Division II Medical/Pharmaceutical Services, Education and Oversight Sen. Carson (Thursday) 12/14/2015

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1 Division II Medical/Pharmaceutical Services, Education and Oversight Carson (Thursday) 12/14/2015 Topic -Division II Expanding Board of Medicine; including practitioner of pain medicine or anesthesiology Bradley 2758; 10 with am Board of Medicine; Medical Review Committee. Amend RSA 329:17, V-a to read as follows: V-a. A medical review subcommittee of [11] 13 members shall be nominated by the board of medicine and appointed by the governor and council. The subcommittee shall consist of one member of the board of medicine and [10] 12 other persons, 3 of whom shall be public members, one of whom shall be a physician assistant, and [6] 8 of whom shall be physicians. One of the physician members shall practice in the area of pain medicine and anesthesiology. Any public member of the subcommittee shall be a person who is not, and never was, a member of the medical profession or the spouse of any such person, and who does not have, and never has had, a material financial interest in either the provision of medical services or an activity directly related to medicine, including the representation of the board or profession for a fee at any time during the 5 years preceding appointment. The terms of the public members shall be staggered so that no 2 public members' terms expire in the same year. The subcommittee members shall be appointed for 3-year terms, and shall serve no more than 2 terms. Upon referral by the board, the subcommittee shall review disciplinary actions reported to the board under paragraphs II-V of this section, except that matters concerning a medical director involved in a current internal or external grievance pursuant to RSA 420-J shall not be reviewed until the grievance process has been completed. Following review of each case, the subcommittee shall make recommendations to the board. Funds shall be appropriated from the general fund for use by the subcommittee to investigate allegations under paragraphs I-V of this section. The board shall employ through the office of professional licensure and certification physician as a medical review subcommittee investigator who shall serve at the pleasure of the board. The salary of the medical review subcommittee investigator shall be established by RSA 94:1-a. Expedited

2 2 PDMP; allow funding beyond grants, repeal prohibition on state funding Bradley 2758, 5 as amended by am 3001s Controlled Drug Act; Controlled Drug Prescription Health and Safety Program. Amend 1 RSA 318-B:32, II-IV to read as follows: 2 II. [All] Any costs incurred by the board for the implementation and operation of the 3 program [shall] may be supported through grants, gifts, or user contributions. The board may 4 charge a fee to individuals who request their own prescription information. The amount charged for 5 an individual's request for his or her prescription information shall not exceed the actual cost of providing that information. III. [There shall be no state general funds appropriated for the implementation or operation of the program. IV.] Prescription information relating to any individual, which information does not meet 10 the level established to suggest possible drug abuse or diversion shall be deleted within 36 months 11 after the initial prescription was dispensed. All other information shall be deleted after 3 years. Expedited PDMP; access by law enforcement, federal health care providers in NH or VT and the Office of the Chief Medical Examiner, case by case Bradley 2758; 6 and 7 as amended by am 3002s and further amended as indicated 1 Controlled Drug Prescription Health and Safety Program; Access to Program. Amend RSA 318-B:33, II-a to read as follows: II-a. Only registered prescribers [and], dispensers, or their designees, the office of the chief medical examiner, and federal health prescribers and dispensers working in federal facilities located in New Hampshire, Massachusetts, Maine, and Vermont shall be eligible to access the program. 2 New Subparagraph; Providing Controlled Drug Prescription Health and Safety Information; Office of the Chief Medical Examiner. Amend RSA 318-B:35, I(c) by inserting after subparagraph (2) the following new subparagraph: Expedited (3) The office of the chief medical examiner for the purpose of investigating the death of an individual. 2

3 3 Sanborn 2955; 2 2 Controlled Drug Prescription Health and Safety Program; Access to Program. Amend RSA 318-B:33, II-a to read as follows: II-a. Only registered prescribers [and], dispensers, and the office of the chief medical examiner shall be eligible to access the program. Not needed; issue covered in 2758 Rep. Ward 2600; all sections 1 Controlled Drug Act; Providing Controlled Drug Prescription Health and Safety Information. Amend RSA 318-B:35, I(b)(3) to read as follows: (3) Authorized law enforcement officials on a case-by-case basis for the purpose of investigation and prosecution of a criminal offense when presented with a court order based on probable cause. [No law enforcement agency or official shall have direct access to the program.] Regular Order Add naturopaths to list of providers using PDMP Sanborn 2955; 1 1 Controlled Drug Prescription Health and Safety Program; Definitions. Amend RSA 318-B:31, VI to read as follows: Early; need new LSR VI. "Practitioner'' means a physician, dentist, podiatrist, veterinarian, pharmacist, APRN, physician assistant, naturopath, or other person licensed or otherwise permitted to prescribe, dispense, or administer a controlled substance in the course of licensed professional practice. "Practitioner" shall also include practitioners with a federal license to prescribe or administer a controlled substance. PDMP updating and access Sanborn 2955; 4 4 New Paragraphs; Program Information. Amend RSA 318-B:35 by inserting after paragraph III the following new paragraphs: Early; need new LSR IV. The program information shall be updated daily. V. The program may access information of any other national data service. 3

