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NATIONAL CONFERENCE OF INSURANCE LEGISLATORS (NCOIL)
BEST PRACTICES TO ADDRESS OPIOID ABUSE, MISUSE & DIVERSION Adopted by the NCOIL Executive Committee on November 24, 2013, and by the Workers’Compensation Insurance and Health, LTC & Health Retirement Issues Committees on November22, 2013. Sponsored for discussion by Rep. Bill Botzow (VT) 1. BACKGROUND
In early 2012, NCOIL began a more than year-long investigation into causes and consequencesof opioid abuse, giving particular consideration to impacts on the workers’ compensationinsurance market. Hours of expert testimony and committee discussion, as well as numerouswritten comments, laid the groundwork for the best practices framework offered below. Theguidelines highlight the items addressed most frequently during NCOIL deliberations.
Opioid abuse is a national epidemic. According to the Centers for Disease Control & Prevention(CDC), enough prescription painkillers were prescribed in 2010 to medicate every American adultaround-the-clock for one month.1 Approximately three out of every four pharmaceutical overdosedeaths in 2010 were due to opioid analgesics like oxycodone, hydrocodone, and methadone.2 Medicaid patients are prescribed painkillers at twice the rate of non-Medicaid patients and are atsix times the risk of prescription painkiller overdose.3 And unintentional overdose deaths relatedto prescription opioids have quadrupled since 1999—and now outnumber those from heroin andcocaine combined.4 The statistics go on and on.
In the world of workers’ compensation, there is significant proof that long-term opioid use leads tolonger claim duration, longer-term disability, higher costs, and higher medical expenses.5 The useof long-acting opioids, for instance, has been found to increase the cost of a workers’compensation claim by nine times.6 And according to the California Workers’ CompensationInstitute, the top one percent of prescribing physicians accounted for 41 percent of allprescriptions for Schedule II drugs.7 The consequences of opioid abuse, misuse, and diversion are varied and far-reaching, meaningthat an array of interested parties, from those who look at the supply-side of opioid use to thosewho address prevention, treatment, and recovery, have a hand in dealing with the problem andshould be part of discussions regarding the development and implementation of effective statestrategies—including the best practices suggested below.
2. PRESCRIPTION DRUG MONITORING PROGRAMS (PDMPs)
Recognize essential role of PDMPs
Although states have made progress in recent years to establish PDMPs—statewidemechanisms that collect, monitor, and analyze prescribing and dispensing data related tocontrolled substances—more work is needed. Programs exist in some fashion in 49states, but the PDMPs in four are not considered operational.8 It is worth noting that“operational” means a program collects data and reporting information. The term doesnot speak to the scope, funding, or effectiveness of a system.
Enhance interstate data sharing
Enhanced interstate data sharing is essential if a PDMP is to help identify sources ofprescription drug abuse, misuse, and diversion and encourage early intervention and prevention, among other objectives—and certainly should be something that states worktoward.
Currently, 18 states allow their PDMPs to exchange data with other PDMPs as well aswith out-of-state entities who are authorized to use them. Eighteen other states allowsharing only with fellow drug monitoring programs, eight only with authorized users fromdifferent states—and five have no sharing rules in place at all.9 Work to expand categories of authorized users
There is significant variation in what states mean by “authorized user,” and this mayprevent a PDMP from realizing its full potential in recognizing trends and identifying at-risk individuals10. For instance, can Medicare and Medicaid access your state’s PDMP?Do mental health and substance abuse professionals have access? Workers’ compspecialists? State licensing boards? What rules are in place for law enforcement? Consider circumstances of mandated use
When deciding whether to mandate physician use of a PDMP, states should take intoaccount how operational a program is—e.g., accuracy and timeliness of data, ease-of-use, and physician accessibility—before requiring practitioners to check one. It’s alsoimportant to consider how physician use of a PDMP would play out in a daily setting.
There may be instances in which checking a PDMP is unnecessary, like when a doctor isperforming a routine pediatric exam, or immediately before, during, and shortly after anoperative or invasive procedure. There also may be medical disciplines, such as dentalsurgery, that may not lend themselves to mandated PDMP checks.
