Category 2 – Prescription Medicine (Continued)

Read our SAFE takes about how hospitals, clinicians, stakeholders can implement best prescription pain management practices.

Legend

RECOMMENDATIONS S.A.F.E. TAKE
NGA:  Congress should extend buprenorphine prescribing privileges (via the Comprehensive Addiction and Recovery Act) to Advanced Practice Registered Nurses (APRNs).

 

STATUS

Done

 

H.R. 6 SUPPORT for Patients and Communities Act provides permanent extension of prescribing authority for physician assistants and nurse practitioners. It also provides authority for clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists for five years.
RECOMMENDATIONS S.A.F.E. TAKE

NGA: Health & Human Services and the Drug Enforcement Agency, via exceptions under the public health emergency declaration, should issue policy guidance on providing Medication Assisted Treatment (MAT) via telehealth and encourage providers to use it. Congress should provide a permanent fix to ensure rural populations can access MAT after the public health emergency declaration expires (currently prohibited by Ryan Haight Online Pharmacy Consumer Protection Act).

Commission #41: The Commission recommends that federal agencies revise regulations and reimbursement policies to allow for substance use disorder treatment via telemedicine.

 

STATUS 

Highly Desired but Slow Going

 

Rural populations are particularly difficult to incorporate into many of the measures combating the opioid crisis. Telehealth might be one way to assist, but there must also be measures to address populations without access to broadband and devices equipped for telehealth which often still require a “physical examination,” performed via video and other computer facilitated equipment. H.R. 6 SUPPORT for Patients and Communities Act requires the Centers for Medicare & Medicaid Services to issue guidelines to states for providing services via telehealth for treatment of substance use disorder (SUD) that are federally reimbursed. It also expands the use of telehealth services by eliminating certain statutory originating site requirements for telehealth services furnished to Medicare beneficiaries for the treatment of SUDs and co-occurring mental health disorders, beginning July 1, 2019.
RECOMMENDATIONS S.A.F.E. TAKE
Commission #44: The Commission recommends HHS implement naloxone co-prescribing pilot programs to confirm initial research and identify best practices. ONDCP should, in coordination with HHS, disseminate a summary of existing research on co-prescribing to stakeholders.

 

STATUS 

Needs More Effort

 

H.R. 6 SUPPORT for Patients and Communities Act includes a provision supporting co-prescribing of naloxone in emergency rooms for patients brought in with an overdose, but doesn’t address co-prescribing in conjunction with opioids for patients in primary care or other specialty settings.  The Indian Health Service’s website has guidance on co-prescribing of naloxone (https://www.ihs.gov/odm/overdose-prevention-treatment/naloxone-prescribing/). The Surgeon General has made it clear that having a high portion of the population carrying naloxone is a priority, and that co-prescribing is an integral part of saving lives from this epidemic. This information should be provided more widely.
RECOMMENDATIONS S.A.F.E. TAKE
NGA:  The Office of the National Coordinator for Health Information Technology within Health & Human Services should require that electronic health record (EHR) vendors make their systems interoperable with all state prescription drug monitoring programs (PDMP).

 

STATUS

Heavy Lift

 

It’s unclear how big the differences might be between PDMP systems, but as states begin to require doctors to check a PDMP before prescribing highly controlled medications, integration between PDMPs and EHRs becomes more critical. Currently, most systems are separate, requiring a provider to log into both, adding more time constraints with a patient. A system that allows for customization and wide interoperability is required.
RECOMMENDATIONS S.A.F.E. TAKE
NGA: The Drug Enforcement Agency should create new requirements that health care providers register with their state PDMP and complete training to prescribe opioids (similar to what is required to prescribe medication assisted treatment (MAT)) – using Center for Disease Control’s (CDC) prescribing guideline in training.

 

STATUS 

Uncertain

 

The DEA’s focus is law enforcement, not the quality of medical training. Currently, there are more bureaucratic hurdles for prescribing MAT than there are for prescribing the opioids themselves. This is at least one factor in a low number of providers prescribing medication for treating opioid use disorder. Education should be the focus here and that change has been initiated within the medical education community.
RECOMMENDATIONS S.A.F.E. TAKE
NGA: Health & Human Services should invest in additional research and evaluation of non-pharmacological therapies for pain and guidance to assist states in making appropriate coverage decisions in Medicaid and other state administered health programs.