4 4 Mandate use of PDMP for all prescribers Sanborn 2955; 5 (first half) 318-B:39 Practitioners Required to Submit Requests to the Program Prior to Prescribing Controlled Substances. I. Practitioners required to register with the program under this subdivision shall submit prescription requests, including renewals, for controlled substances to the program. Prescription requests shall be in electronic form only. II. Notwithstanding paragraph I, a practitioner may issue an emergency prescription for no longer than 5 days; provided, that the practitioner submits the request as soon as practicable to the program. Early; need new LSR Bradley 2758; 8 (first half) with am 3021 New Sections; Certain Registrants Required to Submit Requests to the Program Prior to Prescribing Controlled Substances. Amend RSA 318-B by inserting after section 38 the following new sections: 318-B:39 Prescribers Required to Query the Program Prior to Prescribing Controlled Substances. Prescribers required to register with the program under this subdivision shall query the program for a patient s initial prescription when prescribing schedule II opioids for the management or treatment of pain and then periodically and at least twice per year, except when: Expedited I. Controlled medications are to be administered to patients in a health care setting. II. Treating acute pain associated with serious traumatic injury, postoperatively, or with an acute medical condition, with clear objective findings by the practitioner, for no more than 30 days. CME/Examination for prescribers Bradley 2758; 8 (second half) and 318-B:40 Competency Requirements. All prescribers required to register with the program who possess a United States Drug Enforcement Agency (DEA) license number shall complete 3 contact hours of free appropriate Expedited 4

5 5 9 with am 3021 prescriber s regulatory board-approved online continuing education or pass an online examination, in the area of pain management and addiction disorder or a combination, as a condition for initial licensure and license renewal. Verification of successful completion of the examination or of the required continuing education shall be submitted to the prescriber s regulatory board with the licensee s application for initial licensure or renewal. A list of the prescriber s regulatory boards approved continuing education courses and online examinations in pain management and addiction disorder, shall be available on the office of professional licensure and certification s Internet website. 9 New Paragraph; Board of Medicine; Rulemaking Added. Amend RSA 329:9 by inserting after paragraph XIX the following new paragraph: XX. Content and procedures for the online examination required [referenced] under RSA 318-B: hour Hotline Bradley 2758; Consultation Required Regarding 24-Hour Hotline. The commissioner of the department of health and human services, in consultation with the commissioner of the department of safety, shall determine whether a 24- hour drug crisis hotline should be established. If it is determined that a 24- hour hotline should be established, the commissioner of the department of health and human services shall submit a report, on or before April 1, 2016, with recommendations relative to staffing the hotline, which department would administer the hotline, how the hotline would be paid for, and other issues necessary to implement the hotline to the fiscal committee of the general court, the president of the senate, the speaker of the house of representatives, and the governor. Expedited Mandate use of opiod treatment agreement for 30- Sanborn 2955; 5 (second half) 318-B:40 Opioid Agreements Required. I. A practitioner and his or her patient shall enter into an opioid treatment Early; need new LSR 5

6 day schedule II prescription 6 agreement if the patient is using opioids for more than 90 days within any 6-month period. The agreement shall include, but not be limited to: (a) The medical basis for the use of opioids. (b) A statement of the risks and potential side effects of long-term use of opioids. (c) The patient's agreement to seek opioids only from the practitioner with whom the agreement is made and to not share the medication with others. (d) The name of the single pharmacy at which the prescription will be filled. (e) The patient's agreement to forego controlled substances not included in the pain management agreement. (f) Permission for the practitioner to conduct random drug tests to verify the proper use of the prescription. (g) A statement of the consequences of violating the agreement, including that if the patient breaches the agreement, the practitioner may stop prescribing the pain-control medicines or terminate the practitioner patient relationship. (h) Any other provisions to which the patient and the practitioner agree. Create crosscheck within PDMP for scripts written and delivered Sanborn 2955; 3 3 New Paragraph; Controlled Drug Prescription Health and Safety Program Operation; Reports Required. Amend RSA 318-B:33 by inserting after paragraph VIII the following new paragraph: IX. The board shall submit a monthly report to the commissioner of the department of health and human services relative to prescriptions written as compared to prescriptions delivered. Early; need new LSR Require tamperproof drugs/abuse deterrent drugs Sanborn 2955; 6 6 New Section; Controlled Drugs; Tamper Proof. Amend RSA 318-B by inserting after section 1-c the following new section: 318-B:1-d Controlled Drugs Required to be Tamper Proof. Controlled drugs and controlled drug analogs subject to regulation under this chapter Early; need new LSR 6