Because there is growing concern among medical professionals regarding an increasingfrequency of neonatal abstinence syndrome, legislators may wish to strongly considerrequiring all physicians to check a PDMP as part of prenatal care.11 In doing so, statesshould consult with medical societies to ensure that any new requirements do notdiscourage pregnant women from seeking care.12 To help ensure that practitioners spend a maximum amount of time with their patients,rather than perform more administrative tasks, states might allow a practitioner todesignate auxiliary staff to access the PDMP. Delegates who access a PDMP on behalfof a practitioner should be held to the same legal and ethical standards and penalties aspractitioners and all other authorized users.
Encourage dispenser reporting
A fully functioning, effective PDMP should be a resource for a substantial body ofaccurate information, and so state legislators should give careful consideration todispenser reporting requirements. In Kentucky, for instance, non-resident dispensers ofcontrolled substances, including mail-order pharmacies, are among the entities that mustreport to the Kentucky All Schedule Prescription Electronic Reporting System(KASPER)—but not all states have a non-resident reporting mandate.13(It is worth noting that since Kentucky’s broad HB 1 reform law last year required allprescription providers of controlled substances—including non-resident dispensers—toregister with KASPER, there has been a nearly three-fold increase in the number ofregistered KASPER accounts.)14 Dispensers should know for certain if a patient obtained a prescription, and so legislatorsmight consider whether only dispensers, rather than prescribers, should report to aPDMP.15 2.6 Recognize benefits of real-time reporting
Real-time reporting in Oklahoma, the first state to implement such a requirement, meansthat the Oklahoma PDMP provides especially timely information. Also recognizing thebenefits of a real-time system is New York, whose 2012 reform law called for “real-time”submissions, currently defined by the state Commissioner of Health as “daily” reporting.
Six other jurisdictions require daily entries. All other states have longer data collectionintervals—and in some states, much longer. The National Alliance of Model State DrugLaws (NAMSDL) reports, for instance, that four (4) states require only monthly datasubmission.16 If states are concerned that reporting to a PDMP in real time will provecostly for those who do, then officials may wish to establish a mechanism forcompensating those who report.
Evaluate outcomes
Developing, implementing, and maintaining a drug monitoring program is complex andcostly. It’s crucial that states take the time to evaluate outcomes—through things likesatisfaction surveys of physicians, pharmacists, and other users, as well as audits of howoften a PDMP is used.
As time progresses, states should look at what’s happened to the number of overdoses,emergency room visits, and other consequences of opioid misuse since the PDMPbecame operational. Among other things, the data may help to identify areas in a statewhere additional treatment and prevention services, as well as community-basedoutreach, may be appropriate. Although states may have limited staff to conduct suchevaluations, universities and private research institutions may be of assistance.17 Consider state study approaches
Just recently, nearly one year after HB 1 became law, Kentucky officials announced thatthey would begin a year-long study into how the law, not just the drug monitoring programreforms, is playing out in order to determine successes and to remedy any unintendedconsequences. Wyoming, after beginning to use unsolicited reporting a few years back,began tracking the number of patients who met a certain threshold for being potentialdoctor shoppers. After two years, officials discovered that the number of such patientsdropped significantly—indicating that the unsolicited reporting effort was successful.
And, among other state efforts, Massachusetts recognized a need to develop an onlineportal for active investigations in response to survey responses from law enforcementPDMP users.18 Pursue various funding options
Funding—a word that elicits little enthusiasm among policymakers—for a PDMP must besufficient and consistent if it is to be effective in both the short and long-terms. Thisadmittedly may be an uphill climb. Current PDMP financing falls into four maincategories: grants, licensing fees, general revenue, and board funds.19 Though grant20 and other less common forms of funding—like settlements and privatedonations—certainly may be important and worth pursuing, these money sources may betemporary and inconsistent. A minor surcharge on state licensing fees, for instance, maybe more reliable.21 Dedicated financing through a state’s general fund—assuming thatthe money isn’t directed elsewhere during times of financial stress—also may be stableand effective.
