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The Joint Committee on Prescribing & Dispensing met on October 3 to hear invited and public testimony regarding the Prescription Monitoring Program, implementation updates on Sunset recommendations, and continuing issues. After all invited and public testimony, Chair Sheffield also called on the Texas Medical Board to testify on pill mills.

This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. It is not a verbatim transcript of the hearing, but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

 

Invited Testimony

Steven Ogle, Texas Sunset Advisory Commission

  • Sunset Commission found that PMP did not incorporate national best practices to increase effectiveness
  • Sunset made recommendations, several incorporated into HB 2561
    • Require pharmacists or delegates to enter info into PMP within 1 business day of dispensing
    • Require Board of Pharmacy (TSBP) to develop red flag indicators for potentially dangerous activity
    • Require checking the PMP before dispensing controlled substances
    • Require licensing information for prescribers to the TSBP
    • Monitor prescribing patterns of licensees & allowing licensing board to monitor
    • Authorize push notifications
    • Require wholesale distributors to report sales of controlled substances
  • Sunset evaluated Veterinary Board & veterinarian participation, HB 2561 ultimately did not apply requirements to the Veterinary Board
  • Compliance checking has not yet begun

 

Allison Benz, Texas State Board of Pharmacy

  • PMP was transferred to TSBP in Dec. 2016
  • During FY18, worked with agencies and vendor to incorporate licensee information according to HB 2561
  • Have been working on connecting PMP to other states, currently connected with 24 others
  • Will be requiring checking PMP before dispensing certain controlled substances, exceptions exist for cancer and hospice care
  • Push notifications sent to those with patients with 5 prescriptions, from 5 prescribers, and from 5 pharmacies (555)
  • Bop partnered with DSHS to compile and provide data on opioid prescribing, opioid prescribing may be declining, but stimulate prescribing is increasing
  • Have 605 opioid prescriptions per 1,000 Texans, slightly lower than national rate, with average MME of 56; anything over 50 increases risks significantly
  • Benzodiazepine rates have not been affected much, greatly increases risks when prescribed with opioids
  • Recommendations
    • Statewide integration for the PMP, allows prescriber or pharmacist to access PMP data through EMR or pharmacy data system
    • Add NarxCare and Clinical Alerts to the program
    • Require e-prescriptions for all controlled substances, or at least schedule 2 substances
  • Watson – What agencies right now are
    • Ogle, Sunset – TSBP, TMB, BON, TSBDE, Veterinary Board, TDLR for podiatry
  • Watson – Is DPS able? How?
    • They have their own portal and have sole access to that side
  • Watson – DPS used to manage it, but they don’t anymore?
    • Correct, all regulatory functions moved to the Pharmacy Board
  • Watson – So DPS doesn’t have any regulatory control anymore
    • DPS
  • Watson – In other states requires either a subpoena or demonstration of ongoing criminal investigation
    • For law enforcement there are two avenues, local law enforcement must show an ongoing investigation to DPS, but DPS regulatory services division can run pro-active searches
  • Watson – So for other law enforcement to access this, it requires proof of ongoing investigation; do you know of any procedures DPS has in place before it accesses the system
    • Unaware, would need to ask DPS
  • Watson – Do you have any concerns about whether the statute does or doesn’t require these things?
    • Principles of law enforcement access and health access should be clearly delineated, statute does a poor job of requiring proof of investigation from DPS
  • Buckingham – Can the Pharmacy Board see when DPS accesses the portal?
    • No
  • Buckingham – Hearing from a lot of doctors that they can’t get signed up, system has glitches
  • Buckingham – Can you tell us the mechanisms in place to monitor appropriate usage?
    • Benz, TSBP – Complaint driven for the most part, there have been other incidents where people
  • Buckingham – What are the penalties?
    • TSBP has levied admin penalties between $1,000-$2,500
  • Buckingham – So payment of $10k would far outweigh penalty assessment
  • Buckingham – 555 threshold data shows these prescriptions have dropped significantly, do you have data for those just below 555? Might use 444
    • Have looked at this & many more at the 444 level, nor sure why numbers have gone down
  • Buckingham – Very interested to see how integration with EHR works, do you know how this works?
    • Not sure how it works through an EHR, but it is connected online; if the EHR is not connected, not sure how this data would be available
  • Buckingham – Also interested in contract terms of that & whole will pay for this
    • TSBP are asking for funding & then TSBP would be paying vendor for this; could be potential charge from the EHR
  • Buckingham – If you’re funded this upcoming session, this would go into effect Sept. 1, 2019; how will this work with the enactment dates of PMP regulations?
    • Would need time to implement, so mandatory check in 2019 would likely be done the old way
  • Buckingham – Do you have flexibility with providers if system is not up and running?
    • Inability to access is an exception under law; no penalty
  • Burns – So if you have a provider misusing the system, you’re limited to fine of $1,000-$2,500; is there an ability to block that user?
    • TSBP can terminate access to the system, but then they wouldn’t be able to comply with mandatory lookup; can deactivate anyone at any time
  • Howard – What is the process for being a participant in the system?
    • Would need to create an account, worked with vendor to create shell accounts that will only require them to complete the registration
    • Info is automatically verified against license board databases
  • Howard – Is there a cost to the provider?
    • No
  • Howard – Is there any cost shared with the provider?
    • No charge for access or anything like that
  • Howard – So the $5.1 million for the PMP would cover everything you need to do?
    • Would add the enhancements, integration, NarxCare, Clinical Alerts, etc.

