I-Team: Nevada doctors will have to comply with new opioid regulations on Jan. 1

http://www.lasvegasnow.com/news/i-team-nevada-doctors-will-have-to-comply-with-new-opioid-regulations-on-jan-1/876634765

LAS VEGAS – As of New Year’s day, Nevada doctors who prescribe opioid medication will have to comply with new regulations. On Tuesday night, physicians received a crash course on how the rules will work.

The new law, Assembly Bill 474, was initiated because of concerns about an opioid epidemic. As 8 News NOW has been reporting over the last several weeks, there is another side to the opioid issue, so what happens to legitimate pain patients?

The news release which announced the event declared that Nevada has the fourth highest overdose mortality rate in the country that is, the state did back in 2010. However, a lot has changed in the last seven years.

Opioid prescriptions in Nevada have dropped every year since 2011 while overdoses and hospitalizations have gone up, so how can that make sense?

At city hall Tuesday night, the medical society helped prepare local physicians for the impact of Assembly Bill 474. The law is not as draconian as some opioid crackdowns enacted elsewhere, but it means any doctor prescribing opioid medication must provide a detailed medical history so that pharmacists can decide if the prescription should be filled.

State officials say Nevadans are dying from prescription opioids, even though about 90 percent of overdose deaths involve illicit drugs including heroin, meth, fentanyl, alcohol and other substances. Chronic pain patients in Nevada already sign contracts which require urine screening and other conditions.

Patients were not part of the panel Tuesday night but were in the audience because they worry the new requirements will turn a bad situation worse.

“It’s very burdensome for prescribing physicians, and I’m really afraid what’s going to happen is that a lot of doctors are just going to quit prescribing these opioid pain medications altogether because they don’t want to be bothered with it,” said Rick Martin, chronic pain patient. “They don’t have enough time to deal with patients as it is, and there are not enough pain management doctors in town or elsewhere to handle the patients thrown under the bus by primary care physicians who don’t want to treat them anymore.”

Martin, a retired pharmacist, says millions of legitimate pain patients are being punished because of the actions of addicts who overdose, mostly on illicit drugs. Under Nevada law, pharmacists can already decline to fill prescriptions, though they are supposed to consult with the doctor first.

As reported in our recent series, the other side of opioids, Nevada pharmacists already use patient profiling to decide if they will fill opioid prescriptions. They also have an unofficial blacklist containing the names of doctors.

   This report stated that they had previously reported that Nevada Pharmacists are “profiling” pts as to who is “worthy”, in their opinion, to have a controlled substance filled. Has the Nevada legislature put responsibilities on Pharmacists that exceeds both their training and legal authority under the state’s Pharmacy Practice Act ?

Since we are dealing with subjective diseases… will pharmacists be held to a higher liability when they fail to “get it right” and refuse to fill prescription(s) written by a legal prescriber ?

There was a couple of physicians in the early 90’s that got sued for refusing to treat the pain of end of life cancer pts. The survivors in the families sued … not for malpractice… but for pt/senior ABUSE.. and each lawsuit the plaintiffs were awarded ONE MILLION + for pt/senior abuse..

Normally filling a C-II prescription takes the pharmacist 2-3 times everything else because of administrative tasks that only the pharmacist can do. Asking a Pharmacist to take on the added time consuming task of “evaluating the pt’s needs” for the controlled substance could cause a lot of pharmacists to “just say no” or more commonly stated phrase “I’m not comfortable”…

But this state mandate on pharmacist could come back to haunt their employer by not providing enough staffing hours for the pharmacist to do this mandatory task(s) and/or the pt’s PBM/insurance by not providing proper funding that allows the employer to provide proper staffing.

Since we are talking about a state mandate and potential profiling, and if the board of pharmacy (BOP) can find their “balls and backbone” they should be able to act on consumer complaints of unprofessional conduct  against both the permit holder (employer) and the PIC ( Pharmacist in Charge) and the dispensing pharmacist – if not the PIC.

The primary charge of the BOP is to protect the public’s health and safety… if they fail to act on obvious and gross harm to a specific segment of the population, could those individual members of the BOP be sued for failing to “do their job” ?

Since those pts who are suffering from subjective disease… – in theory – they should be covered by the Americans with Disability Act and Civil Rights Act and if it can be proven that all involved (PBM/insurance, employers, pharmacists) put policies and procedures in place that cause profiling to happen and legit/on time/medically necessary medication was denied … which could be considered a civil rights violation of all those pts covered under those two laws.

