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Nurse licensing laws block treatment for opioid addiction

A vial of Naloxone and syringe are pictured at a Naloxone training class taught by Jennifer Stepp

A vial of Naloxone and syringe are pictured at a Naloxone training class taught by Jennifer Stepp and her daughter Audrey for adults and children to learn how to save lives by injecting Naloxone into people suffering opioid overdoses at the Hillview Community Center in Louisville, Kentucky, November 21, 2015.Photo by John Sommers II/Reuters

Confronting an opioid overdose epidemic that is killing at least 90 people every day, two federal agencies this month gave more than 700 nurse practitioners and physician assistants the authority to write prescriptions for the anti-addiction medication buprenorphine.

The goal: To let them help treat as many of the more than 2.5 million people addicted to painkillers or heroin in the nation as they can.

Tens of thousands more nurse practitioners and physician assistants could be helping, too, by applying for a federal license to prescribe the potentially life-saving medicine. But laws in more than half the states are likely to prevent nurses from using their licenses in rural areas that need it most.

Twenty-eight states prohibit nurse practitioners from prescribing buprenorphine unless they are working in collaboration with a doctor who also has a federal license to prescribe it. The problem is, half of all counties in the U.S. do not have a single physician with a license to prescribe buprenorphine.

In addition, laws in Oklahoma, Tennessee and Wyoming explicitly prohibit nurse practitioners from prescribing buprenorphine — one of three anti-addiction medications approved by the U.S. Food and Drug Administration — with or without a doctor’s supervision. And a law in Kentucky prohibits physician assistants from prescribing the safe and effective drug.

“We’re losing people every day, and governors are asking how long it will take before this additional group of clinicians is able to get out there and start providing medication-assisted treatment,” said Maureen Cahill, senior policy adviser at the National Council of State Boards of Nursing.

But some of those governors should blame their own “scope of practice” laws. Those laws restrict what nurse practitioners and physician assistants can do, including providing buprenorphine to people with opioid addictions to help them kick their habit.

         courtesy of Pew Charitable Trusts

Big Need, Little Licensing

Treating opioid addiction with buprenorphine can be highly effective. It prevents withdrawal symptoms and curbs cravings. But a federal license is required to prescribe it for addiction treatment.

Only one in 10 people in the U.S. with an addiction receive treatment. In large part, that’s because of a shortage of trained treatment providers, especially ones who can prescribe buprenorphine.

To help address that, Congress last year enacted the Comprehensive Addiction Treatment and Recovery Act. One of the law’s most significant provisions allows nurse practitioners and physician assistants to apply for a federal license to prescribe the medicine.

Until now, only doctors could prescribe buprenorphine, and in the 15 years since the drug was approved, fewer than 39,000 doctors have sought a license to do so.

Meanwhile, there are more than 222,000 nurse practitioners and about 109,000 physician assistants in the nation, and many of them offer primary health care in rural parts of the nation where the opioid crisis is most acute.

The two federal agencies that issue licenses — the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Administration — have so far approved them for 560 nurse practitioners and 184 physician assistants.

Mitra Ahadpour, who oversees buprenorphine licensing at SAMHSA, said she expects applications to increase as more health care professionals learn about the new law and take a free, three-day online training course.

Scope of Practice Laws

Applications for licenses to prescribe buprenorphine may not surge, however, unless states change their scope of practice laws to allow nurse practitioners and physician assistants to use their prescribing power on their own.

Some have. West Virginia, which ranks No. 1 in the nation in overdose deaths, last year changed its scope of practice law to allow nurse practitioners to diagnose, prescribe and treat patients without a doctor’s supervision, with the exception of prescribing schedule II drugs such as Percocet, Vicodin and OxyContin. South Dakota granted nurse practitioners full practice authority in February.

Oregon is updating its rules to authorize nurse practitioners to prescribe buprenorphine for addiction. Nurse practitioners in Oregon already have authority to prescribe schedule III drugs, including buprenorphine, for pain management. But previous state rules, which reflected federal law at the time, prohibited prescribing it for addiction.

Changing the laws isn’t easy, though, despite the training that nurse practitioners and physician assistants have.

In addition to an undergraduate nursing degree, nurse practitioners must complete a graduate program to be certified. Physician assistants, who work directly with doctors, must complete at least two years of advanced studies after obtaining a bachelor’s degree.

A 2010 Institute of Medicine report cited nearly 50 years of academic studies and patient surveys in concluding that primary care provided by nurse practitioners has been as safe and effective as care provided by doctors.

