Addressing Substance Abuse Through Legislation in Nevada
Nevada passed AB 474 during the 2017 legislative session to address substance abuse issues, both illicit and licit. The law, supported by Governor Sandoval, aims to combat abuse, misuse, and diversion of substances. It emphasizes the need for responsible prescribing practices and continuing education for healthcare providers to tackle the growing problem of substance abuse in the state. The background of pill mills in Florida serves as a cautionary tale, highlighting the importance of effective regulation in the healthcare industry.
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Brian Sandoval Governor Richard Whitley Director State of Nevada Department of Health and Human Services Division of Public and Behavioral Health John DiMuro, DO, MBA Chief Medical Officer September 25, 2017 Helping People. It s who we are and what we do.
What is AB474? What is AB474? AB 474 Passed during the 2017 Nevada State Legislative Session to combat both illicit and licit substance abuse, misuse and diversion. Sponsored by Governor Sandoval and passed unanimously without opposition Will be implemented January 1, 2018 Helping People. It s who we are and what we do. 2
The Problem The Problem Controlled Substance Abuse, Misuse and Diversion Illicit Drugs Licit Drugs Helping People. It s who we are and what we do. 3
Why do we have a problem? Why do we have a problem? Increased supply of legal drugs Increased access to illegal drugs Dark Web Provider over-prescribing Surgeons Primary Care Logistics Dental prescriptions Providers not wanting to prescribe due to perception Lack of access to appropriate providers Helping People. It s who we are and what we do. 4
Floridas Inability to Regulate Florida s Inability to Regulate HOWTHE GEORGEBROTHERSMADEMILLIONSWITHPILLMILLS $40 MILLIONINCASH, 56 OVERDOSEDCUSTOMERSINTWOYEARS August 25, 2011|By Bob LaMendola, Sun Sentinel It was "the Candy Man" who schooled two bad-boy rich kids in 2007 on how to make a fortune. His advice? Start a pain clinic. The unnamed physician, nicknamed by cops for his large volume of pill prescriptions, launched Wellington twins Jeffrey and Christopher George, then 27, to start a pill mill empire that raked in $40 million in two years in Broward and Palm Beach counties, officials say. On Tuesday, the Georges and 31 co-conspirators were arrested on charges ranging from murder to racketeering to fraud. The brothers had sold 20 million pain pills by the time police and federal agents shut down their four clinics in March 2010, prosecutors said in a 123-page indictment. Each clinic made up to $50,000 a day. Employees carried the receipts to the bank in garbage bags. Their mother who worked in a clinic and got arrested with her sons kept about $4.5 million of their spare cash in two safes in the attic of her house on Primrose Lane in Wellington. DIRECT EFFECT ON APPALACHIA Forward-thinking for Nevada Helping People. It s who we are and what we do. 5
Governor Sandovals Bill AB474 PRIMARYREASONSWHYTHISBILLIS DIFFERENT THAN OTHERSTATEBILLS Preserves provider clinical decision-making Creates rational prescribing requirements at appropriate treatment intervals Creates mandatory continuing education requirements to keep providers current Written from the perspective of both provider AND patient affording equal protections Informed Consent (patient) and drug contract (provider) Helping People. It s who we are and what we do. 6
Governor Sandovals Bill AB474 HOWELSEISTHISBILL DIFFERENT THANOTHERSTATEBILLS? 1) Does not handcuff the physician Preservation of provider clinical decision-making 2) Must register with the PDMP 3) Must have normal follow up 4) Evidence-based diagnosis work-up 5) Changes in Board oversight 6) Prescription changes 7) ADDRESSESTHEPRIMARYSOURCEOFTHELICITDRUG PROBLEM Helping People. It s who we are and what we do. 7
Five Major Points of AB474 1) At the time of the initial or first prescription: Primary Issues to be assessed before writing rx Prescriber must query the PDMP Have a bona fide provider-patient relationship Perform a primary risk assessment Discuss non-opioid treatment options (if any) Discuss why a controlled substance is being prescribed Provide a preliminary diagnosis and treatment plan Completed Informed Consent A voluntary, legally documented agreement by the patient to allow performance of a specific diagnostic, therapeutic, or research procedure Helping People. It s who we are and what we do. 8