 

Jay Alexander, Department of Public Safety

  • Present as a resource witness
  • Watson – You agree that DPS has a means through a separate portal to access the PMP?
    • Yes, DPS does have a separate, secure access portal, contracted through the same company as TSBP
  • Watson – DPS no longer has regulatory control over the system,
    • Illicit drug investigation & must show substantial reason
  • Watson – Has DPS made any rules to handle requests to use this portal?
    • No rulemaking process, but do have internal SOPs
  • Watson – Do you require a subpoena? An ongoing criminal investigation?
    • No requirement for subpoena, but need to be part of a criminal investigation involving drugs; could be used to start an investigation
  • Watson – Would be interested to see the SOPs
  • Watson – How often is this used?
    • We get between 500-600 requests/month from state, local, and federal
  • Watson – It works differently when requested from local law enforcement?
    • Agency would need to be vetted, request needs to be submitted before each check
    • No subpoena needed, but must be part of drug investigation
  • Watson – Who makes these decisions?
    • DPS manager who runs day-to-day operations
  • Watson – Not familiar with this process, can you explain this?
    • Nick Rozumny, DPS Manager is also present at the witness table
  • Watson – Interested in how often DPS has accessed portal itself, doesn’t appear to be a check on how DPS can use this
    • Internal personal must also be vetted & must be in connection with investigation
    • Can get breakdown of how often DPS uses
  • Watson – Would also like to see the SOPs, how the SOPs were determined, and how DPS compares to other states re: due process protections
  • Sheffield – Asks Benz, TSBP, there have been more chronic pain management clinics, my office prescribes much lower than it did due to policy that patients go into pain management; is there a way to loo at how doctors outside pain management numbers are dropping because pain management clinics are writing more?
    • Benz, TSBP – Don’t necessarily know where prescribers are in the database, would need to pull data and study to find where prescriptions are coming from
  • Sheffield – Are you aware of usual operating procedures of pain management clinic? Trying to make sure the bad guys aren’t writing prescriptions, would be good to know if GP rates are dropping coupled with increases elsewhere
    • Can work with DSHS to see if we can get this data together, no staff currently that can run these kinds of numbers

 

