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restrictive drug formulary.

The current restrictions on controlled substance (CS) prescribing in WV are

unnecessarily restrictive. Pain control is imperative for the proper and complete care of patients.

While in WV much focus, rightly so, has been on the significant problems WV has with opiate drug diversion and overdose, patients have a right to quality health care which includes

adequate pain control. In fact there have been disciplinary and legal findings of elder abuse against providers in the US who neglected to provide adequate pain relief by denying CSs (Garcia, 2013). The fact that there are excessive limits on APRN CS prescribing ability places APRNs, as well as their patients, at a significant and troublesome disadvantage.

While the prescription drug abuse problem in WV is well-known, the presumption that amending the law by lifting restrictions on APRNs to prescribe CSs will worsen the problem is erroneous thinking (Trust for America's Health, 2013). First, the current WV law regarding prescribing CSs (a 72-hour supply for Schedule III medications, and no Schedule II) is one of the eight most restrictive states in the country (Drug Enforcement Agency; DEA, 2014). As noted in the application, all of WV’s surrounding states have more expansive prescribing privileges regarding CSs than the APRNs of WV. While there may be varying levels of

restrictions on our surrounding states, such as different rules for collaboration, all of these states have the right to prescribe Schedule II drugs, while WV does not. In addition, all have

permission to prescribe Schedule III drugs for a period much exceeding 72 hours. As of the writing of this response, the restrictions on CSs in our surrounding states are as follows (unless noted, these states do have collaborative requirements):

State or Jurisdiction

Schedule II Schedule III Notes

WV None 72-hour supply (3 days), 0 refills KY 72-hour supply 30-day supply, 0 refills

OH 24-hour supply no noted limit

MD No prescribing limits No prescribing limits State requires only a signed TN 30-day supply 30-day supply, 0 refills

VA No specific limits (defined in practice agreements)

No specific limits (defined in practice agreements)

PA 72-hour supply (must notify collaborative

physician - 24 hours)

30-day supply (refills based upon collaborative physician)

District of Columbia

No prescribing limits No prescribing limits No collaboration requirement

Clearly the problem with opiate abuse, diversion, and overdose is complex and cannot be laid at the feet of WV APRNs. Likewise, having one of the most restrictive states in terms of CS prescribing has not demonstrated a successful strategy to curb WV’s CS abuse problems.

Additionally, limitations such as the 72-hour supply add to the cost of health care in WV. For example if patients who have selected an APRN as their provider were experiencing significant pain requiring a CS, they would have to visit their APRN every 3 days until the pain resolved or they would have to be referred to see a physician who would be willing to provide care for their pain. Visiting a prescriber every 3 days not only introduces expensive market inefficiency, but it also decreases appointment slots which are then filled with repetitive pain

management refill appointments rather than allowing the prescriber to attend to WV citizens’

acute primary care needs.

The auditor’s recommendation on CS prescribing was, admittedly, based upon his personal beliefs and assumption, which he made apparent in an interview on the statewide radio show, Talkline with Hoppy Kercheval, by stating, “given the addiction crisis we have in West Virginia, I cannot in good conscience recommend to the Legislature that 2,149 more individuals in West Virginia be allowed to write prescriptions for Class 2 narcotics” (Allred, 2014).

In addition to the troublesome nature of an auditor making a recommendation based upon his own opinion rather than evidence, the data he quoted were exaggerated and presented in an inflammatory context. While 2,149 APRNs may be registered in WV, only 902 APRNs currently have prescriptive authority (WV BON, 2013), and only 672 of current APRN

prescribers are registered with the DEA – a requirement to prescribe CSs (L. Rhodes, personal communication, February 12, 2014). While this number may increase, it is highly unlikely that every APRN in the state will choose to prescribe CSs. Not all APRNs elect to have prescriptive privileges. Only about half of the APRNs in WV prescribe any medications. Those medications vary according to the needs of the patients in that APRN’s practice. For example, certified nurse-midwives prescribe modest amounts of CS medication for general women’s health concerns, while palliative care and hospice nurses are expert prescribers of pain management.