Five Major Points of AB474 1) INITIAL OR FIRST PRESCRIPTION MANDATES 2) Mandates for prescribing at 30 consecutive days Signed Prescription Medication Agreement Consent to drug test bodily tissue if requested Inform patient about reasons for prescription changes or termination Patient needs to inform prescriber about Patient use of any licit or illicit substances such as alcohol, marijuana (not in PDMP) or amphetamines, etc. Each state where the patient has previously received controlled substances Any prior history of substance abuse treatment or complications (such as overdose) from using controlled substances Helping People. It s who we are and what we do. 9
Five Major Points of AB474 1) INITIALORFIRSTPRESCRIPTIONMANDATES 2) MANDATESFORPRESCRIBINGAFTER 30 CONSECUTIVEDAYS 3) Mandates for prescribing at 90 days Must begin evidence-based diagnostic workup and discuss treatment plan with patient (Can t just use back pain or chronic pain as a diagnosis) Complete Risk of Abuse Assessment PDMP review every 90 days If dose is >90 Mmeq, consider referral to pain medicine specialist and assess for increased risk of adverse effects from long-term controlled substance use Helping People. It s who we are and what we do. 10
Five Major Points of AB474 1) INITIALORFIRSTPRESCRIPTIONMANDATES 2) MANDATESFORPRESCRIBINGAFTER 30 CONSECUTIVEDAYS 3) MANDATESFORPRESCRIBINGAFTER 90 CONSECUTIVEDAYS 4) Mandates for prescribing at 365 days Prescribe 365 Does not restrict the prescriber in any way as they can still write for whatever drug they choose and for any dose and quantity Helping People. It s who we are and what we do. 11
Five Major Points of AB474 1) INITIALORFIRSTPRESCRIPTIONMANDATES 2) MANDATESFORPRESCRIBINGAFTER 30 CONSECUTIVEDAYS 3) MANDATESFORPRESCRIBINGAFTER 90 CONSECUTIVEDAYS 4) MANDATESFORPRESCRIBINGAT 365 DAYS 5) MANDATESFORREQUIREMENTSONANACTUALRX MUST include patient date of birth MUST include ICD-10 diagnosis MUST include minimum number of days to consume rx (adherence to Prescribe 365) MUST include provider DEA number Helping People. It s who we are and what we do. 12
Implementation / Compliance of AB474 Implementation / Compliance of AB474 Common Question #1 Common Question #1 How will the provider ever be able to become compliant with this type of legislation? Creation of DW 474 forms Each form will be specific to the section in the Bill that contains mandates for compliance Will be in editable version on the DHHS website available for download and editing by each provider If forms are complete, provider will be in compliance Helping People. It s who we are and what we do. 13
Implementation / Compliance of AB474 Implementation / Compliance of AB474 Common Question #2 Common Question #2 But my practice should have an exception or carve- out to this Bill! There is no need as the Bill takes into account all prescribers needs by not restricting prescription writing Provider owns the prescription Helping People. It s who we are and what we do. 14
Implementation Compliance of AB474 Implementation Compliance of AB474 Common Question #3 Common Question #3 Why does my practice need this Bill? We all have to do our part to address this issue without exception. We need to change prescribing practices across the board without exception. Physicians hated Electronic Medical Records (EMRs) in the beginning but now can t live without them. Helping People. It s who we are and what we do. 15
Governor Sandovals AB474 Governor Sandoval s AB474 What are the take-home points? 1. Innovative, rational controlled substance Legislation was needed 2. This bill allows prescribers to practice medicine without restrictions 3. Requirements at Day 0, 30, 90 and 365 4. Prescribe 365 is a novel approach based upon the statistical data 5. Depth of knowledge is not well appreciated 6. No carve-outs for any prescriber entity 7. No language on cannabis 8. Compliant-friendly forms being created for download 9. All prescribers must contribute if we are going to make a difference Helping People. It s who we are and what we do. 16
Contact Information John DiMuro, DO, MBA Chief Medical Officer Nevada Division of Public and Behavioral Health Department of Health and Human Services (e) JDiMuro@health.nv.gov (p) 775-684-5850 (a) 4150 Technology Way, Suite 300, Carson City, NV 89706 Helping People. It s who we are and what we do. Helping People. It s who we are and what we do. 17
