STATE BOARD OF OPTOMETRY POLICIES & GUIDELINES Table of Contents 10- Administrative ............................................................................................................. 2 10-1 Annual Review (August 2002; Amended May 23, 2014) ....................................................... 2 20- Licensing .................................................................................................................... 2 20-1 Applications from Optometrists Trained in Foreign Countries (May 2002; Amended May 23, 2014) ... 2 20-2 Jurisprudence – Repealed February 2012 ....................................................................... 2 20-3 Financial Responsibility for Non-Practicing Optometrists (Adopted August 4, 2010; Amended November 2010; Amended May 23, 2014) ............................................................................. 2 20-4 Inactive Status and Reactivation Requirements (Effective November 2010; Amended May 23, 2014) 2 30- Practice ..................................................................................................................... 3 30-1 Contact Lenses – Repealed May 23, 2014 ....................................................................... 3 30-2 Continuing Education (Amended February 2012; Amended May 23, 2014; November 18, 2015) ....... 3 30-3 Continuing Education (“CE”) Audits (Amended May 2011; Amended February 2013; Amended May 23, 2014; Amended May 13, 2015) ..................................................................................... 4 30-4 Continuing Education Requirements During Renewal – Repealed May 23, 2014 .......................... 5 30-5 Practicing on Expired License (Amended November 2012; Amended May 23, 2014) ..................... 5 30-6 Use of Terms (Amended May 23, 2014).......................................................................... 5 30-7 Employment and Independent Contractor Arrangements (Amended May 2012; Amended May 23, 2014) ........................................................................................................................ 5 30-8 Community Vision Screenings with Donated Glasses .......................................................... 6 30-9 Electronic Records (Adopted May 23, 2014) .................................................................... 6 30-10 Prescribing and Dispensing Opiods (Adopted August 13, 2014) ............................................ 6 30-11 Policy Statement Regarding the Provider/Patient Relationship (Adopted August 10, 2016) .... 6 30-12 Guidelines for the Appropriate Use of Telehealth Technologies in the Practice of Optometry (Adopted August 10, 2016) .............................................................................................. 7 40- Discipline .................................................................................................................. 10 40-1 Guidelines Pertaining to Confidential Letters of Concern (Adopted August 2008; Amended May 23, 2014) ....................................................................................................................... 10 40-2 Delegated Authority (Adopted May 2009; Amended August 2009; Amended November 2010; Amended February 2012; Amended November 2012; Amended February 2013; Amended May 23, 2014) . 11 40-3 Process for Handling Complaints involving Board of Optometry Members. (Amended May 23, 2014) 12 40-4 Anonymous Complaints (Adopted November 2011; Amended May 23, 2014) ............................. 13 40-5 Dispensing for a Fee (Adopted November 2012; Amended May 23, 2014) ................................ 13 40-6 Plano and Cosmetic Contact Lenses (Adopted February 12, 2014; Amended May 23, 2014) .......... 13 40-7 Fine Schedule for Violations of the Optometrists Practice Act and Board Rules (Adopted May 23, 2014) ....................................................................................................................... 14 1. Substandard Record Keeping ..................................................................................... 14 2. Failure to Provide Records........................................................................................ 14 3. Failure to Provide a Written Prescription ...................................................................... 14 4. Practicing on an Expired or Inactive License .................................................................. 14 5. Failure to Keep Optometry Premises Clean and Sanitary .................................................... 14 6. False Advertising ................................................................................................... 14 7. Administering, Distributing, Dispensing, and Prescribing Outside of a Patient-Optometrist Relationship ............................................................................................................. 15 8. Failure to Respond to a Board Complaint ...................................................................... 15 9. Aiding or abetting, in the practice of optometry, any person not licensed to practice optometry as defined under this article or any person whose license to practice is suspended. .......................... 15 10. Other Violations ................................................................................................... 15 50- Miscellaneous ............................................................................................................. 15 50-1 Approved Procedural Codes – Repealed May 2011 ............................................................ 15
STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
10- Administrative 10-1 Annual Review (August 2002; Amended May 23, 2014) The State Board of Optometry (Board) will review and revise these policies, as necessary, and the list of procedures acknowledged by the Board as being within the scope of optometry practice in Colorado. 20- Licensing 20-1 Applications from Optometrists Trained in Foreign Countries (May 2002; Amended May 23, 2014) Such applicants are required to choose one of the organizations that belong to NACES (National Association of Credential Evaluation Services, Inc.) to have their transcripts evaluated. The evaluation will include a course-by-course description of classes taken and will tell the Board if the degree is equivalent to an accredited Doctor of Optometry (OD) program degree. If the evaluation shows the program completed is not an equivalent education, it will list the courses that are lacking. The applicant (not the Board) is responsible for any fees charged by the evaluating organization for this service. 20-2 Jurisprudence – Repealed February 2012 20-3 Financial Responsibility for Non-Practicing Optometrists (Adopted August 4, 2010; Amended November 2010; Amended May 23, 2014) Purpose: To provide guidelines and clarification to optometrists with respect to the Board expectation regarding non-practicing licensed optometrists. POLICY: Financial Responsibility for Non-Practicing Optometrists Any person practicing optometry in this state shall establish financial responsibility as outlined in section 12-40-126, C.R.S. 20-4 Inactive Status and Reactivation Requirements (Effective November 2010; Amended May 23, 2014) Purpose: Purpose of this policy is to clarify the inactive license status and how to reactivate that inactive license status to active and practicing status. POLICY: 1) Inactive license status. During such time as a licensee remains in an inactive status, he or she shall not perform those acts restricted to active licensed optometrists. a. Any licensee may apply for an inactive status. Such application shall be in the form and manner designated by the Board. b. Inactive licensees shall renew and pay a fee in the same manner as active license holders. c.