There are so many moving parts to this whole issue…This could keep a lot of personal injury and civil rights attorneys very busy for a long time.

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There are hundreds – thousands of “supplements” that make “suggestions” as to their ability to help a pt’s health and they all have the statement including on the label as to the fact that they are not approved by the FDA

Dietary Supplement Products & Ingredients

https://www.fda.gov/Food/DietarySupplements/ProductsIngredients/default.htm

The Federal Food, Drug, and Cosmetic Act defines a dietary ingredient as a vitamin; mineral; herb or other botanical; amino acid; dietary substance for use by man to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of the preceding substances.

Unlike drugs, supplements are not intended to treat, diagnose, prevent, or cure diseases. That means supplements should not make claims, such as “reduces pain” or “treats heart disease.” Claims like these can only legitimately be made for drugs, not dietary supplements.

Dietary supplements include such ingredients as vitamins, minerals, herbs, amino acids, and enzymes. Dietary supplements are marketed in forms such as tablets, capsules, softgels, gelcaps, powders, and liquids.

Under existing law, including the Dietary Supplement Health and Education Act passed by Congress in 1994, the FDA can take action to remove products from the market, but the agency must first establish that such products are adulterated (e.g., that the product is unsafe) or misbranded (e.g., that the labeling is false or misleading).

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Steve,

I recently started having trouble with the Wal-Mart Pharmacy .  My doctor prescribes a topical cream for dry skin (Clobetasol).  The pharmacy has been giving me this medication without incident for at least two years.  The last two times I attempted to refill my prescription the Wal-Mart employee behind the counter refused to refill my prescription until I provided several pieces of medical information: 1) Application area; 2) Amount being applied; 3) Size of the tube needed.  As aforementioned, it was a refill so they had that information.  As far as the other information is concerned, I refused to answer it and they refused to refill the prescription.  I walked out, called my doctor, and Wal-Mart Pharmacy left a message my prescription was ready.

I called Wal-Mart customer service and explained to them, in no uncertain terms, would I ever give my protected medical information to anybody at Wal-Mart outside of allergies and current medications I am taking.  They insisted they have a legal right to demand this information and will continue to refuse to refill my prescriptions unless I provide it.  They also intimated that insurance companies are insisting on my medical information due to a new policy that has taken effect in the last 6 months.  

I have taken your advice and contacted the Board of Pharmacy.  Before I submit my complaint, could you provide me with any references to the specific HIPAA law that protects the privacy of my medical information and which law that mandates a pharmacist can not refuse to fill a valid on-time prescription.

Thank you,

This is a educated guess… but.. it sounds like to me that your insurance and/or PBM (Prescription Benefit Manager) is demanding this. What I suspected that your PBM showed up at Wal-Mart one day to do a audit… and what I have heard that these PBM auditors show up expecting new data points that have never been looked for in previous audits.

These audits seem to get more and more draconian with each succeeding year…  They start out with supposedly selecting a “random” 1% of a pharmacy’s claim and then like with prescriptions like yours.. rejects the claims because certain “new data points” are not on the prescription… and there is no “making up the missing data points”… and then they reject the claim… and look at all the refills on that single prescription… take the $$ value of the Rx – including refills – and then when they are done with the audit they take the rejected claims and multiple the “amount due” by ONE HUNDRED .. because there was a 1% sampling… so the mistakes on that sampling must reflect all the mistakes that the pharmacy made on all the prescriptions billed to that PBM.  With three PBM’s controlling the vast majority of prescription claims.. and the PBM’s paid for some 80%-90% of all prescriptions… I have heard of some pharmacies get “audit recoup demands” of 10,000’s of dollars and the pharmacies are prohibited by their contract with the PBM to attempt to recoup any money from the pt for the rejected claim(s). With the average Rx price approaching $60 each.. it doesn’t take many clerical errors for a recoup demand to get to those $$$ figures.

And the contracts with the pharmacies are presented on a “take it or leave it” basis.. if you don’t take/sign the contract the PBM will make sure that your Rx patients will be sent to one of your competitors that has signed the contract.

5-6 years ago, Walgreens tried to negotiate with the PBM Medco – now part of Express Scripts – and refused to sign the contract offered.. because they felt that the reimbursement offered was TOO LOW & unprofitable…  Walgreen’s caved after about one year.. because they lost too much business.

And I would bet that Wal-Mart is prohibited by their contract with the PBM to charge you cash and let you file a claim with your insurance company.

