Since the opioid epidemic began, policy makers have been trying to stop the torrent of highly addictive painkillers that providers began pouring into the general population in the 1990s.
But clamping down on prescriptions is not as simple as it might seem. As Virginia nails down regulations that could prevent fraudulent prescriptions, it must also decide who is exempt from the rules.
In 2017 the General Assembly passed a bill that required all opioid prescriptions to be submitted electronically by July 2020 and created a work group that would determine how to go about implementing the requirement. The group met for the last time Wednesday.
Prescribing electronically helps prevent medication errors and theft or forgery, which are more likely with paper prescriptions. It also integrates the prescription records directly into the patient’s electronic health record so other prescribers know how many opioids the patient has received.
It’s an attractive option, especially in light of the death toll that continues to mount. Last year, 1,229 people in Virginia died of an opioid overdose, which includes prescription painkillers and the illicit forms of heroin and fentanyl, according to the Office of the Chief Medical Examiner.
But there are barriers as well, requiring the work group to consider adding exceptions and waivers. For some, electronic prescribing represents an unrealistic option, possibly because they don’t have the necessary technology or because their day-to-day job prohibits it. It’s hard for a veterinarian who needs to prescribe an opioid for an animal’s pain, for example, to plug a prescription into a computer if they’re working on a farm.
Even the state would have difficulty initially transitioning to electronic prescriptions. The Department of Behavioral Health and Developmental Services, for example, would likely need a waiver until it is ready to implement the changes, said Michele Thomas, pharmacy services manager with the department.
During a public comment period at Wednesday’s meeting, Thomas said the agency supports the legislation, but that meeting the requirements would be “quite a hardship for the department.”
It currently has three separate pharmacy systems, and still relies on paper records. By 2023 or 2025, Thomas said, the agency should finish setting up a new single system that will be able to electronically prescribe, but in the meantime, it would be too expensive to transition the current three systems now.
She said the department has many patients in its care with long-term needs who require opioid prescriptions to deal with pain, such as some who live in the state’s mental health hospitals.
Though the law does not mention exceptions, the work group — which is led by the Department of Health Professions and consists of stakeholders such as representatives from some of the state’s medical groups and Virginia’s professional boards — plans to recommend that exceptions for some groups of providers be adopted in its final report to Secretary of Health and Human Resources, Dr. Daniel Carey.
“We’re trying to find common-sense language and common-sense protocols and exceptions, and trying to find the right balance between safety and meeting the requirements and also things that can work in the real world where busy clinicians are also seeing lots of patients,” Carey said during the work group’s Wednesday meeting. “So finding that balance, I think, can be a challenge.”
Veterinarians should be exempt, the work group agreed, as should prescribers who dispense the drugs directly to the patient, rather than sending the prescription to a pharmacy. Others, such as prescriptions administered in a nursing home or hospice facility, for example, are also exempt. And there’s also an exception for a provider who has temporary technological or electrical issues.
Low-volume prescribers are also considered exempt, though they must still follow the prescribing guidelines set up by the Board of Medicine and Pharmacy, which put a limit on the length of time a prescription can last. Low volume is defined as 25 prescriptions over a year.
The final report with all recommended exceptions is due to Senate and House committees by Nov. 1.