Pursuant to section 12-70-101, C.R.S., the holder of an inactive license shall not be required to comply with the continuing education requirements for renewal so long as he or she remains inactive 2
STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
d. Practicing with an inactive license shall constitute unlicensed practice and, therefore, may be grounds for disciplinary or injunctive action, up to and including revocation 2) Reactivation. An inactive license may be reactivated by submitting a reactivation application and paying a reactivation fee. a. If the license has been inactive for more than two years, the licensee shall meet the following requirements: (1) If the licensee is in practice and good standing in another state or territory of the United States or a foreign country, the Board shall require the licensee to take and pass a Board-approved clinical examination; or (2) If the licensee has been actively practicing and in good standing in another state or territory of the United States or a foreign country, he or she may be issued an active license without reexamination if the Board determines that he or she possesses the credentials and qualifications which are substantially equivalent to requirements in Colorado for current licensure by examination. Additional classes and/or courses may also be required as determined by the Board. 30- Practice 30-1 Contact Lenses – Repealed May 23, 2014 30-2 Continuing Education (Amended February 2012; Amended May 23, 2014; November 18, 2015) Purpose: The purpose of this policy is to further delineate Board Rule 21.00: Continuing Education Requirements. It is each optometrist’s responsibility to make certain that credit he or she claims for a course is valid and that the course is delivered by an approved provider. If audited, the optometrist must provide the Board with proof of valid continuing education that meets Board approval. 1) The following are examples of continuing education courses the Board will not accept towards meeting the CE requirement for biennial renewal periods. These include but are not limited to: a. b. c. d. e. f.
leadership training practice/personnel management client relations communication training integrated resource management principles. presentations dealing with financial based subjects including, but not limited to bookkeeping procedures g. financial planning h. retirement planning i. insurance programs
No presentation that is primarily promotional in nature regardless of subject material will be acceptable.
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STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
2) Conferences and Lectures meeting the requirements of Rule 21.00(C) must be sponsored by: a. Council on Optometric Practitioner Education (COPE) b. American Optometric Association (AOA) and AOA-recognized state associations c. American Academy of Optometry (AAO) d. College of Optometrists in Vision Development (COVD) e. Optometric Extension Program (OEP) f. Clinical facilities specializing in eye care that are staffed by professor(s) or adjunct professor(s) of optometry or ophthalmology at accredited optometry or medical schools. 3) Internet Based CE or CE Offered by Professional/Association Journals meeting the requirements of Rule 21.00(C) must also: a. be sponsored/approved by COPE or accredited schools/colleges of optometry, and b. include a post-test evaluation. Only eight (8) of the 24 required hours may be obtained via the internet or from professional/association journals. 4) Clinical Observation/Clinical Examinations One (1) hour of CE credit may be obtained for every two (2) hours of observation at a clinical facility which specializes in eye care and is also staffed by professors or adjunct professors of optometry or ophthalmology at accredited optometry or medical schools. A maximum of four (4) hours of CE of this type may be counted toward each biennial renewal period. 5) ICD-10-CM/PCS Code Training The Board recognizes ICD-10 Training to be clinically based. A maximum of four (4) hours of CE of this type may be counted toward each biennial renewal period. 30-3 Continuing Education (“CE”) Audits (Amended May 2011; Amended February 2013; Amended May 23, 2014; Amended May 13, 2015) During each RENEWAL licensing cycle, beginning with the 2013-2015 cycle, the Board (or its designee) will randomly audit Colorado licensed optometrists to ensure the continuing education requirements have been met. If requested by the licensee, the Board will use the information entered into ARBO’s “OE Tracker” (the Association of Regulatory Boards of Optometry’s “Optometry Education Tracker”) software to perform their audit. There is no obligation of any licensees to use OE Tracker, nor does it change any of the CE requirements.
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STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
CE hours may only be applied to one (1) renewal period (two (2) year cycle). If the Board determines that the renewal licensee has not obtained appropriate CE as outlined in Board Policy 30-2 or the renewal licensee failed to submit the requested proof of CEs satisfactorily to the Board, the Board may consider disciplinary action for failure to comply with statute and rule. The Board may choose to grant a 90 day period to correct the shortage of CEs. 30-4 Continuing Education Requirements During Renewal – Repealed May 23, 2014 30-5 Practicing on Expired License (Amended November 2012; Amended May 23, 2014) Optometrists are permitted a sixty-day grace period after the March 31st expiration date in which they may renew their license without penalty by the Board. For the next six months after that grace period, the Board will consider issuing a Letter of Concern to an optometrist practicing on an expired license. After that (beginning December 1st), the Board will consider disciplinary action. 30-6 Use of Terms (Amended May 23, 2014) “Optometric physician.” Colorado law does not allow optometrists to call themselves “optometric physicians.” The term “physician” is reserved for use only by medical doctors and doctors of osteopathy. “Laser Vision Correction.” State Board Rules do not allow optometrists to use the phrase “Laser Vision Correction” in isolation because it implies that the OD performs surgery. Yellow pages and other advertising should include phrases to clarify that the OD provides consultation or pre- and post-operative care, such as “Laser Vision Consultation” and “Laser Surgery CoManagement.” “Board Certified.” Board Rule does not permit optometrists to advertise themselves as “Board Certified” because they have received a license from the Board. If an optometrist earns a designation of “Board Certified” they may use the term as long as they include the name of the certifying organization granting the title, and the certifying organization is approved by the US federal government’s Centers for Medicare and Medicaid Services (CMS) and the National Commission for Certifying Agencies (NCCA). Practitioners are cautioned against implying in any advertisement that “Board Certification” makes an optometrist more skilled, capable or qualified than a non-Board Certified optometrist licensed by the State of Colorado. 30-7 Employment and Independent Contractor Arrangements (Amended May 2012; Amended May 23, 2014) Our state law prohibits optometrists from working for opticians, stores, corporations or other individuals, with the exceptions that optometrists may work for other optometrists and optometry professional corporations as described in section 12-40-125, C.R.S. Also prohibited are “Independent Contractor” agreements between ODs and opticians, stores, corporations or other individuals (again with the exception that ODs may have an Independent Contractor agreement with other optometrists.) Optometrists may participate in provider networks pursuant to section 6-18-301.5, C.R.S.