The PBM industry is sort of like what we have heard about the Mafia and extorting money from retailers to allow them to stay in business… and it is all perfectly LEGAL… because the insurance industry is exempt from Sherman Antitrust Act by the McCarren Ferguson Act…  they can do things that are ILLEGAL in the rest of the business world …without consequences …

IMO, you can file complaints but your PBM is standing between you and you getting your prescriptions… with the demands for particular personal data points.

I just got a email from a pt on some eye drops and the PBM told the pt that he would have to get by with 4 bottles a month and I calculated that he would need – according to the directions – at least 7 bottles/month and that worked under the presumption that he “hit his eye” 100% of the time with each drop… which – IMO – will not happen in the real world …the pt’s doctor wrote for 10 bottles/month… which to me sounded like a reasonable number.  IMO.. the PBM was just “playing games”… hoping the pt would just accept their mandate… PBM’s and insurance companies are FOR PROFIT business and when it comes to a pt’s quality of life and their bottom line profit.. guess which one get their priority ?

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I have a couple of questions.  1.  Have you heard of a pain management doctor taking away xanax that he never prescribed or has anything to do with?  Nor does he even know why I’m taking it?  He took away my Tizanidine last month, now it’s my xanax.  I have been on them for over 20 years for the things that gave me PTSD, OCD, panic attack, nightmares, anxiety….the list goes on.  Who is he to tell me to stop taking them?  Can you direct me somewhere in hopes I can get this turned around?

2. Remember those 2 guys that sued?  I can’t remember the website or group it was in.  Do you still remember the article?  I really want to start this once all my puppies have gone to their new homes.  

Thanks Steve!

I have heard of some docs insisting that a pt stop taking medication being prescribed by other prescribers the pt is seeing and they are being prescribed certain medications.

Your pain doc may have come to that conclusion from the Beer’s medication list  http://www.pharmacist.com/node/84786

this is just one link… Beer’s list medications that could POSSIBLY cause serious side effects in the elderly…  IMO, according to Beer’s most people over 50 should not take a whole list of classes of medications… also IMO.. by and large it is a bunch of BS

Could have also come to the conclusion from the “medical geniuses “ at the DEA that have publicly stated that they see no valid medical need for a pt taking a opiate, muscle relaxant, benzo together..  They have come to this medical conclusion because many substance abusers  prefer that combination to be taken together and in “high doses” to get high.. on the street it is referred to as “the Trinity”.. if the substance abuser is lucky enough to get their hands on Oxycodone, Xanax, Soma… it is referred to has “The Holy Trinity”.

Much/most/all of what the DEA is stating as “bad” for pts with medical conditions is based on what they see on the street and what substance abusers are taking/doing..  What substance abusers are doing on the street should have nothing to do with what is prescribed to pts with valid medical needs

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As a longtime customer at my local walgreens , like about 9 years, I have had 2 very disturbing conflicts with several pharmacist . I am a disabled 65 yr old who has a complicated medical history and have been taking the same 2 narcotic meds for 12 yrs same dose same instructions thru my long time and only predrilled my primary dr. Several months back instructions went in as I do every 6 was to fill my hard copy scripts and left them and they were very busy. I came back 1 hr later and drove thru the drive thru the lady said the pharmacist  had questions and needed to contact my dr. This was very strange but I found out he was a fill in.  So I went in and ask him why he needed to contact my dr and I did not care if he did. I they were the same as always for the past 9 yrs. He said he had not called yet and then proceeded to ask me what kind of pain I was being treated for and rhinestone started naming off all my others meds I take on and re gera basis as I have for 9yrs. As I’m standing there people all around me in line and waiting in the seating area I was horrified and embarrassed .  I told him I did not think I had to tell him what my medical history was and so he walked over picked up my 2 scripts and said well I don’t have to fill them for you. I went to another pharmacy  and told them what had just happened and she told me he no right to treat me like that. She filled them and told me to report him to the pharmacy  manager and I did, but he seemed uninterested and so I did not nothing else.

Now, they are changing 1 of my meds to one that upsets my stomach  so I requested to get the ones I had been on for years. I gave them 2 days notice and today the same song and dance as they say they can’t get those from there warehouse any more and probably could not however last month when I requested them with no notice they had them in stock so they filled it. I went to another pharmacy which is embarrassing  and they did have them. 

My point is that I believe if I was a cash paying customer and not a medicare part d customer they would have had tried to a com date me. I believe they are putting a class of senior medicare people in a different class as they are losing money on us. This makes me very upset as I feel like they did care but me but do not really ,  money.

Should I make. Complaint or just let it go? I am on social security disability as well.