Thomas Kim, Texas Medical Association

  • Supports efforts in spirit, but predicted massive impact from requirement to check PMP before every prescription; highlighted tech that pushes relevant data during session rather than manual checking
  • Supports TSBP request for funding for integration into EHR, without funding EHR integration could be costly and challenging
  • Will take time to integrate and work with all EHRs, asks for flexibility in implementation
  • PA system and methadone clinics are also not incorporated into the system
  • Recommends appointed advisory board to the TSBP to form recommendations for improvements to PMP
  • Watson – Regarding the TSBP $5.1 million request, can you remind me what this is for & how could funding come from a federal program for this?
    • 3 primary enhancements including EHR integrations, cost effective way to funnel through one vendor rather than one off every EHR integration
    • Federal government has legislation for combatting opioid crisis with funding, integration portion is likely eligible
  • Buckingham – You talk about data interacting where it didn’t before, in most offices I’m aware of, the EHR stays completely within its own system; now that outside entities will interact with EHRs, does this mean it is open to everyone?
    • Trigger for integration is e-prescribing submission which needs to go out, PMP integration collects these datapoints and pushes 555 alert if applicable
    • There will be a competition over viable EHR vendors moving forward, integration will do remarkable things and allow us to use data smartly
  • Buckingham – Confused over how it will work as prescribing alerts come through different channels
    • Correct, this is why not every EHR vendor will survive, shortlist will be able to do what is needed
  • Buckingham – Switching EHRs can incur serious costs, upgrades sound great on paper, but there seem to be hurdles
    • In full favor and support of PMP integration, alternative is to ask prescribers to check PMP too often & breaking up workflow
  • Buckingham – Regarding advisory committee, it does seem like providers, prescribers, etc. should sit together, did you want to elaborate?
    • Essentially a group that will be able to navigate the mountain of incoming data
  • Howard – Still trying to understand cost of providers, dilemma is how to pay for these things; provider cannot bear entire burden of cost, will get passed onto consumers and drive some out of business
    • In 100% agreement, TSBP plan is cost effective and widely supported by stakeholders, avoids issue of one-off integration costs
    • Support strategy, but need to work out a couple of wrinkles

 

Brett Moran, Parkland Hospital

  • Opioid epidemic has significant footprint at Parkland, impacting Parkland financially and morale-wise
  • Many initiatives at Parkland are combating opioids, behavioral emergency response team has focused on opioids, opioid addiction counseling, etc.
  • Nonpharmacological pathways to treat opioid addiction is largely not funded
  • Parkland generally supports PMP and its effects, biggest concern is that organizations have to pay for interface; can access for free if you want to log in, but left without enhancements & significantly disrupts workflow
  • There is a problem with equity, should have access for organizations without as many resources
  • Has several requests
    • Would like audit trails that are verifiable outside of PMP
    • Would like to see it as more of an info hub, i.e. uploading pain contracts
    • Would like to see PMP host adherence scores
    • Would like to see registries and dashboards for patients seen at the hospital that hospital can use to contact patients before a visit
  • Sheffield – What has Parkland done to be more
    • Parkland looking at this through clinical practice, training and teaching, and predictive action
    • Defaulting opioid prescriptions to 7 day with no refills, trying to use many different methods
  • Buckingham – Regarding the audit trail, who would be tasked with gathering this and reporting this to you?
    • Would likely be our pharmacy, if it could be pushed from PMP it could be very simple
  • Buckingham – How would we ensure that audit trail is not just a vehicle to sell data
    • Good question, Parkland shares some EHR already, EHR also has functionality to hide things

 

Nora Belcher, Texas e-Health Alliance

  • Digital data will be essential to addressing public health issues
  • Receives many questions of how many EHRs are ready to integrate, it appears that ~70% have already been integrated with the TSBP at some level
  • Federal government is not slow on this issue, federal government is responsive & have seen changes like removal of mandate to check for existing agreements
  • Integration makes the most sense as anything disrupting workflow will not be adopted as well
  • There was a Medicaid Director letter about some match that is available for PMP enhancements
  • Recommendations
    • Eliminating paper prescription pads
    • Need to have cross-border data sharing
    • Could have a conversation with TRS, ERS, and Medicaid on how they may be able to use the PMP; payers should be part of the discussion
  • Buckingham – Did you want to respond to some of the EHR issues; not understanding how EHR integrates as it does not handle prescribing
    • There is wide variation in e-prescribing tools, many EHRs have this as a module within the EHR
  • Buckingham – And we actually have hedge funds investing in EHRs now
    • Yes, there are investments from many sources, a lot of variation in the market
  • Buckingham – Does it cause concern that you have entities trying to turn significant profit on integrated systems?
    • This technology is incredibly complicated, hedge funds expecting cheap and easy returns would be disappointed
  • Buckingham – Asks after privacy regulations
    • State code for data restrictions is much more robust than federal regulations, more so than HIPAA
    • Have a good platform to build off of if we have bad actors misusing data
  • Buckingham – Many areas of the state will not have highspeed internet access & thus no e-prescribing or pharmacists that will accept those prescriptions
    • According to federal data, 27% of rural areas do not have access to highspeed fixed broadband; but broadband is more important for telemedicine, PMP data transfers are very small
    • FCC also opened up a new pot of broadband funding
  • Buckingham – Would caution against getting rid of paper with current geographic challenges
  • Howard – 85th Legislature invested significant money for school district broadband, need to do the same for other areas of business in the state; what does the FCC pot look like?
    • Does not have data ready; challenge with current scheme is that broadband that is funded is siloed for use by education, or the library, etc.
  • Sheffield – How is the NarxCare score generated?
    • Moran, Parkland – Proprietary tool