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STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
30-8 Community Vision Screenings with Donated Glasses Distribution Programs (February 2004; Amended May 23, 2014) Screenings that involve refractive evaluation must be done by a licensed optometrist. It is allowable for such screenings to include matching used donated glasses to the screening participants’ needs. Screening participants must be informed that this is a screening only, not a full examination, which would include a thorough eye health evaluation. 30-9 Electronic Records (Adopted May 23, 2014) The State Board of Optometry determines electronic records to be adequate if the entire record is date-stamped without the ability to be subsequently altered. 30-10 Prescribing and Dispensing Opiods (Adopted August 13, 2014) This policy begins on page 16. 30-11 Policy Statement Regarding the Provider/Patient Relationship (Adopted August 10, 2016) Policy: The State Board of Optometry (“Board”) adopts the following policy regarding the provider-patient relationship: The Board defines “Provider” to include licensees regulated by the Board and the “ProviderPatient Relationship” as the mutual understanding, between a provider and patient, of the shared responsibility for the patient’s healthcare. This relationship is established when: A. The provider agrees to undertake diagnosis and treatment of the patient, and the patient, or a medical proxy for the patient, agrees to be treated – whether or not there has been an in-person encounter between the patient and the provider; and, B. The provider: i. Verifies and authenticates the patient’s identity and location; ii. Discloses his or her identity and applicable credential(s) to the patient; and, iii. Obtains appropriate informed consent after any relevant disclosures regarding the delivery models and treatment methods or limitations, including any special informed consents regarding the use of telehealth technologies. A “Provider-Patient Relationship” has not been established when either the identity of the provider is unknown to the patient or the identity of the patient is not known to the provider. Further, the Board finds the relationship between a provider and a patient is fundamental, and is not to be constrained or adversely affected by any considerations other than what is best for the patient. The existence of other considerations, including financial or contractual concerns must be secondary to the fundamental relationship. Prevailing models of optometric practice may result in an inappropriate restriction of the provider’s’ ability to practice quality medicine, creating negative consequences for the patient. It is the expectation of the Board that providers take those actions they consider necessary to assure that the procedures in question do not adversely affect the care that they render to their patients.
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STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
30-12 Guidelines for the Appropriate Use of Telehealth Technologies in the Practice of Optometry (Adopted August 10, 2016) Purpose: To provide guidance regarding the appropriate use of telehealth technologies in the practice of optometry. Policy: The State Board of Optometry (“Board’) has adopted the following guidelines for providers utilizing telehealth technologies in the delivery of patient care. 1)
Introduction
The advancements and continued development of medical and communications technology offer opportunities for improving the delivery and accessibility of health care, particularly in the area of telehealth, which includes the practice of optometry using electronic communication, information technology or other means of interaction between a healthcare provider in one location and a patient in another location with or without an intervening healthcare provider. 1 The State Board of Optometry (“Board”) recognizes that using telehealth technologies in the delivery of optometric services offers potential benefits in the provision of optometric care. However, in fulfilling its duty to protect the public, the Board must also consider patient safety concerns in adapting rules and policies historically intended for the inperson provision of optometric care to new delivery models involving telehealth technologies. The Board is committed to assuring patient access to the convenience and benefits afforded by telehealth technologies, while promoting the responsible practice of optometry by providers. The Board has developed guidelines to educate licensees as to the appropriate use of telehealth technologies in the delivery of medical services directly to patients. These guidelines do not set a standard of care, do not alter generally accepted standards of optometric practice, the scope of practice of any health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law. It is the expectation of the Board that providers of optometric care, electronically or otherwise, maintain the highest degree of professionalism and should: • • • • •
Place the welfare of patients first; Maintain the generally accepted standards of optometric practice; Adhere to recognized ethical codes governing the optometric profession; Properly supervise non-optometric staff; and Protect patient confidentiality.
This policy does not apply to the use of telehealth technologies when solely providing consulting services to another provider who maintains the primary provider-patient relationship with the patient, the subject of the consultation.
1
See Center for Telehealth and eHealth Law (Ctel), http://ctel.org/
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STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES 2)
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
Definitions
For the purpose of this policy, the following terms are defined as: a.
"TELEHEALTH" (1) “Telehealth” means a mode of delivery of health care services through telecommunications systems, including information, electronic, and communication technologies, to facilitate the assessment, diagnosis, consultation, treatment, education, care management, or selfmanagement of a person's health care while the person is located at an originating site and the provider is located at a distant site. The term includes synchronous interactions and store-and-forward transfers. (2) “Telehealth” includes the delivery of medical services and any diagnosis, consultation, or treatment using interactive audio, interactive video, or interactive data communication. (3)
This policy defines “telehealth” for purposes of compliance with the Optometric Practice Act. Telehealth may be defined differently in different statutory contexts, including but not limited to, insurance requirements or reimbursement.
(4) Nothing in this policy authorizes optometrists to deliver services outside their scope of practice or limits the delivery of health services by other licensed professionals, within the professional’s scope of practice, using advanced technology, including, but not limited to, interactive audio, interactive video, or interactive data communication. b.
“TELEHEALTH TECHNOLOGIES” means technologies and devices enabling secure electronic communications and information exchange between a licensee in one location and a patient in another location with or without an intervening healthcare provider.
c.
"DISTANT SITE" means a site at which a provider is located while providing optometric services by means of telehealth.
d.
"ORIGINATING SITE" means a site at which a patient is located at the time optometric services are provided to him or her by means of telehealth.
e.
“STORE-AND-FORWARD TRANSFER" means the electronic transfer of a patient's medical information or an interaction between providers that occurs between an originating site and distant sites when the patient is not present.
f.
"SYNCHRONOUS INTERACTION" means a real-time interaction between a patient located at the originating site and a provider located at a distant site.
g.
“PROVIDER” means a licensee regulated by the State Board of Optometry.
h.
“PROVIDER-PATIENT RELATIONSHIP” means the relationship as defined in Board Policy 30-11.
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STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES 3)
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
Guidelines a. Licensure Providers, who evaluate, treat or prescribe through telehealth technologies are practicing optometry. The practice of optometry occurs where the patient is located at the time telehealth technologies are used. Therefore, a provider must be licensed to practice optometry in the state of Colorado in order to evaluate or treat patients located in Colorado utilizing telehealth technologies or otherwise. b. Establishment of a Provider-Patient Relationship Where an existing provider-patient relationship is not present, a provider must take appropriate steps to establish a provider-patient relationship consistent with the guidelines identified in Board Policy 30-11. Provider-patient relationships may be established using telehealth technologies so long as the relationship is established in conformance with generally accepted standards of practice. c. Evaluation and Treatment of the Patient An appropriate medical evaluation and review of relevant clinical history commensurate with the presentation of the patient to establish diagnoses and identify underlying conditions and/or contra-indications to the treatment recommended/provided should be performed prior to providing treatment, including issuing prescriptions, electronically or otherwise. Treatment and consultation recommendations made in an online setting, including issuing a prescription via electronic means, will be held to the same standards of appropriate practice as those in traditional (encounter in person) settings. Treatment, including issuing a prescription based solely on an online questionnaire, does not constitute an acceptable standard of care. d. Informed Consent Appropriate informed consent should be obtained for a telehealth encounter including those elements required by law and generally accepted standards of practice. e. Continuity of Care Optometrists should adhere to generally accepted standards of optometric practice as it relates to continuity and coordination of care. f.
