Painkiller Restrictions Hurt Non-physician Providers, Patients
Painkiller Restrictions Hurt Non-physician Providers, Patients
A recent article in the New York Times and many other newspapers caught my attention. In an effort to curb the illegal diversion of Hydrocodone, the Drug Safety and Risk Management Advisory Committee to the Federal Drug Administration (FDA) voted 19 to 10 to recommend that Hydrocodone be moved the Schedule II category, and that physician assistants (PAs) and nurse practitioners (NPs) be restricted from prescribing Schedule II drugs.
It turned out that the reporters got the facts wrong.
According to two PAs who serve on the FDA advisory committee, it recommended only to reclassify hydrocodone from a Schedule III drug to Schedule II. The recommendation would not ban PAs and NPs from prescribing hydrocodone products. Rather, it would limit prescribing the drugs in states where PAs and other healthcare professionals are not authorized to prescribe Schedule II drugs. PAs may currently prescribe Schedule II medications in all but 14 states.
Although this recommendation does not automatically mean that hydrocodone products will be moved to the Schedule II classification, as a PA, I was upset at the implication of this panel that my profession was part of the problem with the illegal diversion of narcotic medication. Even though HHS' regulatory process would examine the efficacy of this recommendation before it is put in place, it doesn’t take much to see that these proposed restrictions will do nothing to curb the illegal diversion of narcotics, and will have a profound and negative impact on patient care and patient access to care.
I work in a surgical practice, which is inpatient based. I care for populations of burn injured patients and the usual assortment of reconstructive plastic surgery patients. We deal with serious acute pain on a daily basis. Our facility has a significant number of PAs and NPs who daily deliver inpatient and outpatient care, including the treatment of pain.
In California, after attending a mandatory daylong pharmacology course, I have been granted the privilege of prescribing Schedule II narcotics. Every state medical board does this a little differently, but Schedule II authority is common for PAs and NPs in many states. I can honestly say that I cannot effectively do my job without this ability, nor can the other surgical, emergency medicine, and hospitalist PAs and NPs.
In California, and many other states, healthcare providers can be disciplined for ineffective treatment of pain. The California Department of Justice also has the Controlled Substance Utilization Review and Evaluation System (CURES) which, after registration as a licensed healthcare provider, allows me to access information (in a HIPAA-compliant manner) about a patient’s recent narcotic prescription history. This is an effective system to both allow me to feel comfortable treating severe pain, and to avoid contribution to the illegal diversion of narcotics, with less fear of a complaint to the Medical Board of California, which could jeopardize my license to practice medicine. This is just one example of how the state and federal government can help prescribers avoid illegal diversion of narcotics.
There are more than a quarter of a million PAs and NPs practicing in the United States. With the implementation of the Affordable Care Act well underway, pressures on the healthcare system in America center on the shortage of patient care providers. Disparities in the distributions of physicians, PAs and NPs will only get worse, especially in medically under- and un-served communities.
One of the advantages of using PAs and NPs is that — with no loss of quality — it extends the reach of the healthcare team into these areas, and improves access to care at all levels. Erecting new barriers to physician-PA teams at a time when the pressures on the healthcare system human resources is about to get much worse, is a short-sighted and misdirected “solution” to a complex problem.
There is no evidence, not one bit, that PAs and NPs are a source of the problem in the illegal diversion of narcotics within our healthcare system at a higher rate than other prescribers. There is little evidence that more tightly restricting a drug through reclassifying to a higher scheduled effectively reduces its abuse potential.
As a daily prescriber of narcotics, I take very seriously my role and responsibility in making sure that I don’t contribute to the illegal diversion of narcotics, and I know that nearly all of my physician and non-physician colleagues feel the same way. There are always bad apples in every barrel, and this is where we need to focus our attention.
What we need to do is to develop better monitoring systems like CURES in California, and give all healthcare providers the tools that they need to make sure that their patients make good choices in their pain control, and to minimize the illegal diversion of narcotics. We also need to better enforce the laws on the books now, and identify and prosecute all participants in illegal drug diversion.
The American Academy of Physician Assistants, while acknowledging the serious problem of diversion and abuse of opioid drugs, questions whether limiting access to appropriate pain medication for patients with legitimate clinical need is the proper response.
