. See HB1, Section 2 (1)(b).
2 Statistics provided by Kentucky Office of Drug Control Policy.
3 See id.
4 HB1 Section 3(4)
5 201 KAR 8:541 (2) defines oral surgery as “any manipulation or cutting of hard or soft tissues of the oral or maxillofacial area and associated procedures, by any means, as defined by the American Dental Association, utilized by this chapter and within their scope of training and practice.
6 (a) Ambien; (b) Anorexics; (c) Ativan; (d) Klonopin; (e) Librium; (f) Nubain; (g) Oxazepam; (h) Phentermine; (i) Soma; (j) Stadol; (k) Stadol NS; (l) tramadol; (n) Versed, and, (o) Xanax;
7 201 KAR 8:541, Section 4(3)
8 HB1, Section 3 (2)
9 201 KAR 8:541, Section 3