Referrals for Emergency Services An emergency plan should be provided by the provider to the patient when the care provided using telehealth technologies indicates that a referral to an acute care facility or Emergency Department for treatment is necessary for the safety of the patient.
g. Medical Records The medical record should include, if applicable, copies of all patient-related electronic communications, including patient-provider communication, prescriptions, laboratory and test results, evaluations and consultations, records of past care, and instructions obtained or produced in connection with the utilization of telehealth technologies. Informed consents obtained in connection with an encounter involving telehealth technologies should also be filed in the medical record. The patient record established during the use of telehealth technologies must be accessible and documented for both the provider and the patient, consistent with all established laws and regulations governing patient healthcare records.
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STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
h. Privacy and Security of Patient Records & Exchange of Information Providers should meet or exceed applicable federal and state legal requirements of medical/health information privacy, including compliance with the Health Insurance Portability and Accountability Act (HIPAA) and state privacy, confidentiality, security, and medical record retention rules. Written policies and procedures should be maintained at the same standard as traditional in-person encounters for documentation, maintenance, and transmission of the records of the encounter using telehealth technologies. i.
Disclosures and Functionality for Providing Online Services Disclosures and advertising should be made in accordance with state and federal law.
j.
Prescribing Prescribing medications and/or medical devices, in-person or via telehealth technologies, is at the professional discretion of the provider. The indication, appropriateness, and safety considerations for each telehealth visit prescription must be evaluated by the provider in accordance with current standards of practice and consequently carry the same professional accountability as prescriptions delivered during an encounter in person. However, where such measures are upheld, and the appropriate clinical consideration is carried out and documented, providers may exercise their judgment and prescribe medications as part of telehealth encounters.
k. Parity of Professional and Ethical Standards There should be parity of ethical and professional standards applied to all aspects of a provider’s practice. A provider’s professional discretion as to the diagnoses, scope of care, or treatment should not be limited or influenced by non-clinical considerations of telehealth technologies, and provider remuneration or treatment recommendations should not be materially based on the delivery of patient-desired outcomes (i.e. a prescription or referral) or the utilization of telehealth technologies. 40- Discipline 40-1 Guidelines Pertaining to Confidential Letters of Concern (Adopted August 2008; Amended May 23, 2014) Purpose: To clarify the basis for this type of dismissal, when the Optometry Board may reopen such case and designation of a specific retention period for these types of cases. POLICY: It is the policy of the Board that complaints dismissed with Confidential Letters of Concern are not dismissed as being without merit but rather are dismissed due to no reasonable cause to warrant further action at that time. Cases that are dismissed with a Confidential Letter of Concern will be retained in the Board’s files for a period of five years. The Board may reopen a case that was dismissed with a Confidential Letter of Concern in the face of a change in circumstances. Such a change in circumstances would include but not be limited to: •
discovery of new evidence supporting the underlying charges
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STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES •
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
evidence that the licensee has engaged in further unprofessional conduct/grounds for discipline following issuance of the Confidential Letter of Concern in which there is a nexus between the new conduct and that was addressed in the case that was dismissed with the Confidential Letter of Concern.
After five years from the date of the Confidential Letter of Concern, the file will be disposed in accordance with the Division’s records management procedures. If the licensee has other active cases pending at the end of the five year retention period, the Confidential Letter of Concern may be kept for a longer period of time at the discretion of the Board staff. Since a Letter of Concern is confidential, the complaint and investigation materials are also considered confidential and not open records. 40-2 Delegated Authority (Adopted May 2009; Amended August 2009; Amended November 2010; Amended February 2012; Amended November 2012; Amended February 2013; Amended May 23, 2014) Purpose: To clarify the authority delegated to the Deputy Director, Program Director, or designee to assist the Board in carrying out its duties. POLICY: The Board delegates to the Deputy Director, Program Director, or designee the authority to: 1. Forward directly to the Office of investigations, without a 30-day request for response being sent by Board staff to the respondent in the case for complaints: a. with allegations of unlicensed practice. b. with allegations related to fraudulent or substandard recordkeeping or billing issues. c. with allegations involving drugs or alcohol. d. with allegations of sexual misconduct. e. with allegations relating to infections control. f. with allegations relating to practice beyond the statutory or customary scope of practice. g. where any other complaint where it is apparent to the Deputy Director, Program Director or designee that an immediate investigation is warranted. 2. Sign Letters of Concern, Letters of Admonition, Show Cause Orders, Cease and Desist Orders, Desist and Refrain Orders, Stipulations and Final Agency Orders, and other orders authorized by the Board. 3. Sign Suspension Orders as required by the Child Support Enforcement Program. 4. Suspend and reinstate the license of practitioners who are in violation and subsequently in compliance of the Child Support Enforcement Act as notified by the Colorado Department of Human Services. 5. Perform the initial review of complaints relating to the practice of persons under the Board’s jurisdiction and issue 30-day letters relating to the complaints. 6. Initiate complaints on behalf of the Board. 7. Sign and issue subpoenas and/or orders of inspection and otherwise gather information in order to assist the Board in carrying out its duties.
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STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
8. Initiate complaints and issue 30-day letters to licensees currently under Stipulation or other Final Agency Action if, in the opinion of the Deputy Director, Program Director or designee, the licensee has failed to comply with any of the terms of the Stipulation of other Final Agency Action. 9. After consultation with the Board President or other designated Board member, approve termination of stipulations, where the respondent has completed the terms and conditions agreed upon. Any requests for early termination of probation or practice monitoring must be reviewed by and approved by the Board. 10. Issue appropriate discipline to expired licensees in accordance with Board Policy 30-5. 11. Issue the Board’s Procedural Order Regarding Review of the Initial Decision (“Order”) and serve the Order and the Initial Decision upon all parties by first class mail. 12. Perform additional delegated duties as set forth in other Board policies. 13. Coordinate and conduct public rulemaking hearings. 14. Approve continuing education courses that clearly fall within the parameters of 30-2. 40-3 Process for Handling Complaints involving Board of Optometry Members. (Amended May 23, 2014) Purpose: To provide written notice regarding the process by which specific types of complaints against current Board members, licensees who have served on the Board within the past five years, or licensees who have an ongoing formal relationship with the Board will be handled. The purpose of this policy is to assure the integrity of the disciplinary process and prevent any appearance of bias or preferential treatment. POLICY: It is the policy of the Board of Optometry that any signed complaint received by the Board against a current licensee who is a member of the Board or one who has served on the Board within the past five years, or a licensee who has an ongoing formal relationship with the Board will be handled as follows: •
At a minimum, the complaint shall be sent to the Office of Investigations to determine if there is any validity to the allegations. If the complaint alleges sexual boundary violations, substance abuse, or physical or mental impairment, the Board may require the licensee to undergo evaluation by the designated peer assistance provider to the Board or a qualified healthcare provider selected by the Office of Investigations.