Interested parties who offered specific comments on best practices for PDMPs included:American Association of Oral and Maxillofacial Surgeons (AAOMS), written (AprilAmerican Insurance Association (AIA), comments at 2012 meetings/2013 SpringAmerican Medical Association (AMA), written (May 2013, October 2013) and presentations at 2012 Annual/2013 Spring MeetingsAmerican Pharmacists Association (APhA), written (October 2013)KY Office of Drug Control Policy, presentation at 2013 Spring MeetingKY Office of the Governor, presentation at 2012 Annual MeetingNational Alliance of Model State Drug Laws (NAMSDL), presentations at 2012National Council on Compensation Insurance (NCCI), comments at 2012 meetingsPharmaceutical Research and Manufacturers Association (PhRMA), writtenProperty Casualty Insurers Association of America (PCI), comments at 2012Work Loss Data Institute (WLDI), written (September 2013) 3. PRESCRIBING PRACTICES
Use consistent, evidence-based treatment guidelines
Consistent, evidence-based guidelines may be helpful in promoting appropriate use ofopioids for managing pain and should be considered as legislators evaluate ways to reinin opioid-related workers’ compensation costs, while still allowing a provider to use morethan one type of treatment for an illness or injury. Guidelines in Washington State22—which establish dosage thresholds, standards for drug testing and tapering, use of signedtreatment agreements between physicians and injured workers, and consultations withpain management and other specialists, among other things23—are credited withnoticeably lowering mortality rates and containing costs.
Take care not to negatively impact clinical decision-making
When considering policy mandates for opioid treatment, however, legislators should workto ensure that the standards target inappropriate opioid use without negatively affectingclinical decision-making and legitimate treatment, and should seek input from medicaland public health communities. For instance, limiting the duration of an opioidprescription—which may be appropriate following dental and certain other procedures—may have negative consequences for patients with serious illnesses like cancer, AIDS,end-stage emphysema, and heart failure who rely on these medications to ease chronicsuffering. Exempting patients who are on hospice or are being managed by a palliativecare provider may further help to ensure that seriously ill patients receive the relief theyneed.
Treatment guidelines also might address when it’s appropriate to use an anti-inflammatory like ibuprofen in lieu of a narcotic, as well as address concerns thatprescribing opioids to younger patients might encourage future addiction.
Promote use of treatment plans
Legislators might promote use of written, individualized treatment plans, in which apractitioner documents alternatives to using a controlled substance along with reasonswhy the practitioner is or is not pursuing them.24 The plans list treatment objectives thatpatients are measured against periodically. A physical exam, a screen for substanceabuse, and a review of a patient’s PDMP info for the previous 12 months are requiredbefore the practitioner prescribes an opioid.
Create a closed formulary and explore impacts
Legislators also might look into creating a closed formulary to control costs and limitunnecessary use of opioids in the workers’ compensation system. A Texas formulary, in place for new claims since 2011, lists drugs that are not recommended as a first courseof treatment and so require preauthorization. According to a July 2013 TexasDepartment of Insurance analysis of claims stemming from injuries that took placebetween 2009 and 2011, the number of claims involving use of not-recommended (alsocalled “N”) drugs—which include almost all opioids—dropped by 67 percent, while thetotal cost of “N” drugs fell by 82 percent.25 Because there is no one-size-fits-all approach, however, legislators interested inestablishing a formulary should explore how it might affect a physician’s ability to makeindividual treatment decisions. States should keep in mind that physicians andpharmacists can play a critical role in developing cost containment programs—bothformularies and alternatives, such as limiting quantities of off-formulary drugs—thatdirectly affect patient care.
Regulate pain clinics to close down “pill mills”
“Pill mills”—as opposed to legitimate pain clinics in which specialized physiciansevaluate, manage, and treat a person’s pain—are a source of rampant wrongfulprescribing that states should work to rein in. These clinics give people easy and illicitaccess to dangerous controlled substances and encourage a culture of addiction bypromoting “doctor shopping” and other run-arounds to appropriate opioid usage.