7 7 shall be sold only in a tamper-proof form. Rep. Sherman new LSR with am New Section; Accident and Health Insurance; Individual; Coverage for Abuse-Deterrent Opioid Drug Products. Amend RSA 415 by inserting after section 6-t the following new section: 415:6-u Coverage for Abuse-Deterrent Opioid Drug Products. Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for abuse-deterrent opioid drug products listed on the formulary. Insurers subject to this section shall include on the formulary an abuse-deterrent opioid for each opioid product, if available. Benefits provided under this section shall not be subject to any greater copayment, deductible, or coinsurance than any other similar benefits provided by the insurer. This section shall apply to contracts issued pursuant to RSA 420-J and RSA 126-A:5, XXIV-XXVI. Early; Need new LSR 2 New Section; Accident and Health Insurance; Group; Coverage for Abuse-Deterrent Opioid Drug Products. Amend RSA 415 by inserting after section 18-y the following new section: 415:18-z Coverage for Abuse-Deterrent Opioid Drug Products. Each insurer that issues or renews any policy of group or blanket accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for abuse-deterrent opioid drug products listed on the formulary. Insurers subject to this section shall include on the formulary an abuse-deterrent opioid for each opioid product, if available. Benefits provided under this section shall not be subject to any greater copayment, deductible, or coinsurance than any other similar benefits provided by the insurer. This section shall apply to contracts issued pursuant to RSA 420-J and RSA 126-A:5, XXIV-XXVI. 7

8 8 3 Health Services Corporations; Coverage for Abuse-Deterrent Opioid Drug Products; Effective January 1, Amend RSA 420-A:2 to read as follows: 420-A:2 Applicable Statutes. Every health service corporation shall be governed by this chapter and the relevant provisions of RSA 161-H, and shall be exempt from this title except for the provisions of RSA 400-A:39, RSA 401-B, RSA 402-C, RSA 404-F, RSA 415-A, RSA 415-F, RSA 415:6, II(4), RSA 415:6-g, RSA 415:6-k, RSA 415:6-m, RSA 415:6-o, RSA 415:6-r, RSA 415:6-s, RSA 415:6-t, RSA 415:6-u, RSA 415:18, V, RSA 415:18, XVI and XVII, RSA 415:18, VII-a, RSA 415:18-a, RSA 415:18-j, RSA 415:18-o, RSA 415:18-r, RSA 415:18-t, RSA 415:18- u, RSA 415:18-v, RSA 415:18-w, RSA 415:18-x, RSA 415:18-y, RSA 415:18-z, RSA 415:22, RSA 417, RSA 417-E, RSA 420-J, and all applicable provisions of title XXXVII wherein such corporations are specifically included. Every health service corporation and its agents shall be subject to the fees prescribed for health service corporations under RSA 400-A:29, VII. 4 Health Services Corporations; Coverage for Abuse-Deterrent Opioid Drug Products; Effective October 1, RSA 420-A:2 is repealed and reenacted to read as follows: 420-A:2 Applicable Statutes. Every health service corporation shall be governed by this chapter and the relevant provisions of RSA 161-H, and shall be exempt from this title except for the provisions of RSA 400-A:39, RSA 401-B, RSA 402-C, RSA 404-F, RSA 415-A, RSA 415-F, RSA 415:6, II(4), RSA 415:6-g, RSA 415:6-k, RSA 415:6-m, RSA 415:6-o, RSA 415:6-r, RSA 415:6-t, RSA 415:6-u, RSA 415:18, V, RSA 415:18, XVI and XVII, RSA 415:18, VII-a, RSA 415:18-a, RSA 415:18-j, RSA 415:18-o, RSA 415:18-r, RSA 415:18-t, RSA 415:18-u, RSA 415:18- v, RSA 415:18-w, RSA 415:18-y, RSA 415:18-z, RSA 415:22, RSA 417, 8

