Because of the multiple entities involved in this topic, we will report by “group,” specifically those listed below. Notes from meetings will be added in chronological order, with the most recent information at the top.
- Industry Coalition on Prescription Drug Abuse
- Governor’s Summit on Opioids
- NSMA Task force on Opioids
- Attorney General’s Initiative
State CMO
John DiMuro, DO, MBA, formerly with SpineNevada in Reno and Carson City, has been named as the new Nevada chief medical officer has been identified. Dr. DiMuro is dual board-certified in both Pain Medicine and Anesthesiology and fellowship-trained in Pain Medicine.
Industry Coalition on Prescription Drug Abuse
June 6, 2016 meeting: Assemblyman Mike Sprinkle emphasized that no policy initiatives are yet set in stone. He plans to dedicate one of his BDRs to the topic; he won’t file the BDR until December so there is plenty of time to work on the issue in advance of the 2017 Session.
Dave Wuest from the Board of Pharmacy noted he is working with the Department of Public Safety and other law enforcement to ensure compliance with SB 459 passed in 2015. Dr. Lesley Dickson, addiction specialist in southern Nevada, mentioned the difficulty of accessing the PDMP for physicians who are licensed in a state other than Nevada but are practicing at the southern Nevada VA. Mr. Wuest noted the caution exercised in granting access to out-of-state professionals, but if a practitioner has good reason, they are usually granted access; he will look in to the issues at the VA.
Todd Rich gave the update for the Board of Medical Examiners, mentioning the investigation of Dr. Rand and highlighting the challenges of maintaining/managing patient records when a physician is arrested. Keith Lee said the Board is working with Senator Dr. Hardy to introduce legislation that would allow the Board, under certain circumstances, to become temporary custodians of patient records and allow the Board to pay a document management company to help store and manage records.
Ms. O’Mara has heard anecdotes regarding payers not covering opioid addiction treatment. Tracy Woods with Anthem said they cover most treatments, but review on a case-by-case basis and often encourage alternative, non-drug treatments. Ms. Woods also mentioned the challenge of low Medicaid reimbursement issues.
May 12, 2016 meeting: There is significant concern in Washoe Co that the 900+ customers of Dr. Rand (accused of being part of a prescription drug ring) will now be out on the street looking for replacement drugs. Pharmacies and veterinary hospitals have been warned to be on high alert about an anticipated increase in crime now that this source of a regular supply is off the market. Fred Olmstead (Board of Nursing counsel) indicated that they are getting the word out to APRNs and others who may have prescribing practice also. NSMA anticipates there will be an increase in ER visits.
The Board of Pharmacy said they are working with the specialty boards per SB459 to implement the “Red Flag” program. This allows physicians to put a red flag on a patient’s record so that other physicians will be alerted when they look up said patient. The law also requires law enforcement to be notified. According to the Pharmacy Board, they “don’t know what a ‘red flag’ looks like yet.”
The Retail Association of Nevada is discussing investing money in a media campaign about Red Flag and may call on participants to talk about treatment options, feature law enforcement, etc.
Spring 2016 coalition meeting
Licensing Boards
- Board of Pharmacy reported that enrollment and use of the PDMP has increased significantly and is now around 75% – 80%. The system is capable of handling the increased usage, but there are still issues with the accuracy of some information contained within the database, eg, the alphabetizing hyphenated names.
- The Board has an initiative to develop a method to “red flag” over-users in EHRs, so prescribers will know immediately about a patient’s possible abuse.
- Board is tracking the success of the recently passed law in New York that makes NY the first to require electronic prescribing for all controlled and non-controlled substances.
- Board of Medical Examiners has adopted CMS’ Pest Practices for Addressing Prescription Opioid Overdoses, Misuse and Addiction. The expressed that they want to enforce the new law but they don’t want to deter providers from prescribing needed treatment. The Board has hired 2 new investigators in Las Vegas and currently has 5 individuals authorized to access the PDMP.
- Nursing Board The Board of Pharmacy notifies the Board of Nursing (and other licensing boards) when a provider is suspected of prescribing inappropriately. The Board of Nursing addresses each instance on a case-by-case basis, often taking the opportunity to create a “teachable moment,” having practitioners review their prescribing habits.
Public Safety
- Reno PD has a grant in collaboration with UNR and the Board of Pharmacy to use a data driven approach to identify high-risk populations and geographic hotspots, disseminate educational materials (CMEs for providers) and increase collaboration among involved parties. The grant will also fund a prescription fraud hot line, allowing providers a streamlined method of flagging patients who may be at risk for substance abuse and will support 8 training sessions for physicians.