But state medical societies, which represent doctors and wield significant influence in most legislatures, are reluctant to cede professional turf to nurses. Arguing that nurse practitioners lack the necessary level of medical training, they insist that it is unsafe for patients to be treated by nurse practitioners without a doctor’s supervision.

Some doctors also have a financial incentive to limit nurses’ independence. Often carrying heavy medical school loan debt, they can be loath to see their revenue diverted by competing health care services, particularly those with lower fees.

The Federal Trade Commission has weighed in on legislative efforts to give nurse practitioners more autonomy in several states, arguing that physician groups have no valid reason for blocking such laws other than to thwart their competition.

Still, getting state lawmakers to update their scope of practice laws has been a slow process, said Taynin Kopanos, vice president of state government affairs for the American Association of Nurse Practitioners.

“Although nurses care very much about getting more treatment to people who need it, and governors and lawmakers do as well, scope of practice laws are not likely to be changed overnight just because of the opioid epidemic,” Kopanos said.

This story was produced by Stateline, an initiative of The Pew Charitable Trusts. You can view the original report on its website.

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Cherokee Nation files lawsuit targeting CVS and other pharmacies in opioid crisis

A sign is photographed outside of a CVS Pharmacy in New York

A sign is photographed outside of a CVS Pharmacy in New York, U.S., April 29, 2016. Photo by Lucas Jackson/Reuters

Cherokee Nation is suing CVS Health, Walgreens, and other drug companies and retailers, alleging the companies didn’t do enough to stop prescription painkillers from flooding the tribal community and creating a crisis of opioid addiction.

The lawsuit, filed in tribal court on Thursday, alleges that the companies failed to properly monitor opioid prescriptions and orders. The tribal government alleges that those patterns should have raised red flags that the companies are legally responsible for reporting to federal officials.

“These drug wholesalers and retailers have profited greatly by allowing the Cherokee Nation to become flooded with prescription opioids,” the lawsuit alleges. “They have habitually turned a blind eye to known or knowable problems in their own supply chains.”

The rate of drug-related deaths among American Indian and Alaska Native people has nearly quadrupled since 1999, according to the Indian Health Service. It’s now double the rate in the US as a whole. Oklahoma — home to most of the 120,000 citizens of Cherokee Nation — leads the country in prescription painkiller abuse.

Cities and counties across the US have filed similar lawsuits against drug companies. West Virginia included several pharmacy chains as well in a case brought against opioid distributors. But this is the first case brought by a tribal nation seeking to hold those dispensing prescriptions responsible for an epidemic of opioid addiction.

READ NEXT: ‘It can tear a family apart’: The opioid crisis sweeps through Cherokee Nation

In a statement to STAT, CVS Health said it has “stringent policies, procedures and tools to ensure that our pharmacists properly exercise their corresponding responsibility to determine whether a controlled substance prescription was issued for a legitimate medical purpose before filling it.”

Walgreens declined to speak on pending litigation.

Under the Controlled Substances Act, pharmacies and drug distributors are legally responsible to flag federal officials when they see suspicious orders or prescriptions for controlled substances such as opioids.

Those suspicious orders can take several forms. They could involve patients filling multiple opioid prescriptions from different doctors — known as “doctor shopping” — or an order for opioids that’s disproportionately large for the local population.

“Pharmacists have a duty only to fill scripts that are for a legitimate medical purpose,” said Richard Fields, a D.C.-based lawyer who filed the lawsuit on behalf of the tribe. “If a doctor is engaged in prescribing opioids illegally, that doesn’t relieve the pharmacy of liability.”

In 2015, an estimated 845 million milligrams of opioids were distributed in the 14 counties that span Cherokee Nation, according to the Drug Enforcement Agency. That averages out to between 360 and 720 pills per year for every prescription opioid user in the Cherokee Nation, the lawsuit says.

By 12th grade, nearly 13 percent of American Indian teens have used OxyContin, according to the American Drug and Alcohol Survey. And 2.6 percent of American Indian students in 12th grade have used heroin, nearly double the rate of the general population.

READ NEXT: No opioids, please: A growing movement lets patients refuse prescriptions

“As we fight this epidemic in our hospitals, our schools, and our Cherokee homes, we will also use our legal system to make sure the companies, who put profits over people while our society is crippled by this epidemic, are held responsible for their actions,” Cherokee Nation Principal Chief Bill John Baker said in a statement.

There have been a slew of lawsuits filed by local governments accusing drug makers of contributing to the opioid epidemic by downplaying the addictive properties of painkillers and improperly encouraging doctors to prescribe the drugs.