Nine states have specific pill mill regulations.26 They generally target clinics in whichmost patients in any given month are prescribed or dispensed specified drugs for painmanagement. Laws require certain licenses and registrations of the clinic and the ownerand often require the owner or designated medical director to be on-site for a certainamount of time. Kentucky, for instance, requires on-site attendance 50 percent of thetime that patients are at the facility.
Pill mill laws, among other things, also limit the actual prescribing and dispensing of acontrolled substance. In Florida, the practitioner must document why he or sheprescribed more than a 72-hour dosage—and the law also prohibits physicians from on-site dispensing of oxycodone, hydrocodone, and other commonly abused drugs. In WestVirginia, pain clinics cannot distribute more than a 72-hour supply.27 Regulating pain clinics in order to close down “pill mills” is critical, but legislators shouldtake care to avoid rules that discourage physicians in lawful pain management clinicsfrom prescribing opioids for legitimate purposes, as this may significantly burden patientswith chronic pain and/or those who have no history of abuse.
Interested parties who offered specific comments on best practices for prescribingreforms included:American Academy of Hospice and Palliative Medicine (AAHPM), written (JuneAmerican Association of Oral and Maxillofacial Surgeons (AAOMS), writtenAmerican Insurance Association (AIA), comments at 2012 meetings/2013 SpringAmerican Medical Association (AMA), written (May 2013, October 2013) and presentations at 2012 Annual/ 2013 Spring MeetingsAmerican Pharmacists Association (APhA), written (October 2013)Coalition Against Insurance Fraud, comments at 2012 meetings/2013 SpringNational Alliance of Model State Drug Laws (NAMSDL), presentations at 2012National Association of Boards of Pharmacy (NABP), writtenNational Association of State Controlled Substances Authorities (NASCSA), writtenNational Council on Compensation Insurance (NCCI), comments at 2012 meetingsRenee C.B. Manworren, PhD, APRN, BC, PCNS-BC, Connecticut Children’s Medical Center, written (August 2013)Property Casualty Insurers Association of America (PCI), comments at 2012Work Loss Data Institute (WLDI), presentation at 2012 Summer Meeting and written 4. EDUCATION & OUTREACH
Consider mandated CME requirement issues
It should go without saying that anyone who prescribes an opioid must understand itsuses and ramifications, including potential for addiction. But one of the morecontroversial aspects of developing an anti-opioid abuse strategy is how to go aboutdoing that.
If legislators choose to mandate certain opioid-related continuing medical education(CME) requirements, lawmakers should work with medical licensing boards andassociations, including representatives of dentistry, in order to determine what coursesare appropriate for specific medical disciplines—e.g., what should primary care doctorsknow as related to oncologists and other specialists—and that courses do not conflict oroverlap with already-existing CME or other educational standards.28 Among other things,legislators might wish to exempt certain specialties, such as hospice and palliative care,that already require substantial training in opioid prescribing. Boards and associationsmay have a handle on how to address potential cost and other impediments.
At least nine states have CME mandates that focus on pain management/prescribingcontrolled substances.29 Concerns regarding the effectiveness of a voluntary system might be overcome bycreating incentives to encourage physician participation, such as waiving all or part ofstate licensing fees.
Implement media and education programs
A need for education is not limited to practitioners. There is a vast misperception in thegeneral public regarding the safety of prescription painkillers. After all, unlike heroin,cocaine, and other illicit drugs, prescription narcotics come from a trusted source—adoctor.
Utah kicked off an innovative media and education campaign in 2010 with funding from the Utah Commission on Criminal & Juvenile Justice and a federal grant awarded to the Utah Division of Substance Abuse & Mental Health. The “Use Only as Directed” program30—which is a partnership of substance abuse, business, and other entities— includes an interactive, easy to navigate web site featuring short, creative video clips;statistics regarding how prescription painkillers directly affect Utah; a FAQs section thatgives answers to commonly asked questions; articles and other resources; a chat roomwhere people can share their stories and seek help; and tips on using, storing, anddisposing of drugs safely.