- Andy Razor with the Department of Public Safety Investigations Unit gave a brief update on the Department’s efforts which include pharmacist training, investigation of large scale pharmaceutical diversion in Las Vegas and tracking increased fentanyl abuse on the East Coast which the Department is expecting to make its way to Las Vegas and the rest of the State.
Governor’s Prescription Drug Summit Planning Committee Meeting
June 21, 2016
This was an eight-hour meeting to plan a summit that will take place in late August.
Committee Members:
- Governor Sandoval
- Richard Whitley, Director, Department of Health and Human Services
- Linda Lang, Director, Nevada Statewide Coalition Partnership
- Mike Wilden, Chief of Staff to the Governor
- Lidia Stiglich, 2nd Judicial District Court Judge
- James Dzurenda, Director, Department of Corrections
- Reka Danko, MD, Chief Medical Officer, Northern Nevada Hopes
- Robert ? – FBI Supervisory Agent, Satellite Office
- Jim Wright, Director, Department of Public Safety
- Michelle Berry, Project Manager, UNR Center for the Application of Substance Abuse Technologies
- Assemblyman Mike Sprinkle (D)
- Kristy McGill, Executive Director, Healthy Communities Coalition of Lyon and Storey Counties
- Senator Patricia Farley (R)
- Steve Wolfson, Clark County District Attorney
- Jeff Ellis, VP & CFO Corporate HR Shared Services, MGM
- Marsha Turner, PhD, Vice Chancellor of Health Services
According to the Governor, these are the issues going forward:
- Licensing board duties and responsibilities
- Increased collaboration with law enforcement
- Options for addict rehab
During public comment, Catherine O’Mara, NSMA CEO, presented the physician perspective:
- Education
- The community needs to be educated on the dangers of such drugs
- Awareness of take back events – 70% of those adversely taking opioids do not have a prescription
- 1/10 Americans are predisposed to addiction
- PDMP
- Link to work with the Board of Medical Examiners – early intervention is important
- Advised against creating a problem of a barrier to access to needed medication
The Governor’s Chief of Staff, Mike Willden, gave an overview of Governor Sandoval and the First Lady’s past efforts on prescription drug abuse prevention via the 2014 National Governors Association (NGA) Policy Academy. Parallel to this effort, Nevada established a Taskforce chaired by First Lady Sandoval to research prescription drug abuse and related issues including community education, medical provider education, criminal justice interventions, and screening and treatment. The Taskforce established a goal of reducing prescription drug abuse in Nevada by 18% by 2018.
The Taskforce identified a number of recommendations for implementation in certain key areas. An executive summary of these recommendations is linked below:
NGA Policy Association Policy Academy on Prescription Drug Abuse Prevention – State of Nevada Plan to Reduce Prescription Drug Abuse
Julia Peek, Deputy Administrator, Division of Public and Behavioral Health, gave an overview of the data she has collected on the abuse of opioids in the State:
Update on Prescription Data Abuse and Overdose Data
Some key points:
- Most people who abuse prescription opioids get them for free from a friend or relative
- Nevada experienced a decrease in overdose deaths between 2013 and 2014 (-12.8%)
- As many as 1 in 4 people who receive prescription opioids, long term, for non-cancerous pain in primary care settings struggle with addiction
- Hospitalization: Medicare patients (including the disabled) account for the greatest number of inpatient opioid-related admissions
Linda Lang, Nevada Statewide Coalition Partnership, and Kristy McGill, Executive Director, Healthy Communities Coalition of Lyon and Storey Counties, highlighted recommendations in the areas of community education, prescriber education, criminal justice intervention, screening and treatment and data. The full list of those recommendations and strategies for implementation are linked below:
Prevention and Education Efforts and Recommendations
Law Enforcement made the following presentations:
Pat Conmay, Chief, Division of Investigations, Department of Public Safety
Specialty drug courts reported on the successes and challenges associated with specialty courts, specifically specialty courts that use Medication Assisted Treatment (MAT). Onlyone specialty court in the Second Judicial District of Nevada uses MAT to help the offender recover from addiction while providing guidance and monitoring to ensure the offender becomes a productive member of society. The court is relatively new and recently graduated its first participant.
