Experience of Health Care Reform An overview of SB 459 Laurie Squartsoff NV Department of Health and Human Services GOOD SAMARITAN DRUG OVERDOSE ACT

 Origin and Development of Successful Reform  Implementation  Outcomes  State Contacts / Additional Resources 2 Roadmap of Presentation

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Origin and Development of Successful Reform NEVADA DATA 2nd highest for hydrocodone prescriptions (ARCOS) 2nd highest for oxycodone prescriptions (ARCOS) 4th highest for methadone prescriptions (ARCOS) 7th highest for codeine prescriptions (ARCOS) 4th highest drug overdose mortality rate (Vital Statistics) Over 19% of Nevada High Schools students report that they have taken prescription drugs without a doctor’s prescription (YRBS) 4

5 Origin and Development of Successful Reform The goal of the NGA Prescription Drug Abuse Prevention program is, with improved coordination of statewide resources, to reduce the incidence of inappropriate controlled substance use by Nevadans.

Data Defined Goals Reduce overall prescriptions of hydrocodone and oxycodone (ARCOS data) as well as expansion of MAT providers (DEA) and prescribers (SAPTA) and assurance to access to comprehensive, fully integrated treatment (Medicaid data to access) Reduce the number of overdose deaths (Vital Statistics, Coroner data) Reduce number of high school students that have used a prescription drug without a prescription (YRBS) 6 Origin and Development of Successful Reform

Timeline 7 Origin and Development of Successful Reform DateMilestone July 2014Announced as Rx Drug Policy Academy Co-Lead September 2014First meeting with National Governors Association (NGA) staff and other states OngoingStakeholder meetings, core team subcommittee meetings April 2015Legislative hearings May 5, 2015Stakeholder meetings, SB459 Signed into Law June 2015Reconvening of all states at NGA meeting in Vermont September 2015Report turned over to Chief of Staff at Governor’s office

8 Origin and Development of Successful Reform Source linked at end of presentation. Teal slices were TFAH/ASTHO strategies already in place in Nevada and orange slices were added by SB 459.

Mandatory Use of PMP Prescriber Education Requirement Good Samaritan Law Support for Naloxone use Key components of SB 459

 Origin and Development of Successful Reform  Implementation  Outcomes  State Contacts / Additional Resources 10 Roadmap of Presentation

Data collection Community Education Provider Education Law Enforcement Assessment and Treatment 11 Implementation

The Nevada DHHS, Substance Abuse and Prevention Agency (SAPTA) and the Multidisciplinary Prevention Advisory Committee (MPAC) and the State Epidemiologic Workgroup (SEW) were selected to manage implementation. MPAC is a partner advisory group with the SEW, both of which advise SAPTA. The SEW collects and analyzes the data and the MPAC 's role is to create recommendations on strategies and funding in relation to the information the SEW presents. The MPAC also receives Coalition updates. The MPAC meetings provide regular updates on statewide efforts. SAPTA tracks progress and shares information with Governor’s office. 12 Implementation

 Origin and Development of Successful Reform  Implementation  Outcomes  State Contacts / Additional Resources 13 Roadmap of Presentation

Mandatory Use of PMP Prescriber Education Requirement Good Samaritan Law Support for Naloxone use Key components of SB 459

Outcomes Mandatory access and use by practitioners of Prescription Monitoring Program(PMP) Practitioners are required to obtain a PMP report before initiating some prescriptions for a controlled substance

Outcomes PRESCRIPTION MONITORING PROGRAM Prescription is for a controlled substance (Schedule II,III, or IV) Patient is a new patient for the practitioner; or The prescription is for more than 7 days and is part of a new course of treatment for the patient

Outcomes PRESCRIPTION MONITORING PROGRAM Practitioners are obligated to actually review the PMP reports NRS (1) does not apply to inpatient chart orders; it does apply to prescriptions written for out-patients by practitioners working in a hospital emergency department

Outcomes PRESCRIPTION MONITORING PROGRAM Periodic training for practitioners concerning the misuse and abuse of controlled substances The language in sections 15.1 through 15.9 is permissive, not mandatory:

Outcomes PRESCRIPTION MONITORING PROGRAM The language in sections 15.1 through 15.9 is permissive, not mandatory: Each Board “may, by regulation, require…who is registered to dispense controlled substances pursuant to NRS to complete at least 1 hour of training relating specifically to the misuse and abuse of controlled substances during each period of licensure. Any such holder of a license may use such training to satisfy 1 hour of any continuing education requirement established by the Board.”

