DEA Actions May Compromise Hospice Patients in Nursing Homes - UPDATE
Posted by Dr. Jim Joyner
Yesterday (March 24, 2010) The Senate held a hearing regarding this issue.
Read and view the testimonies from the Senate Hearing on DEA Actions on Pain Meds in SNFs at: http://aging.senate.gov/hearing_detail.cfm?id=323367&
Also, there have been several articles this week in the News on this issue:
NY Times Article "U.S. Drug Move Said to Deprive Elderly"
WSJ Article "Nurses' Drug Dispensing Examined"
PR Newswire Article "AHCA/NCAL Praises Senate Committee for Shining Light on Outdated Rules Causing Delays with Medication for Patients in Pain"
Our original article follows:
Recent actions by the Drug Enforcement Agency (DEA) may have an adverse impact upon availability of opioids and other controlled substance medications for hospice patients that reside in skilled nursing facilities (SNFs). The DEA has recently launched a series of enforcement actions against several pharmacies that provide service to SNFs in the state of Ohio. Citations were issued to the pharmacies for following common standards of practice that have evolved over time to meet the needs of patients in long-term care facilities. As a result of the DEA action, many pharmacies, nationwide, are initiating significant changes to their policies and procedures for dispensing prescriptions for controlled substances to patients residing in SNFs. This includes hospice patients. Specifically, pharmacies may refuse to fill any prescriptions for controlled substances (including drugs in schedules II through V) that are written on a chart order from a SNF. The DEA has indicated that it considers chart orders for controlled substances to be invalid prescriptions unless they contain the following information:
1) Full name and address of the patient
2) The drug name, strength, dosage form, quantity prescribed, and directions for use
3) The name, address and registration number of the prescriber
4) Dated and signed by the prescriber on the date it is issued
Most chart orders do not contain this information and therefore the pharmacy cannot legally fill the prescription for a controlled substance off of a chart order. In addition the DEA does not recognize the nurse in the SNF as an agent of the physician and therefore the nurse cannot legally transmit the physician's order for a controlled substance to the pharmacy. For example, it is currently a common practice in many regions for the nurse at the SNF to fax chart orders for schedule II controlled drugs to the pharmacy, or for the physicians to call the orders into the pharmacy. Both of these procedures technically violate the DEA regulations and pharmacies cannot legally dispense these drugs based on chart orders that are faxed by the facility or verbal orders over the phone. In response to requests from pharmacy professional associations, the DEA has responded that it is looking into the possibility of relaxing it's interpretation of the law to allow for the use of chart-orders as recognized legal prescriptions for controlled drugs in schedules III-V, but not schedule IIs.
The DEA has clarified it's view regarding when a pharmacist may dispense a schedule II controlled drug upon the verbal order of a physician. This is allowed only in an emergency situation. The pharmacy may dispense a quantity limited to the amount adequate to treat the patient during the emergency period. The DEA defines an emergency in the following way:
1) immediate administration of the drug is necessary for proper treatment
2) no appropriate alternative is available
3) it is not reasonably possible for the physician to provide a written prescription to be presented to the pharmacist prior to dispensing
Pharmacist and physician groups have expressed concern that many physicians will likely be resistant to complying with the changes that are necessary to meet this new strict compliance with the law. Some physicians may decide to forgo practicing in the long term care environment altogether, further exacerbating the problem.
Pharmacies are striving to comply with the DEA's new strict interpretation of their rules and regulations to avoid potential fines and penalties. As a result, standard operating procedures that have been in place for many years at pharmacies are being evaluated and revised. This may result in significant delays in availability of certain critical medications for hospice patients that reside in a SNF. DEA is apparently aware of the potentially serious negative impact that their actions will have upon the timely availability of controlled substance drugs for hospice patients in the SNF. They have indicated they are considering sending out a "Dear Physician" letter to inform physicians and other health care providers about the need for strict compliance. In the mean time, don't be surprised to see new standard operating procedures emerging from the pharmacies with regard to controlled drug prescription requirements for your SNF hospice patients. The situation is still rapidly evolving and we will keep you informed as new details become available.