Challenges for MAT Specialty Court:
- Stigmatized – “substitutes one addiction for another”
- Medication and drug testing is expensive
- Limited number of treatment centers and physicians trained in addiction treatment
- Medicaid gap – once patients receive work and housing, they often lose Medicaid and can no longer afford the medications out of pocket
Two presentations from the courts are here:
8th Judicial District Specialty Court Programs
Dr. Stephanie Woodard, Psy.D, Division of Public and Behavioral Health, gave an extensive presentation regarding availability and funding for screening, treatment and recovery and public health policy considerations. Presentation: Treatment for Substance Abuse Disorders. Her recommendations include:
- Need for standardized screening tools across disciplines
- Building systems of care, including collaboration with law enforcement
- Increased behavioral health integration in health care systems
- Increased access/funding for MAT
- Education regarding overdose and access naloxone throughout health systems
Dr. Reka Danko, Chief Medical Officer, Northern Nevada HOPES, presented on Clinical and Regulatory Interventions. Important points made by Dr. Danko:
- Pain is subjective – no lab for pain; Expectation to never be in pain is unrealistic
- 1999 – Pain introduced as the 5th vital sign – making pain control as important as blood pressure, heart rate, temperature and respiratory rate
- Beginning of the problem…doctors are expected to treat pain, patients expect not to feel pain
- 2016 – recognition of national epidemic
- Now doctors are expected to curtail use of opioids, meanwhile patients have become accustomed to being prescribed pills for pain
- CDC releases guidelines, March 2016
- providers should only consider adding opioid therapy if expected benefits for both pain and function outweigh risks
- providers should discuss benefits and risk of opioid use with patient
- other guidelines: criteria for stopping, short term reassessment, prescribe short-acting opioids, etc
- Non-opioid, pain management modalities often not covered by insurance/costly
- Patient satisfaction scores create issues
Dr. Danko’s complete presentation is here: Opioid Use, Dependence and Clinical Interventions
The clinical licensing board presented:
Larry Pinson, Executive Secretary, Board of Pharmacy, noted that most fraud that takes place in pharmacies is being committed by pharmacy technicians. The Board has a zero tolerance policy and permanently revokes the license of anyone determined to have committed fraud.
Nevada Board of Pharmacy on Prescription Drug Abuse
Ed Cousineau, Executive Director, Board of Medical Examiners, gave an overview of the board’s investigation process. He made clear that the Board does not make investigatory determinations based on PDMP data, rather, a medical professional looks at the entirety of the physician’s practice, including patient records, considering all evidence before coming to any conclusions.
BME: Before the State Planning Session on Prescription Drug Abuse
Barbara Longo, Executive Director, Board of Osteopathic Medicine, discussed the regulation the Board is in the process of adopting. She gave an overview of the Board’s complaint and discipline process: BOM Complaint and Discipline Flowchart
Debra Shafter-Kugel, Executive Director, Board of Dental Examiners, read a short prepared statement.
BDE Prescription Drug Crisis Report
Fred Olmstead, General Counsel, Board of Nursing Examiners, reviewed the Board’s processes regarding the notification and investigation of APRN prescribing practices. The Board has adopted an “education policy.” When an APRN appears to be overprescribing, they send a letter asking the nurse to justify his or her practice. This usually does not result in an investigation or disciplinary action, but provides an opportunity for the nurse to reevaluate his or her prescribing practices.
In closing:
Recurring themes were identified for possible work during the actual summit. They are:
- Nalaxone – Provider and patient education
- Interrelationship between prescription drug abuse and heroin use
- Focus on youth/juveniles –law enforcement/specialty drug courts
- Continue to address stigma and improve education, culture change (like tobacco)
- Use and reimbursement of MAT
- Ensure treatment is provided after arrest/jail/prison (reduce recidivism), hospitalization, drug treatment and wrap around services
- Innovative programs for system change
- Continued education for prescribers – practice guidelines
- Maximize PDMP data (patient and prescriber education, prescriber report cards – allows for content within areas of specialty and additional data for other boards to investigate)
- Possible policy issues:
- Mandatory training for prescribers with specific standards (differing by specialty)
- Lower the threshold for prosecution
- Establish thresholds for prescribing (number of days, amount)
- Medicaid edibility, prior authorization
- Physicians’ role in establishing policy – Sprinkle
- Recovery high schools – Farley
- Better integration of behavioral health
June 27, 2016
Dr. Michael Lee from DOC and Dr. Bruce Witmer from ROC are representing NVOS on this new task force. The takeaways from the initial meeting are:
- The First Lady and the Governor are very concerned/upset about the opioid epidemic and are looking for answers and action, not excuses.
- We are approaching this problem as a reaction to headlines; we need to talk about health instead.
- This will be one of the Governor’s legacy initiatives. Suggestions for action:
- Reduce supply
- Reduce doc shopping via regular use of the PDMP
- Provide (and have insurance pay for) more/better treatment options
- Involve law enforcement in some significant way in the way we practice medicine
- ID and weed out bad doctors – need self-policing model (suggestion to use term “Practice Management Protocol” instead of “self-policing”)
- Identify docs who are “outliers” in their prescribing patterns as Senator (Dr) Hardy attempted to do with SB114 last session (bill was watered down); would necessitate that licensing boards collect information on physician specialties
- Seek increased funding for mental health treatment
Discussion:
Catherine “Cat” O’Mara, CEO of NSMA, was asked to describe the tone of the recent 8-hour meeting called by the Governor to plan an “opioid summit” in August.
