Brian Sandoval Governor Richard Whitley, MS Director Cody L Phinney, MPH Administrator John DiMuro, DO, MBA Chief Medical Officer Pain Clinics Oversight Paul Shubert Acting Chief, Bureau of Health Care Quality and Compliance Prepared & Presented by:

Department of Health and Human Services 2014 CDC Data indicates: 78 Americans die every day from an opioid overdose Opioid pain relievers are the driving factor in the increase in opioid overdose deaths Prescription opioids sold in the U.S. nearly quadrupled since 1999 At least half of all opioid overdose deaths, involve a prescription opioid Among heroin users, approximately 3 out of 4 report abusing prescription opioids prior to using heroin Department of Health and Human Services

Department of Health and Human Services NUMBER OF METHADONE CLINICS Year 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 # of NTCs 2 5 6 7 8 9 11 13 14 Department of Health and Human Services

Pain Management Facilities In Nevada 4 of 39 currently permitted OPFs and 2 of 64 currently licensed ASCs, address pain syndrome All other physician offices, physician clinics, most urgent care facilities, so called pain management clinics etc., have no oversight by health care facility regulators Any MD, DO, NP, PA-C can write prescriptions for opiates, this means every medical practice could be a “pain clinic” Department of Health and Human Services

What Are Other States Doing? Review of information from 23 other states revealed 7 have decided to regulate pain clinics in some way (LA, WI, TX, FL, AL, TN, KY) 3 states regulate as health care facilities (LA, WI, FL) 4 states regulate by the professional licensing boards (TX, AL, TN, KY) 16 states responded indicating they do not regulate pain clinics (IL, MN, DE, MI, PE, CT, UT, IN, SC, NJ, NC, MO, AR, ID, VT, ND) Department of Health and Human Services

Pain Clinic Definition A pain clinic is any physician’s practice, clinic or facility primarily engaged in the diagnosis and treatment of chronic pain Exclusions from this definition are facilities otherwise licensed or permitted under Chapter 449 of NRS/NAC Included are individual prescribers of certain pharmaceuticals based on an established threshold Department of Health and Human Services

Appropriate Oversight Agencies Problem linked to physicians prescribing opioids Problem linked to pharmacies and pharmacists dispensing opioids Problem linked to health care facility medication diversion Multifaceted approach Department of Health and Human Services

Pain Clinic Regulations Once a pain clinic/physician has met the threshold within the definition, there should be a specific set of regulations governing the practice including ongoing training requirements regarding opioid use/abuse and diversion The training requirement should be for the medical professionals as well as other employees Department of Health and Human Services

Department of Health and Human Services Future Endeavors Nevada needs to find ways to attract or qualify more physicians that are board-certified pain medicine providers Nevada needs to encourage medical professionals to go low and slow when prescribing opioids and to treat the cause, not just the symptoms Department of Health and Human Services

Department of Health and Human Services Panel Discussion Should we promote legislation to address the problem? Is there consensus for defining pain clinics? Is there consensus for pain clinics to register with the state? Should training requirements be enacted for pain clinics? What should the training include? Department of Health and Human Services