9 9 RSA 417-E, RSA 420-J, and all applicable provisions of title XXXVII wherein such corporations are specifically included. Every health service corporation and its agents shall be subject to the fees prescribed for health service corporations under RSA 400-A:29, VII. 5 Health Services Corporations; Coverage for Abuse-Deterrent Opioid Drug Products; Effective January 1, RSA 420-A:2 is repealed and reenacted to read as follows: 420-A:2 Applicable Statutes. Every health service corporation shall be governed by this chapter and the relevant provisions of RSA 161-H, and shall be exempt from this title except for the provisions of RSA 400-A:39, RSA 401-B, RSA 402-C, RSA 404-F, RSA 415-A, RSA 415-F, RSA 415:6, II(4), RSA 415:6-g, RSA 415:6-k, RSA 415:6-m, RSA 415:6-o, RSA 415:6-r, RSA 415:6-u, RSA 415:18, V, RSA 415:18, XVI and XVII, RSA 415:18, VII-a, RSA 415:18-a, RSA 415:18-j, RSA 415:18-o, RSA 415:18-r, RSA 415:18-t, RSA 415:18-u, RSA 415:18-v, RSA 415:18- w, RSA 415:18-z, RSA 415:22, RSA 417, RSA 417-E, RSA 420-J, and all applicable provisions of title XXXVII wherein such corporations are specifically included. Every health service corporation and its agents shall be subject to the fees prescribed for health service corporations under RSA 400-A:29, VII. 6 Health Maintenance Organizations; Coverage for Abuse-Deterrent Opioid Drug Products; Effective January 1, RSA 420-B:3, III is repealed and reenacted to read as follows: III. The requirements of RSA 400-A:39, RSA 401-B, RSA 402-C, RSA 404-F, RSA 415:6-g, RSA 415:6-m, RSA 415:6-o, RSA 415:6-r, RSA 415:6-s, RSA 415:6-t, RSA 415:6-u, RSA 415:18, VII-a, RSA 415:18, XVI and XVII, RSA 415:18-j, RSA 415:18-r, RSA 415:18-t, RSA 415:18- u, RSA 415:18-v, RSA 415:18-w, RSA 415:18-x, RSA 415:18-y, RSA 415:18-z, RSA 415-A, RSA 415-F, RSA 420-G, and RSA 420-J shall 9

10 10 apply to health maintenance organizations. 7 Health Maintenance Organizations; Coverage for Abuse-Deterrent Opioid Drug Products; Effective October 1, RSA 420-B:20, III is repealed and reenacted to read as follows: III. The requirements of RSA 400-A:39, RSA 401-B, RSA 402-C, RSA 404-F, RSA 415:6-g, RSA 415:6-m, RSA 415:6-o, RSA 415:6-r, RSA 415:6-t, RSA 415:6-u, RSA 415:18, VII-a, RSA 415:18, XVI and XVII, RSA 415:18-j, RSA 415:18-r, RSA 415:18-t, RSA 415:18-u, RSA 415:18- v, RSA 415:18-w, RSA 415:18-y, RSA 415:18-z, RSA 415-A, RSA 415-F, RSA 420-G, and RSA 420-J shall apply to health maintenance organizations. 8 Health Maintenance Organizations; Coverage for Abuse-Deterrent Opioid Drug Products; Effective January 1, RSA 420-B:3, III is repealed and reenacted to read as follows: III. The requirements of RSA 400-A:39, RSA 401-B, RSA 402-C, RSA 404-F, RSA 415:6-g, RSA 415:6-m, RSA 415:6-o, RSA 415:6-r, RSA 415:6-u, RSA 415:18, VII-a, RSA 415:18, XVI and XVII, RSA 415:18-j, RSA 415:18-r, RSA 415:18-t, RSA 415:18-u, RSA 415:18-v, RSA 415:18- w, RSA 415:18-z, RSA 415-A, RSA 415-F, RSA 420-G, and RSA 420-J shall apply to health maintenance organizations. 9 Effective Date. I. Sections 4 and 7 of this act shall take effect October 1, 2017 at 12:02 a.m. II. Sections 5 and 8 of this act shall take effect January 1, 2021 at 12:01 a.m. III. The remainder of this shall take effect 60 days after its passage. 10