 

Debbie Garza, Texas Pharmacy Association

  • Critical to work together to ensure PMP in integrated into existing workflow, enhancements can help; software should be in place prior to mandatory checking roll out
  • TPA recommends
    • Legal immunity to Texas practitioners not submitting data or not checking as required – prescribers and dispensers already subject to admin sanctions
    • Access should only be used by prescribers/dispensers, should make clear that it is not accessible to public or subject to open records laws
    • Should establish penalties for wrongful use of data, wrongful access has already been addressed
    • Current law requires pharmacists to check PMP before refill, redundant and burdensome, Schedule II drugs are not eligible for refills
    • PMP should be available to minor patient’s parent or guardian with consent
    • Should establish appropriate linkage from PMP admin to proper licensing agency if individual has been identified with substance abuse issue to direct to treatment
  • Buckingham – TSBP has seen people in domestic issues access the PMP, if you have a scenario where you obtain access to PMP data and uses it in a case or otherwise, there is no penalty?
    • Correct, speaking also to issues where data was accessed appropriately, but then is used for marketing or other inappropriate uses
  • Sheffield – We know what bad doctors look like, what is a bad pharmacy?
    • When they are not being mindful of duty regarding controlled substances, not mindful of patient-physician relationship, clinical need, etc.

 

Dan Freeland, Texas Osteopathic Medical Association

  • Much of the material so far has not been “clinically relevant”
  • TOMA practitioners are largely now non-independent, independent practitioners are rare
  • From a prescriber’s point of view & one who does buprenorphine, buprenorphine clinics have not been recognized so far; much safer than methadone
  • PMP is not difficult to use once established, but it is time consuming; good to have ability to have nurse staff do this
  • Practice usually only checks on patients the practice has concerns about, e.g. those with signs of substance abuse issue
  • PMP has not worked very well in some circumstances

 

Matt Roberts, Texas Dental Association

  • Dentists have an important role in preventing opioid medications from being misused and abused
  • TDA supports dentist registration with PMP in conjunction with education
  • Supports requiring push notifications, requiring TSBP providing information when licensees are included in alerts
  • Concerned about mandatory PMP querying by dentists and disruption it could cause; asking to delay mandatory checking until 86th legislature
  • Understands e-prescribing efforts, but is concerned about costs for those without need or capability
  • Sheffield – What procedures done by dentists require or benefit from narcotic prescriptions?
    • Typically surgical or periodontal procedures
    • In my own practice, only have 12 prescriptions recently & none for Schedule II
    • Dentists likely moving towards more OTC medications to handle pain
  • Sheffield – Doesn’t some of the profession do IV sedation?
    • Mostly the oral surgeons, most opioid prescriptions likely written by this subset; overall expecting TX will see less and less dental controlled substance prescriptions
  • Sheffield – What Schedule III drugs do you write?
    • Tylenol 3 or tramadol usually
  • Sheffield – DO you have an estimate of dentists have EHR and how many use paper?
    • Unsure, can look into this; dentists are going more and more to computer systems, but problem is seamless integration of EHR and vendor integrating with pharmacy, also the cost for so few prescriptions per year
  • Sheffield – For most doctor shoppers I’ve seen, they present with issues that can’t be tested for; when you’re seeing a patient asking for these agents, they’ve had work done, have you seen any go through a dental procedure just to acquire narcotics?
    • Yes, though what I see more of is those with teeth in bad shape and not getting work done to present at multiple different locations
  • Sheffield – So probably subgroup using narcotics the most is oral surgeons?
    • Agrees, though wouldn’t limit it to just those
  • Buckingham – Trying to understand data in the PMP and how it gets there; the PMP had every prescription you’ve written over the last year?
    • Only the narcotic prescriptions, none of the antibiotics, etc.
  • Buckingham – So only the scheduled agents? When I had the TSBP come in and demonstrate the PMP, it had everything they had been prescribed
    • This is not what shows up when I log into the PMP, only shows scheduled drugs