In February, for instance, Erie County, N.Y., sued four companies — Purdue Pharma, Johnson & Johnson’s Janssen unit, Teva Pharmaceuticals, and Endo International — for costing the county government millions of dollars each year to fight the opioid crisis.

“The goal is to get justice for the Cherokee Nation and to recover the extraordinary losses they’ve suffered as a result of the opioid epidemic,” said Fields.

This article is reproduced with permission from STAT. It was first published on April 20, 2017. Find the original story here.

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FDA: Codeine cough syrup should not be given to kids

The FDA issued its strongest level of drug warnings Thursday concerning opioid pain-reliever use in children. Photo by
         DNY59/via Getty Images

The FDA issued its strongest level of drug warnings Thursday concerning opioid pain-reliever use in children. Photo by DNY59/via Getty Images

The FDA issued its strongest level of drug warnings Thursday concerning opioid pain-reliever use in children.

Medicines containing codeine and another narcotic, tramadol, will now require a label indicating that they should not be used by children under 12. For children ages 12-18, and for breastfeeding mothers, the FDA said, the use of these medications should be limited.

The finding comes after a safety review the FDA launched in 2015 to investigate the risks of these two opiate drugs. Presently, codeine is approved to treat pain and cough — including as a frequent ingredient in prescription cough syrups — and tramadol is approved to treat pain.

The analysis found that the drugs carry serious risks for patients under the age of 12, including difficulty breathing and death, and that they carry a risk for adolescents up to age 18 who have breathing troubles.

“We understand that there are limited options when it comes to treating pain or cough in children, and that these changes may raise some questions for health care providers and parents. However, please know that our decision today was made based on the latest evidence and with this goal in mind: keeping our kids safe,” said Dr. Douglas Throckmorton, the FDA’s deputy center director for regulatory programs, in a written statement.

Codeine already carries a black-box warning, which the FDA added in 2013, stating that the medication should not be used to treat a child’s pain after surgery to remove his or her tonsils. Tramadol will now also bear this warning in addition to the other new contraindications and warnings.

The warnings will only apply to prescription drugs; some products with codeine are available over the counter. The FDA is also considering other regulations that would apply to over-the-counter codeine products.

Both Health Canada and the European Medicines Agency have issued similar warnings about codeine within the past five years. Canadian regulators also recently completed a safety review for tramadol with similar findings to the FDA’s.

Unlike codeine, tramadol wasn’t FDA-approved for pediatric patients; however, in September 2015, the agency noted it was likely being used off-label in children.

The American Academy of Pediatrics encouraged doctors to stop giving codeine to children in a September 2016 report published in Pediatrics.

This article is reproduced with permission from STAT. It was first published on April 20, 2017. Find the original story here.

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For doctors, a clamp down on visas could have an uneven effect in the U.S.

Image by Kaiser Health News

Limiting the number of foreign doctors who can get visas to practice in the United States could have a significant impact on certain hospitals and states that rely on them, according to a new study.

The research, published online in JAMA this week, found that more than 2,100 U.S. employers were certified to fill nearly 10,500 physician jobs nationwide, in 2016. That represents 1.4 percent of the physician workforce overall. There were wide variations by state and employer, however.

Employers in New York, Michigan and Illinois accounted for the most H-1B visa applications for foreign physicians, nearly a third of the total. North Dakota, however, had the most applicants as a percentage of its physician workforce: 4.7 percent.

Hospitals use the [H-1B visa] program to recruit doctors to serve in rural or underserved urban areas.

The top three employers that submitted applications for the most doctors through the visa program were William Beaumont Hospital in southeastern Michigan, with 470 physician applications, Bronx-Lebanon Hospital Center in New York City, with 213, and Cleveland Clinic foundation in Ohio, with 180.

“People underestimate the fragility of certain hospitals and their reliance on certain physicians for their functioning,” said study co-author Peter Kahn, who’s graduating from Albert Einstein College of Medicine in the Bronx this spring.

The H-1B visa program allows employers to hire highly skilled professionals from abroad to fill employment gaps in the U.S., typically in high-tech, science, engineering and math jobs. But hospitals use the program as well, often to recruit doctors to serve in rural or underserved urban areas. The number of visas is capped at 85,000 annually.

That could change. On Tuesday, President Donald Trump signed an executive order reiterating his administration’s priority to buy American goods and hire American workers. Among other things, it requires federal agencies to suggest reforms to the H-1B visa program to ensure the visas are awarded appropriately.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. You can view the original report on its website.

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