11 11 Board of Medicine rulemaking Rep. Rosenwald 2677; all sections 1 New Section; Rulemaking for Prescribing Controlled Drugs; Controlled Drug Prescription Health and Safety Program. Amend RSA 318-B by inserting after section 38 the following new section: Early 318-B:39 Rulemaking for Prescribing Controlled Drugs; Use of Program Database. I.(a) Before September 1, 2016, the following boards shall submit to the joint legislative committee on administrative rules, final proposed rules for prescribing controlled substances, specifically opioids, for the management or treatment of pain: (1) The board of medicine, concerning physicians, including psychiatrists, and physician assistants. (2) The board of dental examiners, concerning dentists. (3) The board of nursing, concerning advanced practice registered nurses. (4) The board of registration in optometry, concerning optometrists. (5) The board of registration in podiatry, concerning podiatrists. (6) The naturopathic board of examiners, concerning naturopaths. (b) The rules required under paragraph I shall, at a minimum, contain mandatory standards for the practice components established in paragraph II. II. The rules shall, at a minimum, contain mandatory standards for the following practice components: (a) Conducting and documenting a complete patient evaluation and risk assessment to determine whether a patient is an appropriate candidate for a controlled substance prescription for the management or treatment of pain. A complete patient evaluation shall include the completion of an assessment of the pain or anticipated pain in the case of prescribing opioids in advance of a surgical procedure, a physical examination, and a detailed medical and substance abuse history. A risk assessment shall include the use of a screening tool to assess the patient's risk of opioid abuse, misuse, or addiction as low, moderate, or high. A patient may be prescribed a controlled substance for the treatment or management of chronic pain only when: 11

12 12 (1) Other physical, behavioral, and non-opioid medication measures have not resolved the patient's pain or, in the professional judgment of the prescriber, will not resolve the patient's pain; (2) The potential benefits of opioid therapy are likely to outweigh the potential harm associated with it; and (3) There is no contraindication to the use of a controlled substance for pain. (b) Using the program database when writing an initial controlled substance prescription for the management or treatment of a patient's pain and then periodically as circumstances, such as aberrant drug behavior, dictate. (c) Limiting prescriptions for the management or treatment of pain based on the patient evaluation, risk assessment, review of the program database, and other circumstances deemed appropriate. Limitations shall include, but not be limited to: (1) Allowing no more than a 5-day controlled substance prescription for the management or treatment of pain in an emergency department or urgent care setting; (2) Only prescribing long-acting opioids for acute pain after the use of short-acting opioids has been attempted or considered; and (3) Prescribing at the lowest possible effective dosage and titrating slowly. (d) Documenting informed consent such that the risks and potential benefits associated with the use of controlled substances for the management or treatment of pain are explained to, and understood by, the patient. (e) Documenting controlled substance treatment agreements for treatment or management of chronic pain patients. Such agreements shall include, at a minimum, the patient's agreement to provide samples for drug screening upon request and to take medications at the dose and frequency prescribed, conduct that triggers the discontinuation or tapering of opioid prescriptions, and a requirement that all chronic pain management prescriptions are provided by a single practice and dispensed by a single 12

13 13 pharmacy, if possible. (f) Periodically reviewing patients being prescribed controlled substances for the management or treatment of chronic pain to ascertain compliance with treatment agreements and whether a change to, or discontinuance of, controlled substance therapy is warranted. Periodic reviews, which are conducted at reasonable intervals based on the patient's risk level of substance abuse, misuse, or addiction shall include, at a minimum, a documented: (1) Evaluation of the patient; (2) Assessment of progress or lack of progress in the relieving of pain in light of treatment objectives; and (3) Assessment of the review of the program database and drug screen results. Tapering or weaning a pain patient off controlled substances, or discontinuing certain prescriptions altogether, occurs when the patient engages in aberrant drug behaviors, experiences no progress toward treatment objectives, or experiences intolerable adverse effects. (g) Providing that patients addicted to controlled substances shall be considered for a referral for addiction treatment. Specialist consults or referrals shall be considered for high risk patients and those on long-term opioids. (h) Providing that the content of medical records when a patient is prescribed a controlled substance for the management or treatment of pain includes, at a minimum, the medical history and the physical examination, diagnostic, therapeutic and laboratory results, evaluations and any consultations, treatment objectives, discussion of risks and benefits of the opioid prescriptions, informed consent of the patient, treatments, medications, including date, type, dosage and quantity prescribed, instructions and agreements, and details regarding any periodic reviews. (i) Creating exemptions to the rules required under this section for situations in which a controlled substance is being prescribed for the management of chronic pain for: (1) Patients with cancer. (2) Patients with a terminal condition. 13