 

Danielle Nasr, Sunset Commission

  • Project manager for 2016 review of Veterinary Board, over course of review Sunset found several issues
  • Board had insufficient approach to controlled substance monitoring & enforcement, Board did not efficiently monitor use of controlled substances or compliance with controlled substance regulations
  • No state or federal agency collects comprehensive info on substances moving through veterinarians
  • HB 2561 regulations did not apply all to veterinarians, but some were passed including requiring guidelines for responsible prescribing, requiring Board to monitor patterns of licensees, allowing Board to open investigations based on PMP data, requiring Board to collect & track data, requiring Board to provide info to automatically register veterinarians on PMP
  • Buckingham – We all understand difficulty of tracking based on the animal; are veterinarians included in the PMP in other states and how do they do it?
    • As of June of 2017, there were 18 states with laws requiring veterinarians to report to PMP, other states have checking or limited reporting
    • In 2018, 4 states have begun requiring additional reporting
    • No one-size solution, different approaches in different states
  • Buckingham – Seems like there is a bit of drug diversion and we have no way for tracking that
    • That’s why Sunset Commission required Veterinary Board to work with TSBP to come up with reasonable prescribing guidelines for different veterinarians
  • Burns – Did you find issues in veterinary offices not seen in other practices, as in opioid theft?
    • Yes, one of the large issues we encountered was that veterinarians stock full range of pharmacy medications, but regulated more like practitioners
    • Found a stunning amount of employee pilferage or theft due to this supply

 

Aaron Rainer, Texas Veterinary Medical Association

  • Veterinarians recognize their responsibility in the opioid crisis to not distribute opioids improperly; well aware of issues with pet owners trying to obtain opioids
  • At the end of October, there will be a training program on opioid safety and anti-diversion practices
  • Realities of veterinary profession means that PMP will not fit within it; veterinarians being exempt for certain PMP requirements is appropriate
  • In attempting to utilize PMP, veterinarians have noticed issues; data lookup runs off of first name, last name, and birthdate, but this is not consistent for animals
  • Howard – If there is a problem with entering data for name, birthdate, etc., why can’t the system register the animals by the people bringing animals in?
    • Pet name variations complicate the lookup
  • Howard – Right, but these pets could be tracked according to the person brining in the animal
    • Could do this, but veterinarians are very uncomfortable with privacy laws and HIPAA
    • Very uncomfortable for us without being able to sift out human data
  • Howard – What are other states doing that works?
    • Other states require checking for Schedule II drugs, could be an option
    • Many PMP programs have been repealed
  • Howard – I think Sunset also mentioned problem of veterinary staff improperly taking medications
    • Understand Sunset’s concerns, but DEA data shows these numbers are minor; 19 instances in 2017
  • Howard – If we agree there is a problem & the veterinary practice can help us, I assume you would help us work on this?
    • Yes, would love a seat at the table
  • Sheffield – Define the difference between large animal practice and small animal practice
    • Many practices work on large livestock animals, small animal practices work on dogs & cats, etc., also mixed animal practices that cover both
  • Sheffield – Under what conditions are narcotics used at a large animal practice
    • Phenobarbital, tramadol, etc. are used at large animal practice
  • Sheffield – And this would be intravenous or muscular, but what procedures would this be for?
    • Small animal practitioner, small animal clinics do use tramadol; largely IV and used for surgeries
  • Sheffield – So these are vials, not pills?
    • Correct
  • Buckingham – What type of internal office auditing do you use? What checks exist?
    • Narcotics coming into the clinic are entered into the system, could be manually recorded and dispensing is controlled; balance sheet keeps track, often through both EMR and paper
  • Sheffield – How often does the Veterinary Board audit?
    • My practice has been involved in 2 or 3, in practice for 12 years