Patients have a right to quality healthcare, and this includes effective pain control. Healthcare teams that employ PAs and NPs are part of the solution to this problem, not the cause of it.
This blog was provided in partnership with the American Academy of Physician Assistants.
Dr. Christopher –
As a practicing PA for 32 years in a variety of specialties including adolescent and emergency medicine, I'm painfully aware of the crisis of narcotic use among teens and young adults. We are doing something about it in California by empowering physicians, PAs and other prescribers to play an active role in solving this problem through a prescription drug monitoring program (PDMP).
These programs are highly effective (https://www.ncjrs.gov/pdffiles1/ondcp/pdmp.pdf). For example, a 2010 study found that when PDMP data were used in an emergency room, 41% of cases had altered prescribing after the clinician reviewed PDMP data – with 61% of the patients receiving fewer or no opioid pain medications than had been originally planned by the physician prior to reviewing the PDMP data.(1)
I know from personal experience how CURES in California works as I and other physicians and PAs at a busy metropolitan urgent care were able to establish a reputation on the street as a place to be avoided if you were doctor shopping or drug seeking. The ready availability of narcotic prescription data, and the organizational policy changes championed by the PAs, made a huge difference in responsible prescribing at all levels.
As of 2011, 35 states had operation PDMPs, and all these states have demonstrated success in the battling narcotic diversion through altered prescriber behavior as well as enforcement.(2) Much more needs to be done.
If we are really serious about this problem, we need to implement these programs in all states, and mandate interoperability of systems so that data can be shared nationwide. I truly believe that PDMPs are a much better solution to this problem than further restricting schedule drugs. It also is a better solution for the patients who truly need effective treatment for their pain.
Stephen Hanson, PA-C
1. Baehren DF, Marco, CA, Droz DE, et al. A Statewide Prescription Monitoring Program Affects Emergency Department Prescribing Behaviors. Annals of Emergency Medicine. 56(1):19-23. 2010.
2. GAO Report to the Subcommittee on Oversight and Investigations, Committee on Energy and Commerce, House of Representatives. Prescription Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion. May 2002. http://www.gao.gov/new.items/d02634.pdf.
Does anyone consider all the hassle this causes a doctor and their patients that have legitimate needs? Why do we have so many conflicting rules.
1)All prescriptions must be sent electronically Medicare will start fines for doctors that do not 2014
2)no pain pills can be sent that way
3) no ADD meds can be sent electronically
4) no antidepressants can be sent that way.
5 ) no sedatives hypnotics can be sent electronically
A doctor can only prescribe for 1 month supply, oops rule change by insurance co. Ask your doctor for a year supply oops it's ADD med so doctor can give 90 day supply. Must fill prescription within 1 wk, Texas law change now you have 21 days for controlled substances.
Medico legally blood pressure meds should be every 3-6 mos. but insurance companies have patients coming in belligerent about needing a year supply
Before making such changes how about some open forum with doctors in the real world.
As a practicing physician in a state ravaged by narcotic pain killers let me spread some news to you. The most abused drug of addiction in America by Teenagers and adults alike is no longer marijuana, not methamphetamine, not even alcohol....Its prescription narcotics. The same one that you prescribe for your patient after receiving surgery. And like it or not, but the influx of midlevel providers into America's Primary care shortage has led to the opening of pill mills covered by a physician director that usually covers multiple pain clinics almost all staffed by midlevel providers. These pain clinics, staffed by your midlevel brethren, has led to an epidemic of narcotic pain pills released onto the streets and in the hands leading to young people overdosing and dying. If you think there are not studies on this, then do them. I am 100% sure you will prove me right except your American Academy of PA's or American Academy of NP's don't want these studies done. Why? Because they may paint a bad light on your clinical prescribing and practicing skills. This has to change. There clearly has to be stricter guidelines on the prescribing of these meds with even criminal negligence on the part of the providers if not done appropriately. From a physician, think twice before you willy nilly write a Rx for pain meds because they might not end up in your patient's body but in the body of a child or teenager....Who's fault was that if Motrin could have controlled the pain? Ask yourself that!