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http://www.drugstorenews.com/article/amerisourcebergen-makes-push-curb-opioid-diversion-misuse

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Local Officials Sit Down with Community to Discuss Opioid Epidemic

http://www.mypanhandle.com/news/local-officials-sit-down-with-community-to-discuss-opioid-epidemic/877345033

THERE IS A VIDEO ON THE ABOVE LINK – COULD NOT COPY/EMBED IN THIS POST

BAY COUNTY, Fla. – Policy makers and law enforcement are constantly trying to find ways to put an end to the opioid epidemic that is devastating the nation.

Thursday evening, Representative Jay Trumbull and Bay County Sheriff Tommy Ford, sat down with members of the community for a discussion about opioid addiction.

Scott Clemons, a Board Member for the Big Bend Community Base, said this event is for the local officials to hear the public’s thoughts on this national crisis. 

“It’s not the kind of event where we’re having a panel of experts, Representative Trumbull and Sheriff Ford want people to give their input about their own experiences and their ideas about how we can solve this crisis as a community and as a state,” he said.

Those who have lost someone to drug addictions shared their stories, as well as doctors and pharmacists who deal with pain medications everyday.

Sheriff Tommy Ford said this gave him a perspective he does not get to see everyday.

“I think if we can engage the community we can really make a difference,” he said.

Many members of the community said addiction should be treated like a disease and the community should focus on treatment, while others said the solution should begin with educating students at a young age about this epidemic.

Barb and I went to this meeting last night in Panama City Beach.. there was 4+ dozen people at the meeting, some legislators, law enforcement, a couple of doctors, and large number of people who are social workers or others that work with the consequences of substance abuse.

Local bureaucrat started the meeting by making a short presentation… and of course stated that some 60 K people die of drug over doses.. but to his credit.. did mention that a large percent were not from just opiates or controlled substances… and then at the end of the meeting a state representative talked and quoted the 60 K OPIATE RELATED DEATHS.. in just a matter of a couple of hours the number of people who died from opiate OD’s had JUMPED 50%.

One ER physician stated that he had seen his first newborn dealing with withdrawal from KRATOM..  no way to confirm or deny if that was the only substance that the Mother was using … just that isolated piece of information thrown out ??

One woman … obviously a MJ advocate stating that opiate OD deaths have declined 25% in places where it is legal.. Florida voters approved legalizing MJ in the last election by some 70%-80%… but.. some of the cities/counties have been dragging their feet in granting permits for sellers/dispensers.

One woman, made a statement that the Purdue Pharma family – 5 members – were worth 14 billion and were the cause of all these OD’s… of course Oxycodone was on the market ( Tylox, Percodan, Percocet)  for years before 1996 when Purdue brought out Oxycontin… which was the first long acting Oxycodone.  Her, like most others in that group of Purdue Pharma haters, claim that their promotion of Oxycontin was deceptive..  when they stated that when used in chronic pain .. it was not addicting…  which is true when treating chronic pain pts… when prescribed/taken by people who have undiagnosed addictive personality disorder…  the outcome is typically quite different.

Could we come to the conclusion of blaming  all the deaths from distracted driving and texting directly/indirectly to Steve Jobs and Apple and the invention of the Iphone ?  Could we come to the conclusion that since Henry Ford invented the assembly line for auto manufacturing that the FORD FAMILY is directly/indirectly responsible for the 35,000/yr deaths from auto accidents ? How many deaths can be directly/indirectly connected to some industry/invention – tobacco & alcohol come to mind at first.

There was on doctor there who claimed to be a Geriatrician… and he stated publicly that NO ONE every died of opiate cold turkey withdrawal, and that HIGH DOSE opiates have no place out side of the hospital setting…  I spoke with this physician after the meeting and asked him if he did CYP-450 enyzme testing on pts who appear to need high doses… NOPE.. in thinking back.. I am not sure he even knew what  CYP-450 enzyme test really was ..

This does not surprise me, at the turn of the century, we had decided to sell one of our two rental condos, and move full time to our beach condo,  We totally renovated the condo we intended to live in … with things that are more residential – more expensive – and would not take the use/abuse of renters. Barb ended up in one of the two local hospitals with infected diverticulitis .. I am not sure if “they almost killed her” or “they almost let her died”… the quality of the healthcare here at the beach was – IMO – between PATHETIC and MORONIC…  Our condo became our non-rental second home… which it still is.  But I digress

I tried to talk to one of the bureaucrats about the fake use of the word FENTANYL and that there was only one legal and 17 – or so – illegal analgos and that most people were dying from the illegal forms.. his response …a death is a death.. at which point I pointed out the 550,000/yr deaths from the two drugs of Alcohol & Nicotine and got a SHRUG out of the bureaucrat… so a death is not really a death..