West Virginia Hospice and Palliative Nurses Association (WVHPNA) address this critical need in their letter (Appendix B). Certified nurse practitioners must be able to prescribe occasional pain medication, as well as medication for children and adults with ADHD.

Furthermore, there is no objective evidence that indicates allowing full practice authority to APRNs results in an increase in the diversion, abuse, or overdose of opiates. In an effort to

look at the data in a scholarly fashion, WVNA completed a statistical analysis of the data on opiate overdoses by state in the US and by statutory limits placed upon APRNs (American Academy of Nurse Practitioners, 2013; Trust for America's Health, 2013). Specifically, we looked for a statistical relationship between opiate overdoses and full practice authority for APRNs (up to 20+ years prescribing experience) using an independent sample t-test and Mann Whitney U test. The results of this analysis show there is no association between full practice authority for APRNs and opiate overdoses (p values of .581 and .863, respectively).

The study of general prescribing practices of APRNs began in the 1970s. Studies in the early years showed, in general, that (without CSs being broken out) APRNs prescribe fewer medications than physicians and prescribe significantly more non-drug therapies (Mahoney, 1992). In 2006 a study was conducted comparing physician, physician assistant (PA), and certified nurse practitioner (CNP) prescribing practices and it did separate CS prescribing. The results demonstrated that in primary care, CNPs prescribed CSs at 11% of visits, physician assistants at 12.3% of visits, and physicians at 12.4% of visits. It was noted that, although APRNs prescribed less CSs, the differences were not statistically significant (Cipher, Hooker, &

Guerra, 2006).

A reasonable tactic to analyze the effect of allowing APRNs to prescribe CSs is to study the state of Washington (WA), as it has had the longest experience in autonomous CS

prescribing. Washington has seen an evolution of APRN practice in relation to prescribing over the past 15 years. During this time researchers have been conducting longitudinal studies to determine how the change in practice authority has changed actual practice (Kaplan , Brown &

Donahue, 2010). Washington APRNs have been able to practice independently and prescribe Schedule V - CSs since 1979. In 2001, the law changed to allow APRNs, under a Joint Practice

Agreement (JPA), to prescribe Schedule II, III and IV - CSs. Two years later only 50% of APRNs had a JPA, and of those half said they did not routinely prescribe CSs; in 2005 when the law changed only 60% had acquired JPAs (Kaplan et al., 2010). In 2005 the state eliminated the JPA requirement. Research was subsequently conducted in which the APRNs in the state were surveyed (65% participation), the majority of whom had prescriptive authority, possessed DEA registration, and were prescribing CSs as part of their current practice. The researchers found that only 12% of APRNs surveyed prescribed more CSs than when the JPA was in place (Kaplan et al., 2010). In addition, prior to 2005 when the JPA was still required, the majority (81%) noted it was a “FORMALITY ONLY with NO real restrictions” and 16% said the “ONLY contact they had with their JPA physician was to set up the agreement with no contact since”

(Kaplan et al., 2010).

Key strategy for curbing opioid diversion/abuse

The state of WA, in 2010, became the first state to pass a law requiring specific limits on the prescribing of opiates for ALL primary care prescribers. The new law required five boards (medicine, nursing, osteopathy, dentistry, and podiatry) to adopt new rules, including dosing thresholds over which consults with board-certified pain specialists were required prior to prescribing ( Kaplan , Brown & Donahue, 2010). If legislators in WV are serious about attempts to curb our opiate overdose problem, the tactic used in WA would seem to be a more strategic approach. Permitting more parity for the prescribing of CSs for the state’s APRNs is necessary to allow appropriate treatment for those patients who choose an APRN as their health care provider. If health outcomes are to improve in WV, patients MUST be in charge of their own health, including the right to choose their health care provider. The care they receive, including adequate pain control, should not be impeded by their choice of an APRN. APRNs in

WV are requesting the ability to adequately treat their patients with adjustments to the current CSs prescribing restrictions, but this is not to say the APRNs of the state believe carte blanche prescribing is necessary. The WA approach of placing limits on ALL prescribers is not only acceptable, but supported by WV APRNs.