 

STATUS 

Signs of Progress

 

This is an important goal. Between the Pain Management Best Practices Inter-Agency Task Force, the National Institutes of Health HEAL Initiative, and the numerous new grants coming out of federal agencies, including the passage of H.R. 6 SUPPORT for Patients and Communities Act, research and evaluation will expand, but it will likely not happen quickly.
RECOMMENDATIONS S.A.F.E. TAKE
Commission #12:  The Administration should support the Prescription Drug Monitoring Program (PDMP) Act and mandate that states receiving grant funds comply with PDMP requirements, including data sharing.

 

STATUS

Low Legislative Likelihood

 

Mandates from the federal government that are not accompanied with funding to implement these mandates tend to be problematic. In this case, states could end up shifting money to this effort at the cost of more critical priorities, resulting in a growth of unresolved challenges. All but one state (Missouri) have a statewide PDMP, and many make its use mandatory.
RECOMMENDATIONS S.A.F.E. TAKE
Commission #13: Federal agencies should mandate PDMP checks and consider amending requirements under the Emergency Medical Treatment and Labor Act (EMTALA), which requires hospitals to screen and stabilize patients in an emergency department, regardless of insurance status or ability to pay.

 

STATUS 

Low Viability

 

Like Recommendation 12 – this requirement would not come with direct funding (EMTALA is an unfunded mandate) which means states have to shift money to a requirement like this. States should be making full use of their PDMPs and many, but not all, have mandates to check the PDMP. New grant money for the crisis could help states achieve this, mandate or not. HR 6 SUPPORT for Patients and Communities Act does provide some resources for hospitals and other entities to develop protocols to address the provision of an overdose reversal medication, such as naloxone, upon discharge, connection with peer-support specialists, and referral to treatment and other services that best fit the patient’s needs.
RECOMMENDATIONS S.A.F.E. TAKE
Commission #14: PDMP data integration with electronic health records, overdose episodes, and substance use disorder-related decision support tools for providers is necessary to increase effectiveness.

 

STATUS 

Non-specific/Non-trackable

 

This recommendation is non-agency specific and more of a statement of principle. CMS has issued new guidance with information to help states leverage federal funding into approaches for PDMP and EHR integration and innovation in Health IT. Innovation in both the public and private sector here is a reason to be hopeful.
RECOMMENDATIONS S.A.F.E. TAKE

Commission #15:  The Office of National Drug Control Policy and the Drug Enforcement Agency (DEA) should increase electronic prescribing to prevent diversion and forgery. Revise (DEA) regulations regarding electronic prescribing for controlled substances.

 

STATUS

Mixed Results Possible

 

Electronic prescribing is considered a vital tool in regaining control over prescription opioids. There are already some states that require it, and there is legislation that could incentivize it, federally. Although,  there are areas in rural America that don’t even have consistent broadband internet access. Requiring new technology without funding the requirement, and without appropriate waivers erects barriers to appropriate care even when well intended.
RECOMMENDATIONS S.A.F.E. TAKE
Commission #16: The Federal Government should work with states to remove legal barriers and ensure Prescription Drug Management Programs (PDMP) incorporate available overdose/naloxone deployment data, including the Department of Transportation’s (DOT) Emergency Medical Technician (EMT) overdose database. It is necessary to have overdose data/naloxone deployment data in the PDMP to allow users of the PDMP to assist patients.

 

STATUS 
Long Way to Go
 
A PDMP is only as helpful as the quality and timeliness of the inputs. When information is excluded or delayed, there are missed opportunities to counsel, assist, and protect patients from the risks associated with the use of any prescription medicine. Naloxone prescriptions should be included in that. There is some progress in municipalities that have elected to engage in their own mapping.
RECOMMENDATIONS S.A.F.E. TAKE
Commission #17: Communities should utilize Take Back Day to inform the public about drug screening and treatment services. Hospitals/clinics and retail pharmacies should become year-round authorized collectors and explore the use of drug deactivation bags.

 

STATUS 
Steady Progress
 

Take Back Days are an important tool in reducing the supply of prescription medicines to those who may  misuse them. In addition to the two national Take Back Days (in April and October) sponsored by the Department of Justice and the DEA, many pharmacies have become year-round collectors. Communities should also, to the extent possible, consider deactivation bags where collection is less feasible.

DEA Public Disposal Locator

National Board of Pharmacy Drug Disposal Locator