Encourage safe, environmentally responsible drug disposal
The “Use Only as Directed” web site notes that more than half of the people in Utah whoabuse painkillers get the drugs free from friends or relatives. Nationally, the CDC reportsthat more than three out of four people who misuse prescription painkillers use drugsprescribed to someone else.31 One way that Utah and other states are trying to encourage safe, environmentally responsible drug disposal is through permanent drop-off bins, whichare proving helpful and cost-efficient in the communities that have them.
Drug take-back programs are another, more complicated option. The U.S. DrugEnforcement Agency (DEA) has established National Prescription Drug Take-Back Daysthat are manned by local law enforcement authorities at thousands of locations aroundthe country. Maine, which has the oldest population in the nation, has been a leader indrug take-back efforts, counting the quantities of drugs returned to determine whatprescriptions are returned most often. Based on the data, the state reduced costs in itsMedicaid program by imposing 15-day limits on initial prescriptions of the most wasteddrugs, including opioids.32 The rules regarding take-back events can be complex, since a web of state and federalagencies apply regulations related to hazardous waste, controlled substances, publicsafety, privacy, and other items, and boards of pharmacy may have their ownrequirements. State legislators might seek opportunities to work with federal authoritiesto develop a more comprehensive, harmonized approach, as well as to allow related take-back options—such as permitting pharmacies to accept unused prescriptions—that mightimprove take-back efforts.33 Interested parties who offered specific comments on best practices for education andoutreach included:American Academy of Hospice and Palliative Medicine (AAHPM), written (JuneAmerican Association of Oral and Maxillofacial Surgeons (AAOMS), written (AugustAmerican Insurance Association (AIA), comments at 2012 meetings/2013 SpringAmerican Medical Association (AMA), written (May 2013, October 2013) and presentations at 2012 Annual/ 2013 Spring MeetingsNational Alliance of Model State Drug Laws (NAMSDL), presentations at 2012National Council on Compensation Insurance (NCCI), comments at 2012 meetingsProperty Casualty Insurers Association of America (PCI), comments at 2012 5. TREATMENT & PREVENTION
Encourage and enhance treatment and prevention initiatives
One aspect of an opioid strategy that legislators must not ignore is how to care for peoplesuffering from drug overdose and addiction. The need to address such concerns is clear.
Just one statistic: between 1999 and 2009, there was a 430 percent rise in the rate oftreatment admissions for the abuse of prescription pain killers.34 Encourage use of certain drug treatments
Lawmakers might consider encouraging use of naloxone, an FDA-approved drug thatserves as an antidote to opioid overdose. Naloxone has been used by community-basedprograms since the mid-1990s and, according to a 2010 Centers for Disease Control &Prevention (CDC) survey of 48 such programs, the drug reversed more than 10,000overdoses.35 Sixteen states—California, Colorado, Connecticut, Illinois, Kentucky,Maryland, Massachusetts, New Jersey, New Mexico, New York, North Carolina, Oregon,Rhode Island, Vermont, Virginia, and Washington State—as well as the District ofColumbia have enacted laws that expanded naloxone availability.36 To help remove barriers that physicians face when trying to address a patient’s treatmentand recovery needs, states might work to remove federal limits on the number of patientsa physician may treat with buprenorphine, which is broadly supported by the medicalcommunity as a way to facilitate recovery from opioid addiction.
Legislators also might explore practitioners’ ability to use Suboxone. The drug helps totreat addiction on an outpatient basis and, as with buprenorphine, is subject to federallimits on how many patients a doctor can treat using the drug. Physicians also haveconcerns regarding the regulatory requirements for becoming an authorized Suboxoneprescriber.