14 14 (3) Long-term, non-rehab residents of a nursing home facility. (4) Patients in a hospice program. (5) Patients in a hospital based palliative care program. (j) Providing for the enforcement of the rules required under this section by specifying that any noncompliance with such rules shall constitute unprofessional conduct under the appropriate board's law. (k) Demonstrating competency in the area of pain management or opioid prescribing every 2 years through either obtaining at least 4 continuing education credits or passing an approved online examination on pain management or opioid prescribing. III.(a) Before September 1, 2016, the board of veterinary medicine shall submit to the joint legislative committee on administrative rules, final proposed rules for prescribing controlled substances, specifically opioids, by veterinarians for the management or treatment of pain. For the practice components set forth in this paragraph, the term "patient" refers to the animal being prescribed controlled substances for the management or treatment of pain, and the term "owner" refers to the legal owner of the animal. (b) The rules required under subparagraph (a) shall, at a minimum, contain mandatory standards for the practice components outlined in subparagraph (c). (c) The rules required by subparagraph (a), shall, at a minimum, contain mandatory standards for the following practice components: (1) Conducting and documenting a complete patient evaluation to determine whether or not a patient is an appropriate candidate for a controlled substance prescription for the management or treatment of pain. A complete patient evaluation shall include the completion of an assessment of the pain or anticipated pain in the case of prescribing opioids in advance of a surgical procedure, a physical examination and a detailed medical history. A patient can be prescribed a controlled substance for the treatment or management of chronic pain only when: (A) Other non-opioid medication measures have not resolved the patient's pain or, in the professional judgment of the prescriber, will not resolve the 14

15 15 patient's pain; (B) The potential benefits of opioid therapy are likely to outweigh the potential harm associated with it; and (C) There is no contraindication to the use of a controlled substance for pain; (2) Using the program database to query the patient, its owner and the individual bringing the patient in to see the veterinarian, if applicable, when writing an initial controlled substance prescription for the management or treatment of a patient's pain and then periodically as circumstances dictate. (3) Limiting prescriptions for the management or treatment of pain based on the patient evaluation, review of the program database and other circumstances deemed appropriate. Limitations shall include, but not be limited to, prescribing at the lowest possible effective dosage and titrating slowly. (4) Documenting controlled substance treatment agreements between the veterinarian and the patient's owner. Such agreements include, at a minimum, the owner's agreement to give the medications to the patient at the dose and frequency prescribed, conduct that triggers the discontinuation of opioid prescriptions, and a requirement that all opioid prescriptions are provided by a single veterinary practice and dispensed by a single pharmacy, if possible. (5) Periodically reviewing patients being prescribed controlled substances for the management or treatment of pain to ascertain whether or not a change to, or discontinuance of, controlled substance therapy, is warranted. Periodic reviews, which are conducted at reasonable intervals, shall include, at a minimum, a documented: (A) Evaluation of the patient; (B) Assessment of progress or lack of progress in the relieving of pain in light of treatment objectives; and (C) Assessment of the review of the program database. Tapering or weaning a pain patient off controlled substances, or discontinuing certain prescriptions altogether, occurs when the patient experiences no progress 15

16 16 toward treatment objectives, experiences intolerable adverse effects or when the veterinarian has a reason to believe that the patient's owner has been diverting the prescribed medications intended for the patient. (6) Providing that the content of medical records when a patient is prescribed a controlled substance for the management or treatment of pain includes, at a minimum, the medical history and the physical examination, diagnostic, therapeutic and laboratory results, evaluations and any consultations, treatment objectives, treatments, medications, including date, type, dosage and quantity prescribed, instructions and agreements, and details regarding any periodic reviews. (7) Providing for the enforcement of the rules by specifying that any noncompliance with the rules shall constitute unprofessional conduct under RSA 332-B. (8) Demonstrating competency in the area of pain management or opioid prescribing every 2 years through either obtaining at least 4 continuing education credits or passing an approved online examination on pain management or opioid prescribing. 2 New Paragraph; Board of Medicine; Rulemaking; Rules for Prescribing Controlled Drugs. Amend RSA 329:9 by inserting after paragraph XIX the following new paragraph: XX. Prescribing controlled drugs pursuant to RSA 318-B:39. 3 Board of Dental Examiners; Rulemaking; Rules for Prescribing Controlled Drugs. Amend RSA 317-A:12, XII-c and XIII to read as follows: XII-c. Notwithstanding any other provision of law, rules, as the board deems necessary, relative to qualified dental assistants performing coronal polishing. Such rules shall not authorize a qualified dental assistant to 16