Cat said it is very clear that the Governor wants action. Later in the meeting, we discussed that this will be one of the Governor’s “legacy” initiatives; he is determined to take significant action that will impact the problem. The Governor exhibited visible frustration with the BME. He not-so-obliquely expressed frustration with certain groups that make excuses and fail to take action.
There has been a slight improvement in the opioid ‘epidemic’, with a reduction in opioid deaths both nationwide and in Nevada. However, in some areas (e.g. Nye County) where programs to reduce opioid use have been very successful, there has been a parallel increase in heroin use as a substitute. Nye County also discovered that PAs are often the prescriber, and often the physician was not fully aware of their PA’s prescribing practices. Also, there was mention of the recent news coverage of physicians being influenced by drug company “gifts.”
There was much discussion about CMEs; CA requires 8 related CMEs, Mississippi requires 5, and Nevada 2. Cat is researching best practices in all states and will report back. Richard Perkins, former City of Henderson Chief of Police, former Assemblyman/Speaker of the House, and current lobbyist for NSMA reminded everyone that NSMA worked to defeat an onerous CME requirement last session, so we’ll need to explain to legislators why it was not okay in 2015 but it is okay in 2017.
Dr. Frey said he’d like to have a reporting mechanism built into the PDMP system so that physicians can report outlier patients, but there is currently no such function and no one to whom these patients can be “reported” or referred.
The importance of physicians fully documenting their treatment plans, including verification that they checked the PDMP, was discussed as an important tactic. Also, it is important for physicians to consider multi-modal interventions, not just prescribing drugs. The challenge here is the limited alternatives – insurance companies that will not pay of alternate treatments, or the challenge of referring a patient and their options for receiving timely treatment.
Twice it was mentioned that insurance carriers – who will pay for opioids to a point – often will not cover clinical alternative treatment for pain or MAT for addiction. The physician community needs to focus on this (lack of) coverage and explore how carriers could/plan to address the issue. Cat has reached out to the health insurance association in the hopes of sparking some collaboration. Any statutory or regulatory changes will not affect ERISAs or self-insured plans, but would send a message.
The overall need for education – public health media campaigns , legislators, law enforcement, school-age children and early education — was discussed as tool to reduce use.
There was mention of holding more “take back” days, where “mountains” of prescription drug are collected by law enforcement. There are nuances here, as “mountains” of drugs could be construed as evidence of over-prescribing.
One doctor mentioned that when she asks patients where they get the opioids., they often answer that they bought them on the street. Where did the guy on the street get them? Apparently, elderly patients are cleaning out their medicine cabinets and selling their drugs to a middle man for extra income.
There was mention of a 7-day limit on opioid prescriptions. However, a physician who specializes in palliative/end of life care said that is not an option for her patients. As it is now, her terminal cancer patients have a difficult time refilling prescriptions because pharmacies refuse to refill. There must be some sort of carve-out for that population/specialty practice.
Attorney General’s Initiative
AG Adam Laxalt has reappointed members to the Substance Abuse Working Group; the group is focused on prevention, treatment and enforcement and last met on June 8, 2016.
There was discussion of a West Virginia model to support “Best Practices” recommendations on prescribing and management issues. http://www.dhhr.wv.gov/bms/WV%20Health%20Homes/ProviderInformation/Documents/Opiate%20Diversion.pdf.
Wisconsin laws passed in 2015 imposes more responsibility on the providers’ prescribing practices and mandatory reporting to law enforcement. Bill summary and links:
- Requires prescribers to review PDMP information about a patient prior to issuing a prescription order for a Schedule II or III controlled substance,
- states that when a controlled substance is dispensed, the pharmacy or dispensing practitioner must report the dispensing to the PMDP by midnight of the next business day
- identifies several health care providers who may access PDMP information, including registered nurses without independent prescribing authority, medical directors, and substance abuse counselors
- eliminates the requirement for law enforcement agencies and prosecutorial units to obtain a court order to request PDMP information
- Requires law enforcement agencies to report to the state’s PDMP controlled substance violations, opioid-related drug overdoses or deaths, and stolen prescriptions for controlled substances
- Such information would then be disclosed to relevant practitioners, including pharmacists, and others to whom PDMP information may be disclosed
The National Council of State Legislatures has issued a review of model programs in a variety of state. The document is here: http://www.ncsl.org/documents/health/PainManagement216.pdf