The state House has passed a bill to let physician assistants to prescribe highly regulated drugs, a step advocates say is needed to improve health-care access in rural Kentucky, the only state where PAs lack such authority.

House Bill 135, sponsored by Rep. Steve Sheldon, R- Bowling Green, would allow "modified prescriptive authority" of controlled substances in federal Schedules II, III, IV, and V after the assistant has been licensed and has practiced for one year.

It passed the House Feb. 6 on a 91-1 vote, with Rep. Lynn Bechler, R-Marion, voting against it. This was the fourth time the legislation had been filed, and the first time it's gained any traction.

Sheldon said the Kentucky Board of Medical Licensure, the Kentucky Academy of Physician Assistants, the Kentucky Pharmacists Association and the Kentucky Medical Association were involved in the drafting of this bill.

Rep. Susan Westrom, D-Lexington, asked about KMA's position on the legislation, since it had opposed such bills in the past. Sheldon and other members assured her that KMA was not against it.

KMA told Kentucky Health News in an e-mail, "The KMA continues to have concerns regarding the expansion of prescriptive authority for controlled substances among non-physician groups. KMA did work, however, with the Kentucky Academy of Physician Assistants to ensure safeguards such as a "team approach" were included in House Bill 135 that promote public safety, along with oversight by the Kentucky Board of Medical Licensure. KMA will monitor the progress of this bill and urge that measures such as these be included as the legislative process continues."

Rep. Daniel Elliot, R-Danville, who has introduced the legislation in the past, summarized the benefits of this bill, as described in a letter from a PA. He said it would lead to better and more efficient access to care and allow a more accurate account of who is actually prescribing drugs, since now all scheduled drugs prescribed by a PA are attributed to the supervising physician.

"Kentucky is the only state in the nation which presently has a complete prohibition on physician assistants prescribing controlled medications," he noted.

Rep. John Blanton, R-Salyersville, said he once had reservations about changing that, having worked as a police officer on an investigation that sent a doctor to prison in 2001 for overprescribing opioids, but has since changed his mind.

"The first thought to me was that we don't need more people prescribing opioids, we've already got a problem," he said. "But I also realized that we can't punish the good people that are doing good work because of someone we fear to be a bad actor -- there are things in place to take care of those bad actors."

Also, he said of PAs, "In Eastern Kentucky, they are vitally important to us because oftentimes, when we go in, that's who we're seeing, rather than a doctor, and they need to have every tool in their toolbox they can to be able to administer good health care to the people that they see each and every day."

Rep. Tina Bojanowski, D-Louisville, said PAs have told her that if they can't practice to the full scope of their practice, as they can in other states, they will leave Kentucky.

Moser, who is known for her opposition to increasing the scope of practice for non-physicians, especially when it comes to prescribing controlled substances, said she could support the bill for several reasons: It requires PAs to get additional training and continuing education for prescribing at every level of drug classification; it maintains a strong collaborative agreement with a physician; a supervising physician can decide which drugs their PA prescribes, if at all; and they will be regulated under the Board of Medical Licensure.

Rep. Stan Lee, R-Lexington, cautioned that non-physician groups keep coming back to ask to expand their scope of practice and that while this piece of legislation provides a strong collaborative agreement between a PA and their supervising physician, "other collaborative agreements with other professions have been under assault."

Nurse practitioners are also asking to expand prescriptive authority

Lee apparently alluded to a bill to expand the prescriptive authority of advanced practice registered nurses, They too, say this would increase health care access for Kentuckians. So far, it hasn't gained any traction.

Nurse practitioners have been able to prescribe Schedule II drugs, the highest level of painkillers, since 2006, under the supervision of a physician. House Bill 286, a bipartisan bill sponsored by Rep. Russell Webber, R- Shepherdsville, would allow them to prescribe them without a supervising physician after four years, if their license is in good standing. The General Assembly approved similar authority in 2014 for non-scheduled drugs.

Lawmakers continue to express concerns that such a move would increase the opioid supply in the state, but that hasn't been the case, according to a fact sheet from the APRNs' lobbying group.

It says, "Although the number of APRNs in Kentucky has increased, the average APRN prescribing of Schedule II opioids has decreased 33 percent from 2015 through 2018, the last year for which we have complete data. In contrast, the average dentist prescribing Schedule II opioids has decreased 25.8% and the average physician prescribing of Schedule II opioids has decreased 21.2%."

HB 286 has 28 sponsors. It is in the House Licensing, Occupations and Administrative Regulations Committee.

What's in the PA bill?

The PA bill includes several restrictions, including only allowing PAs to prescribe a three-day supply of Schedule II drugs, with no refills. Schedule II and III non-narcotic substances would be limited to a 30-day supply with no refill; and Schedule IV and V drugs would be limited to the original prescription, with refills to not exceed a six-month supply.

It also carves out several Schedule IV drugs that can only be written as a 30-day supply without any refills, including: diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax) and carisoprodol (Soma).

A PA's license to prescribe such drugs would need to be renewed every two years. The measure also includes new rules around continuing education requirements, including a number of required hours related to controlled substances.

Under the regulation, PAs would still have to work under the supervision of a medical doctor and that physician would be allowed to limit which controlled substances their PAs can prescribe, or if they want to participate in the program.

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