17 17 perform a complete oral prophylaxis; [and] XIII. Prescribing controlled drugs pursuant to RSA 318-B:39; and XIV. Other matters related to the proper administration of this chapter. 4 New Paragraph; Board of Nursing; Rulemaking; Rules for Prescribing Controlled Drugs. Amend RSA 326-B:9 by inserting after paragraph XI the following new paragraph: XII. Prescribing controlled drugs pursuant to RSA 318-B:39. 5 New Paragraph; Board of Registration in Optometry; Rulemaking; Prescribing Rules for Controlled Drugs. Amend RSA 327:31 by inserting after paragraph IX the following new paragraph: X. Prescribing controlled drugs pursuant to RSA 318-B:39. 6 New Paragraph; Board of Podiatry; Rulemaking; Prescribing Rules for Controlled Drugs. Amend RSA 315:4 by inserting after paragraph XI the following new paragraph: XII. Prescribing controlled drugs pursuant to RSA 318-B:39. 7 Naturopathic Board of Examiners; Rulemaking; Rules for Prescribing Controlled Drugs. Amend RSA 328-E:10, I(e) to read as follows: (e) Prescribing controlled drugs pursuant to RSA 318-B:39. (f) Any other rules which are necessary or proper for the administration of this chapter. 17

18 18 8 New Paragraph; Board of Veterinary Medicine; Rules for Prescribing Controlled Drugs. Amend RSA 332-B:7-a by inserting after paragraph XIV the following new paragraph: XV. Prescribing controlled drugs pursuant to RSA 318-B:39. 9 Effective Date. I. RSA 318-B:39, II(b) and III(c)(2) as inserted by section 1 of this act shall take effect January 1, Limit prescription of controlled drugs; 34-day supply or 100 doses Rep. Ward 2235; all sections 1 Controlled Drugs; Sale by Pharmacists. Amend RSA 318-B:9, IV to read as follows: IV. No prescription shall be filled for more than a 34-day supply or 100 dosage units; whichever is less upon any single filling for controlled drugs of schedules II or III; provided, however, that for controlled drugs, in schedules II or III, that are commercially packaged for dispensing directly to the patient, such as metered sprays and inhalers, liquids packaged in bottles with calibrated droppers, and certain topical preparations packaged with metered dispensing pumps may be filled for greater than a 34-day supply or the 100 dosage units, but not more than 60 days, utilizing the smallest available product size, in order to maintain the dosing integrity of the commercially packaged containers; and, provided that with regard to amphetamines and methylphenidate hydrochloride, a prescription may be filled for up to a 60-day supply if either such prescription specifies it is being used for the treatment of attention deficit disorder, attention deficit disorder with hyperactivity, or narcolepsy. Regular Order Prescription through telemedicine Rep. McKay 2087; all sections 1 Controlled Drug Act; Acts Prohibited; Exceptions. Amend RSA 318-B:2, XII-f to read as follows: Regular Order 18

19 19 XII-f. It shall be unlawful for any person to prescribe by means of telemedicine a controlled drug classified in schedule II through IV, except as provided in RSA 318-B:2, XVI, (a) and (b). 2 Controlled Drug Act; Acts Prohibited; Exceptions. Amend RSA 318-B:2, XVI(a) to read as follows: XVI.(a) The prescribing of a non-opioid controlled drug classified in schedule II through IV by means of telemedicine shall be limited to prescribers as defined in RSA 329:1-d, I and RSA 326- B:2, XII(a), who are treating a patient with whom the prescriber has an in-person practitioner-patient relationship, for purposes of monitoring or follow-up care, or who are treating patients at a state designated community mental health center pursuant to RSA 135-C or at a Substance Abuse and Mental Health Services Administration (SAMHSA)-certified state opioid treatment program, and shall require an initial in-person exam by a practitioner licensed to prescribe the drug. Subsequent in-person exams shall be by a practitioner licensed to prescribe the drug at intervals appropriate for the patient, medical condition, and drug, but not less than annually. 3 Physicians and Surgeons; Telemedicine. Amend RSA 329:1-d, IV(a) to read as follows: IV.(a) The prescribing of a non-opioid controlled drug classified in schedule II through IV by means of telemedicine shall be limited to prescribers as defined in RSA 329:1-d, I and RSA 326-B:2, XII(a), who are treating a patient with whom the prescriber has an in-person practitioner patient relationship, for purposes of monitoring or follow-up care, or who are treating patients at a state designated community mental health center pursuant to RSA 135-C or at a Substance Abuse and Mental Health Services Administration (SAMHSA)-certified state opioid treatment program, and shall require an initial in-person exam by a 19