 

Sam Miller, State Delegate to American Veterinary Medical Association

  • AVMA is extremely concerned about the opioid epidemic
  • AVMA Opioid workgroup came to several conclusions; only 6 states actively require veterinary queries, but no consistency, with movements towards exemptions
  • Opioid prescriptions from veterinary medical providers are 0.34% of opioids dispensed through retail pharmacies
  • Nationwide survey identified less than 10 instances of veterinary clinic shopping per year; physical exam is required for each animal brought in & controlled substances not always used; very expensive for pet owner
  • Issues of concern for veterinary reporting: lack of consistent animal registration, inconsistent ownership, & lack of interface software
  • Veterinarians reporting through PMP significantly exceeds level of risk
  • Watson – We’ve heard of uniqueness of the profession, we understand this, but also understand that there is a need to maybe do something about this issue
  • Watson – Concerned that veterinary profession doesn’t bring the legislature mechanisms for finding solutions, only hear testimony that the profession is so unique that nothing should be done
  • Watson – While retail pharmacy dispensing may be low, but veterinarians are also unique in that they can also dispense drugs; almost a distraction to suggest this as a reason we shouldn’t be looking at veterinarians
  • Watson – You also indicated that there is a low number identified for veterinarian shopping, but also hear testimony on how difficult it is to identify animals; possibly focusing on the few cases with specific finding, but that number could be much higher due to difficulty in identifying pets
  • Watson – You also spoke to needing to do an exam each time, but an animal can be taken to multiple places for the same condition
  • Watson – Testimony is very flawed, focuses on ways to get around helping the legislature come up with a fix rather than helping solve the problem
    • Was hoping to present some issues that may make it difficult to achieve the end goal of trying to identify the person misusing controlled substances
    • Would be happy to sit at the table and develop a comprehensive plan that would track activities
  • Howard – You mentioned that 50 state survey identified less than 10 vet shoppers per year, is there anything looking at issues within the office itself
    • There are resources we are trying to reach out to and identify controlled substances in the veterinary channels
  • Howard – My impression is that the bigger part of the problem is what might happen within the office
  • Buckingham – Asks Sunset to clarify findings regarding veterinarians
    • Nasr, Sunset – Sunset did have DEA data for theft, loss, and diversion within offices; data shows that veterinarians lost 100x more than the next highest practitioner
    • Veterinary Board also does not have stringent inspection process, each veterinarian is inspected roughly once every 10 years, but not inspecting every facility
    • Rainer, AVMA – Veterinarians keeps the inventory of tramadol so we are subject to lost or stolen pills, but loss numbers are very low compared to breadth of market
  • Watson – This skews what we are looking at, understands every vet is not losing pills or prescribing pills they shouldn’t, but numbers are only small when divided in beneficial ways across the veterinary industry
  • Watson – Will only hurt your cause if you skew the data in this way, misses point & should be assisting us in finding solutions; legislature will act of its own accord if you do not participate

 

Public Testimony

George Thompson, Walgreens

  • Requirements in Sept. 2019 will go a long way to ensure medications are safely prescribed & dispensed
  • Everyone wants to work together to address this issue
  • Sheffield – When you find a pharmacy ordering 10x more than their population, what do you do?
    • Can’t speak to this specifically, our team does monitor, usually a weird one-off scenario requiring this
    • Occasionally also a pharmacist that is not paying close enough attention to ordering

 

Jeremy Ashley, Brookshire Grocery Company, National Association of Chain Drug Stores

  • Asking that legislation pass bill for mandatory e-prescribing for opioids, can combat forged prescriptions
  • Leads to increased safety & security, reduction in errors, and ability to track fills & refills
  • Gives overview of process for pharmacists to enroll in e-prescribing and national data on e-prescribing laws, 14 states have laws in this area
  • Provides model language from NACDS for e-prescribing with case by case waivers for rural pharmacies
  • Sheffield – How would rural mostly paper pharmacies pursue a waiver under your model language?
    • Rural means many things, needs to be case-by-case depending on availability of technology, vendor, etc.