ADDITIONAL PROVISIONS IN SB459 Ability for practitioners to “Red Flag” Doctor Shoppers – Section 13 Next Day reporting to the PMP Database Section -13(2) Outcomes

GOOD SAMARITAN OVERDOSE ACT Authority to Prescribe and Dispense to Non-Patients Outcomes

GOOD SAMARITAN OVERDOSE ACT Section 7 of SB459 applies to a health care professional otherwise authorized to prescribe an opioid antagonist may directly or by standing order, prescribe and dispense and opioid antagonist to a person other than the patient. Outcomes

GOOD SAMARITAN OVERDOSE ACT Section 7 describes other persons as “a family member, friend or other person in a position to assist such a person at risk of experiencing an opioid-related drug overdose.” Outcomes

GOOD SAMARITAN OVERDOSE ACT Significant departure from traditional pharmacy law. Outside the scope of SB459, prescriptions must be written for the patient in a prescriber-patient relationship. See NRS (2) and (4). Prescribers cannot generally write prescriptions for persons who are merely related to or associated with the patient. Outcomes

GOOD SAMARITAN OVERDOSE ACT Per the statute, such prescriptions are to be regarded as “being issued for a legitimate medical purpose in the usual course of professional practice.” Section 7(1) Prescribers who write such a prescription in good faith and with care are immune from civil or criminal prosecution directly associated with writing the prescription. Section 7(2) Outcomes

GOOD SAMARITAN OVERDOSE ACT Section 7(3), not withstanding any other provision of law, any person may possess and administer an opioid antagonist to another person who he or she reasonable believe is experiencing an opioid-related drug overdose. Outcomes

GOOD SAMARITAN OVERDOSE ACT Any person is undefined, but the statute specifically states that law enforcement personnel, EMTs, advanced emergency medical technicians or paramedics are included, as being able to possess and administer an opioid antagonist Outcomes

GOOD SAMARITAN OVERDOSE ACT Persons who act in good faith and with reasonable care in administering an opioid antagonist- although they would have no legal authority to administer other medications-are immune from criminal prosecution, civil liability and sanction from professional licensing boards. Section 7(4) Outcomes

GOOD SAMARITAN OVERDOSE ACT Section 7(5) does not create a duty to prescribe or dispense an opioid antagonist. A prescriber who declines to prescribe the medication for any reason is immune from criminal, civil and administrative proceedings Outcomes

GOOD SAMARITAN OVERDOSE ACT Section 8 Authority of unlicensed persons to store, possess and administer opioid antagonists Outcomes

GOOD SAMARITAN OVERDOSE ACT Section 8 allows non-registered persons to store and dispense opioid antagonists pursuant to a standing order from a properly authorized prescriber. The caveat is that ‘those activities [must be] undertaken without charge or compensations.” Where the person has a standing order from a prescriber, the person can possess and dispense without charge without a license from the Board of Pharmacy pursuant to NRS Chapter 639. Outcomes

GOOD SAMARITAN OVERDOSE ACT Authority of pharmacists to dispense opioid antagonists in accordance with standardized procedures or protocols developed and approved by the State Board of Pharmacy Recent workshop held on October 15, 2015 Another workshop scheduled for December 2015 Pending regulations will be forwarded to LCB before adoption Outcomes

GOOD SAMARITAN OVERDOSE ACT Section 12 addresses protections for persons who seek medical assistance for another person who is experiencing a drug or alcohol overdose Outcomes

GOOD SAMARITAN OVERDOSE ACT Section 12(1) says that if a person seeks aid in good faith on behalf of himself/herself, or for another, that person “may not be arrested, charged, prosecuted or convicted, or have his or her property subjected to forfeiture” or other penalty. Outcomes

GOOD SAMARITAN OVERDOSE ACT Even in cases where immunities in subsection 12(1) do not apply, the Court, before sentencing, “shall consider in mitigation any evidence or information that the defendant, in good faith, sough medical assistance for a person in connection with the events that led to the violation.” Section 12(2). Outcomes

ISSUES STILL AT HAND Section 10: DHHS MAY MONITOR/WATCH CHANGE TRENDS IN RISK FACTORS AND PUBLISH ANNUAL REPORT Outcomes

IMPORTANT TO ASSURE THAT “PAIN” PATIENTS RECEIVE APPROPRIATE TREATMENT WITHOUT BARRIERS Outcomes

 Origin and Development of Successful Reform  Implementation  Outcomes  State Contacts / More Information 38 Roadmap of Presentation

State Contacts Larry Pinson, Pharm.D., Nevada State Board of Pharmacy; Tracey Green MD, Chief Medical Officer: Dena Schmidt, Deputy Director, DHHS: Laurie Squartsoff, R.Ph, DPBH: More Information Nevada Legislature: SB459: SAPTA: Trust for America’s Health Report: Data Resources: YRBS data for NV: 39 State Contacts / More Information

40 Experience of Health Care Reform An overview of SB 459

Thank you! 41 Experience of Health Care Reform An overview of SB 459