Establish/expand use of drug courts
In addition, there may be opportunities for legislators to promote use of drug courts, whichstudies show are a cost-effective way to reduce drug use and crime rates. Addicts whoare non-violent offenders receive intensive treatment for at least one year and are subjectto random drug tests and requirements that they meet certain obligations to the court,their families, themselves, and others. According to the National Association of DrugCourt Professionals (NADCP), these courts, which are endorsed by the Office of NationalDrug Control Policy (ONDCP), have a 75 percent success rate and save at least $6,000per participant as compared to using the criminal justice system.37 Interested parties who offered specific comments on best practices for treatment andprevention included:American Medical Association (AMA), written and presentations at 2012 Annual/National Alliance of Model State Drug Laws (NAMSDL), presentations at 2012 6. CONCLUSION
State legislatures deserve a great deal of credit for their wide-ranging efforts to tackle theopioid epidemic, particularly their work in recent years. Opportunities exist, though, toestablish additional and perhaps even more successful reforms. Best practices are notintended to be a final word on how states should approach a multi-faceted opioid strategy, butthey hopefully do provide a starting point for legislative discussion and decision-making. Thestatistics of abuse are disturbing. States may have little time to waste.
1 “Policy Impact: Prescription Painkiller Overdoses,” Centers for Disease Control & Prevention, November 2 “Opioids drive continued increase in drug overdose deaths,” Centers for Disease Control & Prevention “Policy Impact: Prescription Painkiller Overdoses,” Centers for Disease Control & Prevention, November “Topics in Brief: Prescription Drug Abuse,” National Institute on Drug Abuse, December 2011.
Paduda, Joseph. “Wasted Dollars, Wasted Lives—How Opioid Overprescribing and Physician Dispensing Are Harming Claimants and Employers,” Workers’ Compensation 2012 Issues Report.
“The Effect of Opioid Use on Workers’ Compensation Claim Cost in the State of Michigan,” Journal of Occupational and Environmental Medicine, August 2012.
“Prescribing Patterns of Schedule II Opioids in California Workers’ Compensation,” California Workers Compensation Institute (CWCI), March 2011.
In most states, the Board of Pharmacy or Department of Health administers the PDMP, though law enforcement agencies, among other entities, sometimes do so.
http://www.namsdl.org/IssuesandEvents/NAMSDL%20With%20the%20National%20Safety%20Council%20Part%201%20State%20PMPs%2C%20May%202013.pdf (accessed June 2013) AZ, CT, IN, KY, LA, MI, NJ, NM, NY, ND, OH, OR (practitioner access limited to those in CA, ID, andWA), SC, TN, VT, VA, WA, and WV allow data sharing between their PDMPs and both out-of-statePDMPs and authorized users. States that allow access only for out-of-state authorized users are AK, CA,CO, ID, IA, MN, TX, and WY. States that allow access only for other PDMPs are AL, AR, DE, HI, IL, KS,MD, MA, ME, MS, MT, NV, NH, NC, RI, SD, UT, and WI. The following states have no sharing rules inplace: FL, GA, NE, OK, and PA. MO does not have a PDMP.
http://www.namsdl.org/library/17A9675F-1C23-D4F9-742C62EED4805F68/ (accessed December 2013) 10 A state may wish to require that individuals who are identified as at-risk for opioid dependence have their prescriptions filled by a single pharmacist or prescribed by a single physician.
11 Letters to NCOIL from the American Medical Association (AMA), May 30, 2013; National Association of Boards of Pharmacy (NABP), May 31, 2013; and National Association of State Controlled SubstancesAuthorities (NASCSA), June 2, 2013.
12 The American Academy of Pain Medicine, American Academy of Pediatrics, American Congress o Obstetricians and Gynecologists, American Medical Society, and American Society of AddictionMedicine may be of assistance in addressing PDMP requirements related to neonatal abstinencesyndrome (NAS).