One person who indicated they were a representative of United Way stated that we needed more CIVIL ASSET FORFEITURES to help fund more services for the substance abusers.

Many stated that addiction is a disease and a substance abuser is not going to “clean up” until they are ready…

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Hi, good morning, I need to ask questions regarding about a incident that happen with CVS pharmacist and talking badly about me as patient to my md office.  Also, refused to give back a prescription that required me and still at this time to take to other pharmacy to get refill.  What are my rights as a patient?  What can I do?  When discussing my prescription which I feel he violated my rights due to fact, that he stated out loud what the md wrote on the prescription,  when other patient around.  What can I do to hold this pharmacy responsible for their actions?

Unless a prescription has been forged, altered or some other reason that it is not a LEGAL PRESCRIPTION… and the authorities should be contacted… otherwise, the prescription BELONGS TO THE PT… and a Pharmacist confiscating a pt’s prescription is nothing short of THEFT. Since the authorities were not called… I must presume that the prescription was LEGAL…

I can only speculate why the Pharmacist confiscated this prescription and one of them could be that the Pharmacist could be involved in abusing or diverting (selling) controlled substances and this would be one way that he/she could get their hands on a C-II drugs without having the Rx dept’s C-II inventory being out of balance. Could even bill the pt’s insurance to lessen his/her out of pocket costs. 

On the down side for the pt and prescriber… if the prescriber gives the pt another prescription and to be filled at a different pharmacy.. the insurance company would reject the claim… because of the previous prescription diverted by the pharmacist that confiscated the first prescription.  Also on the state’s PMP.. it would be viewed as the pt being a pharmacy shopper and the prescriber being viewed as “over prescribing”.

Will the local prosecuting attorney or Sheriff/Chief of police accept and pursue a claim of theft of personal property by a known person ?  I don’t know…  I would suggest that after a week has passed … the pt should contact their insurance company to see their was a claim in their name for the medication on the specific date from that specific pharmacy. I would also suggest that the pt request the prescriber to check the state’s PMP database to see if the prescription was filled under the pt’s name on that date … if the prescription had been filled for cash.

If any of those issues prove to be true the pt then should contact the chain pharmacy’s legal dept and/or loss prevention with the facts that would suggest diversion by one of their employees.

I see almost every week where a healthcare professional is charged with drug diversion..  this theory is not far outside of what is going on everyday in healthcare.

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Pharmacy Board Releases Guidance on How to Issue a Valid Prescription

https://www.natlawreview.com/article/pharmacy-board-releases-guidance-how-to-issue-valid-prescription

Ohio prescribers need to be aware of new rules for prescribing controlled substances that will take effect on December 29, 2017. First, prescribers will be required to include the first four characters of the ICD-10 diagnosis code or the full CDT procedure code on all prescriptions for opioids.^[1] Similarly, beginning June 1, 2018, prescribers will need to include the ICD-10 diagnosis or CPT procedure code on prescriptions for all other controlled substances. In addition, prescribers will be required to indicate the days’ supply on all prescriptions for controlled substances and gabapentin starting June 1, 2018.

The aforementioned requirements follow previously enacted rules for prescribing opioid analgesics for the treatment of acute pain.^[2] These rules, which became effective August 31, 2017, generally limit the prescribing of opioid analgesics for acute pain to no more than a seven (7) day supply for adults and a five (5) day supply for minors. Prescribers may prescribe opioids for an acute condition in excess of the day supply limits only if they provide a specific reason in the patient’s medical record. Finally, the acute prescribing rules also require that the total morphine equivalent dose (MED) not exceed an average of 30 MED per day.

To assist prescribers in complying with these and other requirements, Take Charge Ohio, in partnership with the State of Ohio Board of Pharmacy, recently published a guide entitled “Issuing a Valid Prescription – What Every Prescriber Needs to Know,” which can be accessed at:https://www.pharmacy.ohio.gov/Documents/Pubs/Special/DangerousDrugs/Issuing%20a%20Valid%20Prescription%20%20What%20Every%20Prescriber%20Needs%20to%20Know.pdf.

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And now this is hitting not only me but my son….he had a bad seizure, fell down a flight of stairs, broke his collarbone…was hospitalized. Discharge notes…Advil as needed. He is in misery

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