20 20 practitioner licensed to prescribe the drug. Subsequent in-person exams shall be by a practitioner licensed to prescribe the drug at intervals appropriate for the patient, medical condition, and drug, but not less than annually. 4 Nurse Practice Act; Telemedicine. Amend RSA 326-B:2, XII (d)(1) to read as follows: (d)(1) The prescribing of a non-opioid controlled drug classified in schedule II through IV by means of telemedicine shall be limited to prescribers as defined in RSA 329:1-d, I and RSA 326-B:2, XII(a), who are treating a patient with whom the prescriber has an in-person practitioner-patient relationship, for purposes of monitoring or follow-up care, or who are treating patients at a state designated community mental health center pursuant to RSA 135-C or at a Substance Abuse and Mental Health Services Administration (SAMHSA)-certified state opioid treatment program, and shall require an initial in-person exam by a practitioner licensed to prescribe the drug. Subsequent in-person exams shall be by a practitioner licensed to prescribe the drug at intervals appropriate for the patient, medical condition and drug, but not less than annually. Collaborative pharmacy practice agreements Rep. McKay 2692; all sections 1 Pharmacists; Collaborative Pharmacy Practice Agreements RSA 318:16- a is repealed and reenacted to read as follows: 318:16-a Standards for Collaborative Pharmacy Practice. I. For a pharmacist to participate in a collaborative pharmacy practice agreement, the pharmacist shall: Regular Order (a) Hold an unrestricted and current license to practice as a pharmacist in New Hampshire. (b) Have at least $1,000,000 of professional liability insurance coverage. (c) Have the knowledge base necessary for proper monitoring, including, 20

21 21 but not limited to, associated disease states, relevant laboratory tests, adverse events, drug and food interactions, safety, and efficacy. Depending upon the complexity of the services being provided, the pharmacist may be required to have additional credentials or training and shall demonstrate the receipt of approval by the board of pharmacy. II. Any practitioner with prescriptive authority who holds an active, unrestricted license in the state of New Hampshire may enter into a collaborative pharmacy practice agreement. A service authorized by a practitioner to be performed by a pharmacist under a collaborative pharmacy practice agreement must be within the practitioner's current scope of practice. III. Collaborative pharmacy practice agreements may be between single or multiple pharmacists and a single or multiple practitioners. IV. Collaborative pharmacy practice agreements shall meet the following general requirements: (a) Each protocol developed pursuant to the collaborative pharmacy practice agreement shall contain detailed direction concerning the services that the pharmacist may perform for patients. The protocol shall include, but not be limited to: (1) The specific drug or drugs to be managed by the pharmacist. (2) The terms and conditions under which drug therapy may be implemented, modified, or discontinued. (3) The conditions and events upon which the pharmacist is required to notify the collaborating practitioner and the manner and time frame in which notification will occur. (4) The laboratory tests that may be ordered in accordance with medication therapy management. (5) Activities which may be performed by the pharmacist in conjunction with the protocol, which shall be documented as specified in the protocol. (6) A statement of the expected amount of time the pharmacist will dedicate to performing duties specified under the protocol. (b) Collaborative pharmacy practice agreements shall state the beginning and ending dates of the period of time during which the agreement is in 21

22 22 effect, and may be terminated, in writing, by either party at any time. Collaborative pharmacy practice agreements shall be renewed at a minimum every 2 years. When collaborative pharmacy practice agreements are terminated, the patient shall be informed and provided with details to allow for the uninterrupted continuation of their medication therapy management regimen. (c) Ongoing metrics for quality assurance and safety monitoring shall be agreed upon by the practitioner and pharmacist and shall be included in the collaborative practice agreement. These metrics shall be consistent with metrics adopted or enforced by regulatory bodies. V. Supervision of the collaborative pharmacy practice agreement shall include: (a) Protocols developed based on evidence-based guidelines for best practices. (b) The referring practitioner receiving progress visit notes from each patient encounter in a time specified in the agreement. (c) The referring practitioner providing supervision for the treatment management of the referred patient. (d) The retention on file of the collaborative pharmacy practice agreement and protocols at the pharmacist's place of practice and at the practitioner's administrative office or place of practice, which shall be available upon request. VI. Neither the attending practitioner nor the pharmacist in a collaborative practice pharmacy agreement may seek to gain personal financial benefit by participating in any incentive based program or accept any inducement that influences or encourages therapeutic or product changes or the ordering of tests or services. 22

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