 

Craig Benton, Doctor of Chiropractic

  • Approach to pain management is a critical portion of the solution to opioids, non-pharmacological care offers the same or better results
  • Chiropractic and other non-pharmacological treatments can assist
  • Howard – Need to be looking at alternatives & I think this is happening now, highlights work done at Dell medical Center
    • Dell Medical Center has good efforts with doctors of chiropractic

 

Adam Zalinski, Doctor of Chiropractic

  • Can prevent opioid addiction on the front end by diverting patients to non-pharmacological care
  • Should adopt 7-day limitations and require referral to non-pharmacological care before additional fills

 

Matt Boutte, Texas Academy of Physician Assistants

  • PMP does not record directions for taking medications, could be useful to record
  • Shares experience from his practice with person directed to correct treatment with help from PMP
  • Sheffield – Thank you for pointing out that directions are not included

 

Brian Francis, Texas Department of Licensing and Regulation

  • TDLR has been on top of providing weekly updates to TSBP to allow registration of podiatrists; TSBP has coordinated very well

 

Christen McGarrity, Self

  • PMP can have beneficial use, but also can be used to identify high prescribers and effectively discriminate against those with disabilities
  • Shares experience of having painful congenital condition requiring ongoing high-volume pain medications; PMP has led to many doctors not taking patients like her
  • Push notifications and NarxCare causes tremendous pressure to cut prescriptions regardless of medical need
  • Should work on palliative exceptions for Texas law where needed
  • Sheffield – Very important to consider as we move forward, would like you to explain how often you visit pain management clinic and the guidelines you follow
    • Very strict safeguards, go in every month with drug testing
  • Sheffield – If drugs do not appear in the drug test, what happens?
    • They kick me out, assumption is drugs are sold
    • Pain management is necessary, but abusers reflect badly upon the whole profession
    • Rules like maximum dosage are not appropriate for everyone
  • Sheffield – Because some patients need above the maximum dosage
  • Howard – Need to consider palliative exceptions, decisions need to be made by those best suited to determine need
  • Sheffield – Are you aware of the “fly by night” pain management clinics?
    • Have heard of them, but haven’t seen one

 

Jack Diamond, Self

  • Shares experience of father enrolled in program that improperly prescribed agents leading to his death, was put into hospice care under fraudulent and void contract
  • References June news reports from Dallas Morning News and NBC detailing improper prescribing and possible intentional killing via misuse of controlled substances
  • Sheffield – Your father was ill and entered into a hospice program?
    • He had mild dementia & illegally entered into a hospice program
  • Sheffield – Who approached your father?
    • Not sure it would be appropriate to discuss criminal activity publicly
    • Here to suggest new laws or modifications to kidnapping, etc.
  • Sheffield – Asks Diamond to get in touch with his office staff

 

Sheffield calls the Texas Medical Board to speak on pill mills

Stephen Brint Carlton, Texas Medical Board

Scott Freshour, Texas Medical Board

  • Sheffield – Asks TMB to speak about pill mills
    • Carlton, TMB – Look at top 15 prescribers & 555 reports tog et an idea of inappropriate dispensing of controlled substances, also field complaints
  • Sheffield – Have you been in one yourself?
    • Intending to accompany investigation team in April
  • Sheffield – You would agree that these contribute far more to the problem?
    • Yes, problem is not with registered clinics
  • Sheffield – And how do they present themselves?
    • Freshour, TMB – Presenting as wellness clinics, etc., we also look at long lines of patients, cash only, high patient volume during very limited hours
    • Houston and Dallas have areas known for pill mills
    • Have rules in place to allow us to go into unregistered pain clinics
  • Sheffield – Is there something that can be changed about the PMP to make it more effective
    • Carlton, TMB – We do look at the type of specialty a physician may have, why they dispense, etc.
    • As far as additional resources, going from top 50 list to top 15 has helped a lot, 555 is a good tool, though people are savvy and can alter one parameter to get around the 55 system
    • Currently 34 investigations ongoing and 11 pending inspections for pain management clinics
    • Freshour, TMB – Investigative team has new team focused on PMP data analysis and data coordination
  • Sheffield – Can you speak to chain pharmacies overriding doctor’s prescriptions?
    • Carlton, TMB – Have heard reports that pharmacists are refusing to dispense portion of medications, agent, or quantity
    • Have contacted TSBP, we are aware and trying to work with them to address the issue