•
If the complaint alleges a violation of the Practice Act, the complaint will be sent to the Office of Investigations within the Division of Professions and Occupations for a formal investigation.
•
If the complaint alleges substandard practice, the Office of Investigations will also have the case reviewed by an independent optometry consultant selected by the Office of Investigations.
Upon completion of the investigation or evaluation, the report will be referred to the Board for appropriate action.
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STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES •
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
If the complaint alleged sexual boundary violations, substance abuse, or physical or mental impairment and the report from the Office of Investigation substantiates such allegations, the Board shall require the licensee to undergo evaluation by the designated peer assistance provider to the Board or a qualified healthcare provider selected by the Office of Investigations, if the Board has not already done so.
All other customary procedures for the handling of a complaint by the Board will apply.These may include but are not limited to issuance of a 30-day letter, notification to the licensee and complainant of Board decisions, and the confidentiality of the complaint and investigation as provided by the Practice Act. Anonymous complaints filed against a current licensee who is a member of the Board or one who has served on the Board within the past five years, or a licensee who has an ongoing formal relationship with the Board will be evaluated. 40-4 Anonymous Complaints (Adopted November 2011; Amended May 23, 2014) The Board, or its designee, shall determine if anonymous complaints (or complainants who wish to remain anonymous) will be investigated or not by the Board on a case by case basis. 40-5 Dispensing for a Fee (Adopted November 2012; Amended May 23, 2014) The Optometry Board has taken the position it is not unlawful for Optometrists to charge a fee for dispensing prescription medications. (This policy clarification is due to the changes to the Optometry Practice Act enacted through HB12-1311.) 40-6 Plano and Cosmetic Contact Lenses (Adopted February 12, 2014; Amended May 23, 2014) The legislature has declared that the practice of optometry in the State of Colorado affects the public health and that regulation and control is in the public interest. The legislature has also declared that it is a matter of public interest that the practice of optometry be limited to those persons who are qualified. It is the policy of the Board that unlicensed persons who are engaged in the over-the-counter sale of cosmetic contact lenses to the public, without a prescription, are engaged in the practice of optometry. If it appears to the Board, based upon credible evidence, that such unlicensed practice of optometry is occurring, the Board may exercise any of its remedies at law, including, but not limited to, issuing an order to cease and desist such activity, or applying to the district court for an order enjoining such persons from engaging in such unlicensed practice of optometry.
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STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
40-7 Fine Schedule for Violations of the Optometrists Practice Act and Board Rules (Adopted May 23, 2014) Purpose: The Board may utilize this table to consider imposition of such fines including, but not limited to, the following violations and fining amount as referenced in Board Rule 18.00. However, nothing in this table precludes the Board from considering the nature and seriousness of the violation prior to determining a fine amount. 1. Substandard Record Keeping a. $250 for the 1st violation b. $500 for the 2nd violation c. Up to $5,000 for the 3rd or subsequent violation 2. Failure to Provide Records a. $500 for the 1st violation b. $1,500 for the 2nd violation c. Up to $5,000 for the 3rd or subsequent violation 3. Failure to Provide a Written Prescription a. $1,000 for the 1st violation b. $2,500 for the 2nd violation c. Up to $5,000 for the 3rd or subsequent violation 4. Practicing on an Expired or Inactive License a. $500 for the 1st violation b. $2,500 for the 2nd violation c. Up to $5,000 for the 3rd or subsequent violation 5. Failure to Keep Optometry Premises Clean and Sanitary a. $1,000 for the 1st violation b. $2,500 for the 2nd violation c. Up to $5,000 for the 3rd or subsequent violation 6. False Advertising a. $250 for the 1st violation b. $500 for the 2nd violation c. Up to $5,000 for the 3rd or subsequent violation 14
STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES
STATE BOARD OF OPTOMETRY POLICIES EFFECTIVE AUGUST 10, 2016
7. Administering, Distributing, Dispensing, and Prescribing Outside of a PatientOptometrist Relationship a. $1,000 for the 1st violation b. $2,500 for the 2nd violation c. Up to $5,000 for the 3rd or subsequent violation 8. Failure to Respond to a Board Complaint a. $1,000 for the 1st violation b. $2,500 for the 2nd violation c. Up to $5,000 for the 3rd or subsequent violation 9. Aiding or abetting, in the practice of optometry, any person not licensed to practice optometry as defined under this article or any person whose license to practice is suspended. a. $1,000 for the 1st violation b. $2,500 for the 2nd violation c. Up to $5,000 for the 3rd or subsequent violation 10. Other Violations a. $1,000 for the 1st violation b. $2,500 for the 2nd violation c. Up to $5,000 for the 3rd or subsequent violation 50- Miscellaneous 50-1 Approved Procedural Codes – Repealed May 2011
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Policy for Prescribing and Dispensing Opioids Colorado Dental Board, Colorado Medical Board, State Board of Nursing, and State Board of Pharmacy In collaboration with the Nurse-Physician Advisory Task Force for Colorado Healthcare
Policy for Prescribing and Dispensing Opioids
PREAMBLE Prescribing and dispensing medication for the appropriate treatment of pain is a priority for Colorado healthcare providers. However, in 2013 the misuse and abuse of prescription opioids became a public health epidemic in the United States in general, and Colorado in particular, leading to drug addiction, death from overdose, and increased costs to society. In order to address this crisis, the Colorado Dental Board, Colorado Medical Board, State Board of Nursing, State Board of Pharmacy, and the Nurse-Physician Advisory Task Force for Colorado Healthcare collaborated to identify opportunities and provide meaningful guidance to prescribers and dispensers in Colorado. The Boards recognize that reversing the trend of opioid misuse and abuse requires coordinated efforts to increase public awareness, take-back events for safe disposal, addiction treatment and recovery options, and enforcement, among others. The Boards and the practitioners they license are one part of a multi-pronged solution. The Boards recognize the complexities faced by prescribers in the appropriate management of pain.1 The demands on practitioners considering opioid prescribing differ depending on patient diagnosis, practice settings, and/or conditions. Importantly, long-term therapies addressing cancer-related treatment, palliative and/or hospice care involve different considerations from short-term therapies appropriate for acute or chronic non-cancer pain. Pain and addiction specialists play an important role in healthcare and the communities they serve to compassionately and safely care for patients. Many of the tools and practices referenced in this policy were developed by such specialists. The need for therapeutic care of pain in Colorado patients exceeds the supply of specialists in the state. However, other types of providers can successfully treat many painful conditions and achieve the function and relief the patient seeks. Accordingly, this policy is intended to educate prescribers and dispensers broadly by providing useful tools that may be utilized at the point-of-care to support clinical decision making. The Boards further recognize that decreasing opioid misuse and abuse in Colorado should be addressed by collaborative and constructive policies aimed at improving prescriber education and practice, decreasing diversion, and establishing the same guidelines for all opioid prescribers and dispensers. This includes opioid therapies for both acute and chronic non-cancer pain, 2 because the Boards find that treatment for pain often does not fall clearly into one category or another.
