The California Department of Justice mandate to consult CURES (Controlled Substance Utilization Review and Evaluation) prior to prescribing, ordering, administering, or furnishing a Schedule II, II or IV controlled substance becomes effective on October 2, 2018.
The law states that CURES must be consulted the first time a patient is prescribed, ordered or administered a Schedule II, III or IV controlled substance. CURES must be consulted every four months thereafter if the medication remains part of the patient’s treatment plan.
It is recommended that you document any reason that you do not consult CURES.
You do NOT have to consult CURES if:
- The patient is admitted.
- The patient is seen in the Emergency Department and the substance does not exceed a seven day supply.
- The substance is part of a surgical treatment plan and does not exceed a five day supply.
- The patient is receiving hospice care.
- CURES cannot be accessed in a timely manner and the prescription does not exceed a five day supply.
- CURES cannot be accessed because of technology limitations.
- Trying to access CURES would result in an inability for the patient to receive the prescription in a timely manner and does not exceed a five-day supply.
Other states are closer than California at having an interface with common electronic health records. Meanwhile, despite considerable effort and new sections built into the software, consulting CURES is time-consuming and cumbersome.
I was demonstrating the process to one of the twenty-something-year-old Epic whiz kids. I was able to get to the DOJ CURES website easily, as the link is embedded in our EHR. Score 1. After that, things went downhill. I didn’t remember my password. Yes, I’m supposed to be reasonably adept at this stuff! However, the CURES site requires a password change every ninety days. Of course, I don’t remember. To reset the password, the link is sent to your email, which does not have a link in the EHR. I breezed through the security questions. The whiz kid wondered why I can remember a phone number from the 1960s and not my password. I did not snarl at him. Score 2. You cannot use any of your last twenty passwords. Ack! I run out of children and pets at that point. Then there were the CAPTCHAs. The pleural is intentional. It went on and on. There were at least five different CAPTCHAs. I squinted and struggled to know which picture had street signs. At last! My password was reset. Score 3.
Once successfully in the CURES site, you have to manually enter the patient and birthdate. Of course, by now, you’ve hidden the EHR screen behind the CURES screen, and quite probably your email… so you have to go back and find the patient data. That interface with the EHR needs to get here NOW.
What do you do with the information? Your duty to consult CURES is complete once you have accessed the record. Note, it has to be the prescribing clinician, not your nurse or any delegate, no matter what you document. There is an audit trail. Of course, the DOJ is careful to warn against providing your password to anyone. (The horror! No physician has EVER in frustration given a member of the staff a password.) Regardless, you probably want to record the information in the chart. There is no interface. You can screen capture and paste into your note, or take a picture with your SmartPhone app. Awesome.
In both my demonstration and in the clinic, facing a real patient, I become frustrated. And, remember, I’m good at this technology stuff. What is going to happen in most offices? Some clinicians will ignore the law risk their license. Others will cheat and give a trusted delegate access. Many more, I imagine, will obey the law, not by spending the time to consult CURES, but by avoiding prescribing any controlled substance. Most of us didn’t like writing those drugs anyway. Now there is one more reason to avoid writing the script.
Did we need this law to affect all physicians? We have prescribing data. Would looking at those outliers (and excluding oncologists) have been a more sensible approach? Additional training for those who prescribe above a predetermined threshold would make sense. Embedding decision support and socializing guidelines for use makes sense. Having total morphine equivalent visible in the header is already implemented. SureScripts data that easily allows visualization of prescriptions from other providers has been an amazing step in the correct direction.
Months from now, when the prescriptions of opioids are down, perhaps the politicians will view this as a success. But what really happens? What about the patients who truly have pain? Many patients will be referred to pain specialists. There are not that many pain specialists out there and the access is already limited in many (most) areas. Other patients will seek other solutions to their pain- some legal, some not.
Pain should never have been made the fifth vital sign. We can be an empathetic and helping profession without aiming for a pain level of zero. Yet, on many levels, opioids are great drugs. They do what they were designed to do. What a shame the CURES act will, for many, take away a valuable tool. Yes, the law allows for five days in postop patients, or seven days after an emergency department visit. Does that cover all the people who wouldn’t become addicted and who will hurt for more than a week? Defining appropriate usage is in its infancy. Advances in research will continue, and with this information around safe prescribing strategies will be refined.
Our care should be safe, compassionate and appropriate. I applaud the intention to reduce prescribing practices that contributed to the opioid crisis. Well this law preserve access to safe and appropriate usage of opioids?
Yes, the opioid crisis is a crisis. I do not think CURES in its current format is the answer.
Lisa Masson, MD, is a board-certified primary care physician in Los Angeles. Her passion for primary care motivated her to take on an active role in clinical informatics. She is a 2018–19 Doximity Author and a proud mother of three daughters.