Commonwealth of Massachusetts
-From Eileen Sullivan, Acting Commissioner, Massachusetts Department of Public Health: I am writing on behalf of Governor Deval Patrick in response to your recent letter, dated September 23, 2014, requesting information on Massachusetts' policies to reduce the use of prescription medication while operating a transportation vehicle, as described in recommendations I-14-1 and I-14-2. The Commonwealth of Massachusetts, through its boards of licensure for health professionals, has enacted regulations and issued guidance to address prescribing and patient education practices by licensed prescribers.
Under the Department of Public Health, the Board of Registration in Dentistry, the Board of Registration in Nursing, the Board of Registration in Pharmacy, and the Board of Registration of Physician Assistants have existing regulations and guidelines in place requiring licensees to discuss with patients the effects of medical conditions and dug products prescribed and dispensed:
i. Board of Registration in Dentistry-
234 CMR 5.06(1) requires registered dentists to prescribe controlled substances in conformity with M.G.L. c. 94C, its regulations and all applicable state and federal statutes and regulations pertaining to controlled substances.
o 234 CMR 5.06( 4) requires licensed dentists, prior to prescribing a hydrocodone-only extended release medication that is not in an abuse deterrent form, to thoroughly assess the patient, including an evaluation of the patient's risk factors, substance abuse history, presenting condition(s), current medication(s) and to discuss the risks and benefits of the medication with the patient.
o Advisory on the Management of Pain (adopted March 11, 2009 and amended July 20, 2011) advises that Board-licensed dentists are responsible for developing and implementing evidence-based pain management plans that include comprehensive and on-going pain assessments, appropriate pharmacological and non-pharmacological modalities, and the substantiation of adequate symptom control. Additionally, it advises that dentists maintain effective pain management competencies, as required at M.G.L. c. 94C, §18( e), that include counseling patients about the side effects of their medications.
ii. The Board of Registration in Nursing-
244 CMR 4.06 requires those engaged in APRN practice (Nurse Anesthetist, Nurse Midwife, Nurse Practitioner and Psychiatric Clinical Nurse Specialist) to perform health education and counseling for patients.
a 244 CMR 4.07(3) requires the APRN, prior to prescribing a hydrocodoneonly extended release medication that is not in an abuse deterrent form, to thoroughly assess the patient, including an evaluation of the patient's risk factors, substance abuse history, presenting condition(s), current medication(s) and to discuss the risks and benefits of the medication with the patient.
a Advisory Ruling 09-01: Management of Pain provides guidance to Massachusetts nurses with prescriptive authority and specifies that all nurses are responsible and accountable for engaging in the practice of nursing in accordance with accepted standards of care which include, among others, the provision of patient, family/significant other and/or caregiver education; and that APRN s with prescriptive authority will acquire and maintain competencies, as required at MGL c. 94C, § 18( e), that include counseling patients about the side effects of their medications.
iii. The Board of Registration in Pharmacy-
M.G.L. 94C, § 21A and 247 CMR 9.07 Maintaining Patient Records, Conducting a Prospective Drug Utilization Review and Patient Counseling requires a pharmacist to maintain patient records and conduct a prospective drug utilization review (DUR) before each new prescription is dispensed. A DUR may alert a pharmacist to medical conditions or prescriptions that may result in consultation with the patient or prescriber.
a 247 CMR 9.07 (3) further requires that a pharmacist or designee offer the services of a pharmacist to discuss, with all patients presenting new prescriptions, issues that in the pharmacist's professional judgment are deemed to be significant for the health and safety of the patient, including the patient's ability to safely operate vehicles and machinery.
a 247 CMR 9.04(8)(e) requires a pharmacist to counsel patients regarding the use of hydrocodone-only extended release medication that is not in an abuse deterrent form.
a 2009-01, Policy on the Management of Pain was implemented to ensure patient access to appropriate and effective pain management. This policy outlines best practices when dispensing controlled substances for pain management.
IV. The Board of Registration of Physician Assistants-
263 CMR 5.07 Prescription Practices of a Physician Assistant requires a Physician Assistants to follow the guidelines of the Board of Registration in Medicine for the use of Controlled substances for the treatment of pain.
o 2009-01 Policy on Management of Pain outlines pain management practices including counseling of patients about side effects of controlled substances.
o 263 CMR 5.07 (12) Prescribing Hydrocodone-Only Extended-Release Medication. Prior to prescribing a hydrocodone-only extended release medication that is not in an abuse deterrent form, a licensee must assess the patient, including an evaluation of the patient's risk factors, substance abuse history, presenting condition(s), current medication(s) and a check of the online Prescription Monitoring Program and discuss the risks and benefits of the medication with the patient A Joint Alert for the Board of Registration in Dentistry, the Board of Registration in Nursing, the Board of Registration in Pharmacy and the Board of Registration of Physician Assistants has been posted to each Board's website and/or sent electronically to Board distribution lists to remind licensees with prescriptive and dispensing authorities of their obligation to discuss the effects of medical conditions and medications prescribed with patients.
Under the Executive Office of Health and Human Services, the Board of Registration in Medicine (BORIM) has a prescribing guideline which is widely distributed among physicians and other health care professionals. BORIM's Prescribing Practices Policy and Guidelines (Adopted 8/111989, Amended 11117/2010) contains this caution: "It is the responsibility of the physician to prescribe drugs with proper regard for their action and potential dangers. Physicians should carefully describe to patients the purpose and use of the drug, as well as any significant side effects that the patient may experience, and basic information on how to take the medication correctly."
BORIM has also adopted the Federation of State Medical Board's pain policy, the "Model Policy for the Use of Controlled Substances for the Treatment of Pain (2004)." This policy discusses informed consent, and the need to inform the patient about drug. In addition to these policies, the QPSD has put out a Report on Hydromorphone (Dilaudid) that cautions health care professionals on the use of that particular opioid. This report alerts prescribers to the medication's side effects and to the dangers of using Dilaudid at the same time as other analgesics.
At that time, BORIM can include a recommendation to the Prescribing Policy that health care providers discuss with patients about the effect that their medical condition and medication may have on their ability to operate a vehicle, in any mode of transportation.
BORIM also communicates with physicians through the use of Board newsletters, the Board's website, through occasional email "blasts" to all physicians and by participating in grand rounds and other presentations to physicians and to the public. Through this, the Board can include information about the impact of driving through these outreach methods, and often share alerts and other material from our partners in state and federal government through these options, particularly email blasts.
I appreciate the opportunity to share Massachusetts' ongoing work to address prescription drug misuse and abuse, and the National Transportation Safety Board's work to reduce the use of such substances while operating vehicles to ensure public safety. If I can provide any additional information in response to this request, please do not hesitate to contact me.