1
“Boards” as used in this policy means the Boards overseeing prescribing and dispensing of opioids and involved in the drafting of this policy: the Colorado Medical Board, State Board of Nursing, Colorado Dental Board, and the State Board of Pharmacy. 2 Pain is categorized by a number of descriptors ranging from duration, impact, or physiological response, among others. For the purpose of this policy, the term "chronic, non-cancer pain" is utilized to refer to pain that lasts longer than 90 days and is non-terminal. It does not include conditions such as cancer, scleroderma, multiple sclerosis, muscular dystrophy, or rheumatoid arthritis.
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Policy for Prescribing and Dispensing Opioids
Diversion and “doctor shopping” accounts for 40% of drug overdose deaths.3 To address the dual issues of access to appropriate pain management and opioid-related adverse outcomes, prescribers have dual obligations: to manage pain and improve function while reducing problems resulting from misuse and abuse of prescription opioids in the patient and community. Pharmacists share a corresponding responsibility with the prescriber to assure that a prescription order is valid in all respects and is appropriate for the patient and condition being treated. Therefore, the Boards have agreed to the following guidelines regarding opioid prescriptions in Colorado. Providers prescribing and/or dispensing opioids should: ● Follow the same guidelines ● Use the Colorado Prescription Drug Monitoring Program (PDMP) ● Be informed about evidence-based practices for opioid use in healthcare and risk mitigation ● Educate patients on appropriate use, storage and disposal of opioids, risks and the potential for diversion ● Collaborate within the integrated healthcare team to decrease over-prescribing, misuse and abuse of opioids. Opioid prescribers and dispensers must conform to the regulations set forth by the respective licensing board and other laws. To this end, we, the Boards regulating the prescribers and dispensers in Colorado, have developed this joint policy incorporating the guidelines above. This policy provides guidelines, and does not set a standard of care for prescribers and dispensers. This policy represents the Boards’ current thinking on this topic. It does not create or confer any rights for or on any person and does not operate to bind Boards or the public. Prescribers may use an alternative approach if the approach satisfies the requirements of the applicable statutes, regulations, and standard of care. The Boards will refer to current clinical practice guidelines and expert review in approaching cases involving the management of pain. 4
3
Paulozzi, L., Baldwin, G., Franklin, G., Ghiya, N., & Popovic, T. (2012). CDC Grand Rounds: Prescription drug overdoses — a U.S. epidemic. Center for Disease Control and Prevention, Morbidity and Mortality Weekly Report (MMWR), 61(01), 10-13. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm 4 A “policy” is adopted by a board to provide guidance to licensees regarding the board’s position on various subjects. Policies are unlike statutes or rules in that they are not law. Conversely, “board rules” have the force of law and set forth requirements to which licensees must adhere.
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Policy for Prescribing and Dispensing Opioids
Table of Contents BEFORE PRESCRIBING OR DISPENSING ...................................................................................................... 1 WHEN PRESCRIBING OR DISPENSING ........................................................................................................ 2 PRESCRIBING AND DISPENSING FOR ADVANCED DOSAGE, FORMULATION OR DURATION .................................... 4 PATIENT EDUCATION ............................................................................................................................ 5 DISCONTINUING OPIOID THERAPY ........................................................................................................... 5
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Policy for Prescribing and Dispensing Opioids
BEFORE PRESCRIBING OR DISPENSING Develop and maintain competence Prescribers, including prescribers who dispense, must maintain competence to assess and treat pain to improve function. This includes understanding current, evidencedbased practices and using other resources and tools related to opioid prescribing and dispensing. In some clinical situations consultation with a specialist is appropriate. Pharmacists must maintain competence in the appropriateness of therapy. See the Appendix for a list of resources and tools for developing and maintaining competence.
Utilize safeguards for the initiation of pain management The decision to prescribe or dispense opioid medication for outpatient use may be made only after a proper diagnosis and complete evaluation which should include a risk assessment, pain assessment, and review of relevant PDMP data. These safeguards apply to acute and chronic, non-cancer pain but not to palliative end-of-life care. Not all pain requires opioid treatment. Prescribers should not prescribe opioids when non-opioid medication is both effective and appropriate for the level of pain.
1. Diagnose Prescribers should establish a diagnosis and legitimate medical purpose appropriate for opioid therapy through a history, physical exam, and/or laboratory, imaging or other studies. A bona fide provider-patient relationship must exist.
2. Assess Risk Prescribers should conduct a risk assessment prior to prescribing opioids for outpatient use and again before increasing dosage or duration. Risk assessment is defined as identification of factors that may lead to adverse outcomes and may include: ● Patient and family history of substance use (drugs including alcohol and marijuana) ● Patient medication history (among other reasons, this is taken to avoid unsafe combinations of opioids with sedative-hypnotics, benzodiazepines, barbiturates, muscle relaxants or to determine other drug-drug interactions) ● Mental health/psychological conditions and history ● Abuse history including physical, emotional or sexual ● Health conditions that could aggravate adverse reactions (including COPD, CHF, sleep apnea, elderly, or history of renal or hepatic dysfunction) ● Prescribers and dispensers should observe the patient for any aberrant drugrelated behavior and follow-up appropriately when aberrant drug-related behavior is presented. See the Appendix for a description of such behaviors. 1
Policy for Prescribing and Dispensing Opioids
See the Appendix for additional resources related to assessment, including resources for alcohol and substance use screening and guidelines for treating patients with risk factors. If the assessment identifies risk factors, prescribers should exercise greater caution before prescribing opioids as detailed in subsequent sections, consider conducting a drug test or consulting a specialist and put in place additional safeguards as part of the treatment plan.