13 National Association of Model State Drug Laws (NAMSDL), States with Statutory Authority to Require Nonresident Pharmacies to Report to Prescription Monitoring Program. http://www.namsdl.org/library/8573B7C9-19B9-E1C5-31F3C2D5B041C157/ 14 Kentucky Office of Drug Control Policy, http://odcp.ky.gov/ (accessed June 2013) 15 During a Nov. 22, 2013, NCOIL meeting in which legislators adopted these best practices, the American Insurance Association (AIA) raised the following concern: “On the final sentence in 2.5 our concern wasthat while at this time [in the best practices document], only dispensers report prescription information toPDMPs, the language is overly restrictive and does not allow for likely technological innovation. It isconceivable that when electronic prescriptions for controlled substances are implemented more fully thatprescribers could send a copy of each prescription issued to the PDMP simultaneous with sending it tothe pharmacy—an ideal situation. Suggesting states limit reporting requirements to dispensers only doesnot leave space for such a situation. Further, some prescribers not only prescribe, but also dispense. Inthis circumstance, most but not all states require the dispensing prescriber to report to the PDMP thedispensing of the controlled substance. Limiting the language to dispensers only does not fullyencompass the dispensing prescriber.” 16 New York switched to real-time reporting as of August 27, 2013. Delaware, Kansas, Kentucky, Minnesota, North Dakota, and West Virginia require daily/24-hour reporting. National Association ofModel State Drug Laws (NAMSDL), http://nationalrxdrugabusesummit.org/wp-content/uploads/2013/03/Green-pt1_STATE_PMP.pdf (accessed June 2013) 17 Pew Charitable Trusts report, Prescription Drug Monitoring Programs: An Assessment of the Evidence for Best Practices, September 20, 2012, available athttp://www.pdmpexcellence.org/sites/all/pdfs/Brandeis_PDMP_Report_final.pdf 20 The National All Schedules Prescription Electronic Reporting (NASPER) Act established a formula grant program administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) to help fund state PDMPs. NASPER has not been reauthorized, however, and currently is not providinggrants. Harold Rogers Prescription Drug Monitoring Program grants, offered through the U.S.
Department of Justice, are currently available.
21 Twelve (12) states, however—Arizona, California, Florida, Kansas, Kentucky, Maryland, Nebraska, New Hampshire, New York, Ohio, Vermont, and Washington—explicitly exclude licensing and other fees fromfunding. (National Alliance of Model State Drug Laws,http://www.namsdl.org/documents/FundingProvisionsofPMPs07312012.pdf) 22 California also has chronic pain medical treatment guidelines, available at www.dir.ca.gov/dwc/DWCPropRegs/MTUS_Regulations/MTUS_ChronicPainMedicalTreatmentGuidelines.pdfThe Work Loss Data Institute’s Official Disability Guidelines may be another resource, as well asguidelines produced by the American Pain Society (APA). Legislators may wish to consider fundingopportunities that could help certain entities develop and update evidence-based treatment guidelines, aswell as encourage research into pain management.
23 “Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain,” Washington State Agency Medical Directors Group, 2010. (Effective July 1, 2013, the guidelines were expanded to address acuteas well as chronic pain, among other things.) 24 Legislators may wish to consider how a practitioner’s use of alternative treatments (e.g., physical therapy, cognitive behavioral therapy, guided imagery, massage, hypnosis, and other items) may be affected bythird-party payers’ willingness to pay for such treatments.
25 Texas Department of Insurance report available at http://www.tdi.texas.gov/reports/wcreg/documents/Pharma_070913.pdf The report looked at injuries withnine-month maturities. (The Texas formulary kicked in for older claims in September 2013.) 26 Arizona, Florida, Georgia, Kentucky, Louisiana, Ohio, Tennessee, Texas, and West Virginia have specific “pill mill” regulations (as of June 2013).
27 In some other jurisdictions, policymakers have prohibited medical practitioners in emergency rooms from prescribing long-acting opioid painkillers.
28 One resource may be a Prescriber Clinical Support System for Opioid Therapies (PCSS-O), which offers a series of educational webinar courses. PCSS-O is a collaborative project funded by a three-year grantfrom The Substance Abuse and Mental Health Services Administration (SAMHSA). The project is led bythe American Academy of Addiction Psychiatry and also includes the American Dental Association,American Medical Association, American Osteopathic Academy of Addiction Medicine, AmericanPsychiatric Association, American Society for Pain Management Nursing, and International NursesSociety on Addictions. http://www.pcss-o.org/ 29 Krupa, Carolyne. “Hot-button issues drive state CME mandates,” amednews.com, February 13, 2012.