APRN Pharmacology Education

Finally, pharmacology requirements and competencies in nursing education seemed to be in question in the initial PERD report. To give some specific clarification regarding the training of APRNs who prescribe and monitor the use of medications within their individual scope of practice, it may help to understand the educational preparation and requirements for APRN prescriptive authority.

Undergraduate nursing education and practice regarding medications

Every undergraduate RN has at least in her/his basic nursing education program courses which allow for the following to be achieved as defined in WV Code §30-7-1(c): “The practice of "registered professional nursing" means the performance for compensation of any service requiring substantial specialized judgment and skill based on knowledge and application of principles of nursing derived from the biological, physical and social sciences, such as responsible supervision of a patient requiring skill in observation of symptoms and reactions and the accurate recording of the facts, or the supervision and teaching of other persons with respect to such principles of nursing, or in the administration of medications and treatments as prescribed by a licensed physician or a licensed dentist, or the application of such nursing procedures as involve understanding of cause and effect in order to safeguard life and health of a patient and others”. Nurses are required to know the actions, dosages, contraindications, drug interactions, side effects, and routes of administration for every medication they administer to

every patient. In addition, in their clinical experiences nurses must monitor the effects of each medication on the patient and also be held professionally accountable for checking medication orders to be sure they are appropriate for that patient. The nurse is additionally responsible to question unwarranted or inappropriate medication orders based on the nurse’s observation and assessment of the patient’s condition. As a result, nurses are well-versed in the medications for every patient in their care from their first day as a student in the clinical setting.

Advanced nursing education and practice regarding medication

All APRNs in graduate education tracks must have at least an additional three credit hour course with evidence of successful completion of forty-five (45) contact hours of

education in pharmacology and clinical management of drug therapy under a program approved by the board, fifteen hours of which shall be completed within the two-year period immediately before the date of application (WV Code; WVC, §30-7-15b), including Advanced

Pharmacotherapeutics in the Master of Science in Nursing (MSN), Doctor of Nursing Practice (DNP), or other graduate degree program. APRNs also spend an additional 600 (MSN) and 1000 (DNP) graduate clinical practice training hours, writing and managing prescriptions.

Specialty nursing education in anesthesia

The Council on Accreditation of Nurse Anesthesia Educational Programs (COA)

accreditation standards require three separate comprehensive graduate level courses in advanced physiology/pathophysiology, advanced health assessment and advanced pharmacology (Council on Accreditation of Nurse Anesthesia Educational Programs, 2014).

The Doctor of Management Practice in Nurse Anesthesia Program (DMPNA) through the Charleston Area Medical Center School of Nurse Anesthesia and Marshall University curriculum includes seven semester credit hours in advanced pharmacology (CAMC Institute,

2014). Furthermore, WVNA is in agreement with the West Virginia Association of Nurses Anesthetists (WVANA) response letter (see Appendix C).

Continuing education in pharmacology requirements

Every APRN in WV who has prescriptive privileges is required to attain 8 hours of continuing pharmacology education every two years. (WVC §30-7-15c) Neither physicians nor PAs have this additional requirement.

In closing, the legislative auditor’s recommendation to retain the limitations on APRN prescriptive authority, by retaining the current restrictive drug formulary is unsubstantiated, is cost prohibitive, does not provide any safety net, and is not in the best interest of patients, physicians, or WV APRNs. We reject the aforementioned

recommendation and respectfully request an unrestricted APRN formulary, which has been proven effective throughout the US.