3. Assess Pain An appropriate pain assessment should include an evaluation of the patient’s pain for the: ● Nature and intensity ● Type ● Pattern/frequency ● Duration ● Past and current treatments ● Underlying or co-morbid disorders or conditions ● Impact on physical and psychological functioning
4. Review PDMP Prescribers and dispensers should utilize the Prescription Drug Monitoring Program (PDMP) prior to prescribing or dispensing opioids.
Collaborate with the healthcare team Prescribers and dispensers should collaborate within the healthcare team to prevent under-prescribing, over-prescribing, misuse and abuse of opioids. See the Appendix for additional resources.
WHEN PRESCRIBING OR DISPENSING Verify a provider-patient relationship A bona fide provider-patient relationship must exist. The prescriber or dispenser should verify the patient’s identification prior to prescribing or dispensing opioids to a new or unknown patient. For pharmacists, this includes exercising judgment and conducting research if appropriate (such as use of the PDMP or communication with the prescriber or relevant pharmacies) when the prescription order is: ● For a new or unknown patient 2
Policy for Prescribing and Dispensing Opioids
● ● ●
For a weekend or late day prescription Issued far from the location of the pharmacy or patient’s residential address Denied by another pharmacist.
Additional Safeguards Ensure the dose, quantity, and refills for prescription opioids are appropriate to improve the function and condition of the patient, at the lowest effective dose and quantity, in order to avoid over-prescribing opioids. Factors that have been associated with adverse outcomes include: 1) opioid doses greater than 120 mg morphine equivalents per day 2) certain formulations and 3) treatment exceeding 90 days. Additional safeguards have been found to reduce these risks.
Dosage Opioid doses >120 mg morphine equivalents per day is a dosage that the Boards agree is more likely dangerous for the average adult (chances for unintended death are higher) over which prescribers should use clinical judgment, put in place additional safeguards for the treatment plan (such as utilizing a treatment agreement), consult a specialist or refer the patient; and dispensers should be more cautious.5 Benzodiazepines are known to potentiate the effects of opioids and may increase the risk of adverse outcomes. See the Appendix for additional resources on dose calculators
Formulation In addition to noting and responding to this dosage marker, prescribers and dispensers must use clinical judgment regardless of dose, especially when: The prescription is considered an outlier to what is normally prescribed, or Transdermal, extended relief or long-acting preparation is prescribed.
Duration Treatment exceeding 90 days should be re-evaluated as opioids may no longer be as effective. One way to distinguish pain is as either acute (that lasting less than 90 days) or chronic (that lasting 90 days or greater). Management of each presents its own unique challenges. The overwhelming majority of prescribers treat patients with acute pain; in fact the pain for these patients lasts considerably less than 90 days.
5
Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152(2):85-92.
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Policy for Prescribing and Dispensing Opioids
If a prescriber extends short-term treatment, and results in exceeding 90 days, prescribers should re-conduct the risk and pain assessments, review the PDMP and undertake the additional safeguards.
PRESCRIBING AND DISPENSING FOR ADVANCED DOSAGE, FORMULATION OR DURATION Tools and Trials Prior to issuing prescriptions that are outliers to the dosage, formulation and duration guidelines described above (for chronic, non-cancer pain), prescribers should determine whether the patient improves functionally on opioids, which could include an opioid trial, and whether the pain relief improves his/her ability to comply with the overall pain management program.
Monitoring The prescribing and dispensing of opioids for chronic pain must be monitored on an ongoing basis, such as: assessing for improved function rechecking the PDMP, and random drug screening according to the prescriber’s clinical assessment. These monitoring tools and others should be documented in a treatment agreement signed by the patient, described more below. Prescribers should not increase an initial opioid dosage without rechecking the PDMP.
Treatment Agreements Prescribers should utilize treatment agreements (also commonly referred to as a plan or contract) and should ensure the patient understands the terms of the agreement. This may be accomplished by having the patient review and sign the treatment agreement. A treatment agreement often includes information about proper: ● Goals of treatment ● Patient education (proper use, risks of addiction, alternatives) ● Controls (single prescriber, single pharmacy for refills) ● Random drug testing and restrictions on alcohol use ● Storage, disposal, and diversion precautions (including detailed precautions related to adolescents and/or children and visitors to the home). ● Process and reasons for changing/discontinuing the treatment plan; communicating reduction or increase of symptoms; and referring to a specialist. See the Appendix for resources on sample agreements.
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Policy for Prescribing and Dispensing Opioids
PATIENT EDUCATION Prescribers should educate patients regardless of the dosage, formulation and duration of opioid therapy on proper use, risks of addiction, alternatives, storage, and disposal of opioids and the potential for diversion (see the Appendix for resources on disposal). Risks may include but are not limited to: overdose, misuse, diversion, addiction, physical dependence and tolerance, interactions with other medications or substances, and death. Pharmacists should offer to review information with the patient about risks, disposal, and other applicable topics. Providers should educate patients about the risks and benefits of medications that exceed the dosage, formulation and duration guidelines indicated above which may place them at increased risk for long-term dependence and unintended adverse drug effects. Patients who have a previous history of substance use disorder (including alcohol) are at elevated risk. When alerted to these risk factors, patients can make more informed decisions about their healthcare treatment. For example, some patients have reduced or forgone opioids when alerted to the risk factors. If a decision is made to continue with opioid therapy, a satisfactory response to treatment would be indicated by a reduced level of pain, increased level of function and/or improved quality of life. The use of an interdisciplinary team and family members may be considered as a part of the treatment plan and ongoing monitoring.
