Painkiller Restrictions Hurt Non-physician Providers, Patients

A recent article in the New York Times and many other newspapers caught my attention. In an effort to curb the illegal diversion of Hydrocodone, the Drug Safety and Risk Management Advisory Committee to the Federal Drug Administration (FDA) voted 19 to 10 to recommend that Hydrocodone be moved the Schedule II category, and that physician assistants (PAs) and nurse practitioners (NPs) be restricted from prescribing Schedule II drugs.

It turned out that the reporters got the facts wrong.

According to two PAs who serve on the FDA advisory committee, it recommended only to reclassify hydrocodone from a Schedule III drug to Schedule II. The recommendation would not ban PAs and NPs from prescribing hydrocodone products. Rather, it would limit prescribing the drugs in states where PAs and other healthcare professionals are not authorized to prescribe Schedule II drugs. PAs may currently prescribe Schedule II medications in all but 14 states.

Although this recommendation does not automatically mean that hydrocodone products will be moved to the Schedule II classification, as a PA, I was upset at the implication of this panel that my profession was part of the problem with the illegal diversion of narcotic medication. Even though HHS' regulatory process would examine the efficacy of this recommendation before it is put in place, it doesn’t take much to see that these proposed restrictions will do nothing to curb the illegal diversion of narcotics, and will have a profound and negative impact on patient care and patient access to care.

I work in a surgical practice, which is inpatient based. I care for populations of burn injured patients and the usual assortment of reconstructive plastic surgery patients. We deal with serious acute pain on a daily basis. Our facility has a significant number of PAs and NPs who daily deliver inpatient and outpatient care, including the treatment of pain.

In California, after attending a mandatory daylong pharmacology course, I have been granted the privilege of prescribing Schedule II narcotics. Every state medical board does this a little differently, but Schedule II authority is common for PAs and NPs in many states. I can honestly say that I cannot effectively do my job without this ability, nor can the other surgical, emergency medicine, and hospitalist PAs and NPs.

In California, and many other states, healthcare providers can be disciplined for ineffective treatment of pain. The California Department of Justice also has the Controlled Substance Utilization Review and Evaluation System (CURES) which, after registration as a licensed healthcare provider, allows me to access information (in a HIPAA-compliant manner) about a patient’s recent narcotic prescription history. This is an effective system to both allow me to feel comfortable treating severe pain, and to avoid contribution to the illegal diversion of narcotics, with less fear of a complaint to the Medical Board of California, which could jeopardize my license to practice medicine. This is just one example of how the state and federal government can help prescribers avoid illegal diversion of narcotics.

There are more than a quarter of a million PAs and NPs practicing in the United States. With the implementation of the Affordable Care Act well underway, pressures on the healthcare system in America center on the shortage of patient care providers. Disparities in the distributions of physicians, PAs and NPs will only get worse, especially in medically under- and un-served communities.

One of the advantages of using PAs and NPs is that - with no loss of quality - it extends the reach of the healthcare team into these areas, and improves access to care at all levels. Erecting new barriers to physician-PA teams at a time when the pressures on the healthcare system human resources is about to get much worse, is a short-sighted and misdirected “solution” to a complex problem.

There is no evidence, not one bit, that PAs and NPs are a source of the problem in the illegal diversion of narcotics within our healthcare system at a higher rate than other prescribers. There is little evidence that more tightly restricting a drug through reclassifying to a higher scheduled effectively reduces its abuse potential.

As a daily prescriber of narcotics, I take very seriously my role and responsibility in making sure that I don’t contribute to the illegal diversion of narcotics, and I know that nearly all of my physician and non-physician colleagues feel the same way. There are always bad apples in every barrel, and this is where we need to focus our attention.

What we need to do is to develop better monitoring systems like CURES in California, and give all healthcare providers the tools that they need to make sure that their patients make good choices in their pain control, and to minimize the illegal diversion of narcotics. We also need to better enforce the laws on the books now, and identify and prosecute all participants in illegal drug diversion.

The American Academy of Physician Assistants, while acknowledging the serious problem of diversion and abuse of opioid drugs, questions whether limiting access to appropriate pain medication for patients with legitimate clinical need is the proper response.

Patients have a right to quality healthcare, and this includes effective pain control. Healthcare teams that employ PAs and NPs are part of the solution to this problem, not the cause of it.

This blog was provided in partnership with the American Academy of Physician Assistants.