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Lawsuit: Purdue Targeted Nurse Practitioners, PAs

The medical community has long valued “midlevel providers” — nurse practitioners and physician assistants — for the role they can play in providing hands-on, lower-cost primary care, especially in rural and urban areas that don’t have enough primary-care doctors.

But to Purdue Pharma, their value was as high prescribers of pain medication who were seen as more susceptible to the information Purdue’s sales reps pushed.

The lawsuit led by Tennessee Attorney General Herbert Slatery outlines specic strategies by Purdue to target these midlevel providers of primary care. In a 2015-2016 training session on selling the OxyContin brand, the lawsuit notes, Purdue told reps, “NP/PAs are critical to our success, contributing to both volume and growth,” and tagging them “high-value OxyContin prescribers.”

In 2013 training, reps were told, “NPs and PAs desperately seek information, typically from sales representatives.”

And the reps listened: Over 10 years, Purdue made 63,445 sales calls to nurse practitioners, more than to any other single specialty, and an additional 20,704 sales calls to PAs.

The state said in its lawsuit that Purdue targeted primary-care providers — including family doctors, internal medical physicians, nurse practitioners and PAs — because they had high patient loads, less experience in prescribing pain medications, and less time to do research on the company’s claims about OxyContin’s safety and ecacy. More than half — 62 percent — of all sales calls went to these providers.

Though as a group they’ve written fewer opioid prescriptions than primary- care doctors, nurse practitioners have borne a lot of the blame for overprescribing. In the fallout, some doctors organizations have cited that as one reason nurse practitioners shouldn’t have more freedom to practice medicine independently in Tennessee.

Yet, there’s a good argument against that: In Tennessee during the lawsuit’s time period, and still today, doctors must supervise nurse practitioners, which includes signing o on their prescriptions.

“Organizational medicine is holding dearly to the necessity for them to supervise nurse practitioners,” said Carole Myers, associate professor in the University of Tennessee’s College of Nursing and Department of Public Health. “And yet, many of them are not doing that well. They’re ‘supervising’ in name only. They can’t have it both ways — they can’t say it’s necessary and then not do it.”

When the Tennessee Board of Nursing has disciplined individual nurse practitioners for overprescribing, whether their supervising doctors — who must sign o on each opioid prescription — were disciplined by the Board of Medical Examiners varied widely.

Myers said statistics on nurse practitioners’ prescribing habits could be skewed because doctors in specialties that prescribe a lot of medications — oncology, for example, or psychology — sometimes hire nurse practitioners speci cally to do “medication management” for their patient load, including writing prescriptions.

“You showing up on that top 50 prescribers list raises questions but does not provide answers,” she said. “There’s a physician behind every one of those (nurse practitioners). … We have aberrant nurse prescribers, aberrant physician prescribers and aberrant physician assistant prescribers. Each of those professions need to act swiftly on those.”

Myers is among those who believe nurse practitioners are the answer to providing needed primary care — and lower health care costs, fewer hospital visits and better general health overall — in areas such as rural Tennessee that have diculty attracting enough doctors to serve all residents and rarely have enough providers who accept TennCare, or Medicaid. In June 2016, the federal government designated 61 of Tennessee’s 95 counties as having a shortage of primary-care providers.

So far, 23 states and the District of Columbia have given nurse practitioners full authority to practice medicine, including evaluating patients; diagnosing; ordering and interpreting diagnostic tests; and initiating and managing treatments, including prescribing medications, even controlled substances. Fourteen more states give nurse practitioners some reduced authority. Tennessee is among 13 states with the most restrictive laws for nurse practitioners.

For six months, a state task force worked to nd a middle ground between nurse practitioners and physician interest groups, but it failed to reach a consensus. Now it will be next year before the issue comes up again in legislation.

Meanwhile, physicians, midlevel providers and pharmacists all are subject to a plethora of new rules that took eect July 1 as part of Gov. Bill Haslam’s sweeping TN Together opioid reform plan. Those regulations limit the amount and strength of painkillers that can be prescribed.

“This epidemic has so many causes,” Myers said. “The problem is not unique to any one of the professions. … We need to stop the turf wars and come together.”

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