DISCONTINUING OPIOID THERAPY The prescriber should consider discontinuing opioid therapy when: ● The underlying painful condition is resolved; ● Intolerable side effects emerge; ● The analgesic effect is inadequate; ● The patient’s quality of life fails to improve; ● Functioning deteriorates; or ● There is aberrant medication use. The prescriber discontinuing opioid therapy should employ a safe, structured tapering regimen through the prescriber or an addiction or pain specialist. There is a risk of patients turning to street drugs or alcohol abuse if tapering is not done with appropriate supports. Prescribers of opioids should be familiar with treatment options for opioid addiction. See the Appendix for tips on tapering.
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Policy for Prescribing and Dispensing Opioids
APPENDIX PDMP Colorado Prescription Drug Monitoring Program (PDMP): http://www.hidinc.com/copdmp
Preventing diversion through appropriate disposal In order to prevent diversion, providers should provide information regarding appropriate disposal, including the following: ● Secure unused prescription opioids until such time they can be safely disposed. Specifically, ensure that prescription opioids are not readily accessible to other family members (including adolescents and/or children) or visitors to the home. ● Take-back events are preferable to flushing prescriptions down the toilet or throwing them in the trash. Only some medications may be flushed down the toilet. See the FDA’s guidelines for a list of medications that may be flushed: www.fda.gov ● Utilize take-back events and permanent drop box locations ● Utilize DEA disposal guidelines if take-back or drop boxes are unavailable. Those guidelines include: ● Take the drugs out of their original containers and mix them with an undesirable substance, such as used coffee grounds or kitty litter; then put them in a sealable bag, empty can, or other container to prevent the medication from leaking out of a garbage bag; ● Before throwing out a medicine container, tell the patient to scratch out all identifying information on the prescription label to protect their identity and personal health information; and ● Educate patients that prescriptions are patient specific. Patients may not share prescription opioids with friends, family or others and may pose serious health risks, including death. ● Use activated charcoal absorption technologies to inactivate unused medications or used fentanyl patches.
Record keeping Prescribers who treat patients with opioids should maintain accurate and complete medical records according to the requirements set forth by their licensing board.
Discontinuing/tapering opioid therapy Weaning from opioids can be done safely by slowly tapering the opioid dose and taking into account several factors related to risk, symptom, and alternatives. Opioid Taper Plan and Calculator: “Interagency Guidelines on Opioid Dosing for Chronic Non-Cancer Pain” State of Appendix Page 1
Policy for Prescribing and Dispensing Opioids
Washington Agency Medical Directors Group. 2010 Online: www.agencymeddirectors.wa.gov Withdrawal Symptoms Assessment: “Clinical Opiate Withdrawal Scale” The National Alliance for Advocates for Buprenorphine Treatment. Online at: www.naabt.org
Aberrant drug-related behavior Prescribers and dispensers should use clinical judgment when aberrant drug-related behaviors are observed. Such behavior should be reported to the proper authorities and/or healthcare team as appropriate. Aberrant drug-related behaviors broadly range from mildly problematic (such as hoarding medications to have an extra dose during times of more severe pain) to felonious acts (such as selling medication). These are any medication-related behaviors that depart from strict adherence to a prescribed therapeutic plan of care. Prescribers and dispensers should observe, monitor and take precautionary measures when a patient presents aberrant drug-related behaviors such as: ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Requesting early and/or repeated refills Presents at or from an emergency department seeking high quantities of a prescription Denied by other prescribers or dispensers Presents what is suspected to be a forged, altered or counterfeit prescription. Forging prescriptions Stealing or borrowing drugs Frequently losing prescriptions Aggressive demand for opioids Injecting oral/topical opioids Unsanctioned use of opioids Unsanctioned dose escalation Concurrent use of illicit drugs Failing a drug screen Getting opioids from multiple prescribers Recurring emergency department visits for chronic pain management*
Prescribers and dispensers should be alert for subjective behaviors such as being nervous, overly talkative, agitated, emotionally volatile, and evasive, as these may be signs of a psychological condition that may be considered in a treatment plan or could suggest drug misuse.** *“Interagency Guidelines on Opioid Dosing for Chronic Non-Cancer Pain” State of Washington Agency Medical Directors Group. 2010 Online: http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf **Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain. Sunrise River Press, North Branch, MN 2007.
Appendix Page 2
Policy for Prescribing and Dispensing Opioids
Practitioner Considerations Healthcare team: Consider that the patient may be receiving opioids from another prescriber. Contact the patient’s healthcare team when appropriate which may include the following: ● Physician ● Specialist (pain, addiction, etc.) ● Dentist ● Advanced Practice Nurse (APN) ● Physician assistant ● Pharmacists ● Area emergency rooms ● Surrounding (within 5 miles) or historical pharmacies Authorities: ● If the prescriber or dispenser suspects illegal activity, the matter should be referred to the Drug Enforcement Agency (DEA) and local law enforcement. ● If a prescriber or dispenser suspect illegal activity on behalf of another prescriber or dispenser, at a minimum, the matter should be reported to the appropriate licensing board. Prescribers and dispensers should be aware that: ● There is no legal obligation to prescribe or dispense a prescription; and, ● Colorado law strongly encourages prescribers and dispensers of opiate antagonists “to educate persons receiving the opiate antagonist on the use of an opiate antagonist for overdose, including but not limited to instructions concerning risk factors for overdose, recognition of overdose, calling emergency medical services, rescue breathing and administration of an opiate antagonist.” (Section 18-1-712(3)(b), C.R.S.)
Additional Resources and Tools Establishing and maintaining competence: Tenney, Lili and Lee Newman. “The Opioid Crisis: Guidelines and Tools for Improving Pain Management” Center for Worker Health and Environment, Colorado School of Public Health. Functional and pain assessment: “Functional Assessment” Colorado Division of Workers Compensation Patient agreements: “Screener and Opioid Assessment for Patients with Pain - Revised (SOAPP - R)” PainEDU.org Online at: www.painedu.org Pain tool kit: Various resources for assessing and managing pain including risk assessments, patient Appendix Page 3
Policy for Prescribing and Dispensing Opioids
agreements, dose and conversion calculators among others. Center for Worker Health and Environment, Colorado School of Public Health. Online at: http://www.ucdenver.edu/academics/colleges/PublicHealth/research/centers/maperc/ online/Pages/Pain-Management-CME.aspx Substance use screening and brief counseling: SBIRT Colorado www.ImprovingHealthColorado.org Drug abuse resources: Substance Abuse and Mental Health Services Administration: www.samhsa.gov NIH National Institute on Drug Abuse: www.drugabuse.gov or www.nida.nih.gov
Appendix Page 4