California, Florida, Iowa, Massachusetts, Oklahoma, Oregon, Rhode Island, Tennessee, and WestVirginia have pain management/prescribing controlled substances mandates.
30 http://www.useonlyasdirected.org (accessed June 2013) 31 “Policy Impact: Prescription Painkiller Overdoses,” Centers for Disease Control & Prevention, November 32 A proposed DEA rule that would expand the kinds of entities that could collect unused prescription drugs would ultimately, in an effort to prevent drug diversion, put an end to tabulating efforts like those in Maine.
“New Rules Could Hurt Maine Drug Takeback Programs,” Maine Sunday Telegram, January 27, 2013.
33 Legislators also might direct state agencies to identify programs in other jurisdictions that could be used as models for the state and/or wish to consider how implementing a drug take-back program affects thedaily operations, health, and security of providers, including pharmacists, and whether reimbursement isappropriate.
34 Carnevale, Ph.D., John T. Presentation before NCOIL, November 15, 2012.
35 “Community-Based Opioid Overdose Prevention Programs Providing Naloxone – United States, 2010,” Morbidity and Mortality Weekly Report (MMWR), February 17, 2012 / 61(06); 101-105. Centers for
Disease Control and Prevention (CDC). http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6106a1.htm
36 “Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Good Samaritan Laws,” The Network for Public Health Law, July 2013.
37 National Association of Drug Court Professionals (NADCP), http://www.nadcp.org/nadcp-home The following interested parties submitted written comments offering specific best practicerecommendations following the 2013 Spring and/or Summer Meetings: American Academy of Hospice and Palliative Medicine (AAHPM)American Association of Oral and Maxillofacial Surgeons (AAOMS)American Medical Association (AMA)American Pharmacists Association (APhA)National Alliance of Model State Drug Laws (NAMSDL)National Association of Boards of Pharmacy (NABP)National Association of Chain Drug Stores (NACDS)National Association of State Controlled Substances Authorities (NASCSA)Renee C.B. Manworren, PhD, APRN, BC, PCNS-BC, Connecticut Children’s Medical CenterPharmaceutical Research and Manufacturers Association (PhRMA)Work Loss Data Institute (WLDI) The following contributed more generally to NCOIL discussions regarding opioid issues and state reforms: American Insurance Association (AIA)Carnevale Associates LLC (John T. Carnevale, PhD)Coalition Against Insurance FraudInternational Association of Industrial Accident Boards & Commissions (IAIABC)Kentucky Office of Drug Control PolicyKentucky Office of the GovernorNational Council on Compensation Insurance (NCCI)Property-Casualty Insurers Association of America (PCI) “PARKING LOT” ISSUES:
NCOIL believes that these best practices should evolve in response to emerging state needs,trends, and other opioid-related concerns—in order to be of greatest assistance to states. Inkeeping with that commitment, legislators at the 2013 Annual Meeting determined to explore thefollowing items, among others, in a future version of the Best Practices to Address Opioid Abuse,Misuse & Diversion: • Good Samaritan/Safe Harbor Laws for drug overdose reporting• development by medical and hospital associations of policies aimed at limiting • expanded/enhanced guidance regarding opioid treatment, prevention, and recovery• governmental entities (in addition to the DEA) that deal with drug take-back programs• information regarding the relative effectiveness of various painkillers National Conference of Insurance Legislators (NCOIL)K:/NCOIL/2013 Docs/2007964d.doc

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CHE 230 Organic ChemistryExam 1, September 22, 1999 Before you begin this exam : First : You are allowed to have a calculator and a simple model set at your seat. Please put away all other materials. Second : Place your student identification on your desk. A proctor will come around to check everyone’s ID. Third : Read through the entire exam. Your goal, as always, is to score as many poin

Exam13

1. Paralysis of intestinal muscle contractions is called: A) distention or contraction of hollow organs. B) the hunger associated with anorexia. C) high temperatures in infants. 3. Pain felt at a location other than its origin is: 4. Shock may occur with an acute abdomen because: A) acute abdomen causes internal hemorrhage. B) fluid shifts from the bloodstream into body tissues. C) abdominal

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