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Educating and Overseeing OTC & BTC Medication in AT Practice Settings

This article discusses how athletic training boards should educate and oversee the actions of the profession in relation to over-the-counter (OTC) and behind-the-counter (BTC) medication. It provides background information, terminology, and responses from the Nevada State Board of Pharmacy regarding the use and administration of prescription drugs in athletic training facilities. The article also outlines what the Nevada law says about the possession and administration of dangerous drugs.

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Educating and Overseeing OTC & BTC Medication in AT Practice Settings

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  1. www.bocatc.org How Athletic Training Boards should educate and oversee the actions of the profession as it relates to OTC & BTC Medication within the AT Practice Setting Jim Porter, LAT, AT, MA Nevada State Athletic Training Board President

  2. “The practice of NCAA Athletic Trainers’ dispensing prescription drugs in not uncommon. A 2003 study in the Journal of AthleticTraining found that 55.9% of Athletic Trainers do it.” Sports Illustrated Magazine May 20, 2013

  3. Do you know your State Laws?

  4. Do you know your State Laws? “Because individual State laws vary and Federal laws may overlap or override a State’s statutes, it is essential the athletic trainer is aware of all state and federal laws and regulations that impact the facility.” “Lack of knowledge of applicable laws is not acceptable”

  5. Caution should be exercised when providing prescription or OTC medication to any athlete

  6. Background Information • Consumer Complaint against a specific Nevada Licensed Athletic Trainer • Attorney General Office received complaint and requested a Board Investigation • Board assigned an investigator and investigation initiated

  7. Investigation Resources • NATA Consensus Statement: Managing Prescriptions and Non-Prescription Medication in the Athletic Training Facility • Medical Records • NRS 640B;NRS 453;NRS 454;NRS639;NRS 630;NRS 633 • Nevada State Board of Pharmacy • FDA • Individual witness • Medical Record of Athlete and Statements from Physician • Statement from Athletic Trainer accused of wrongful act • Statement from Athletic Trainer’s Supervisor and Institution

  8. Terminology“Legalese” • Hypodermics (NRS454.480; 639.008) • Drug (NRS639.007) • Dangerous Drugs (NRS454.201) • Controlled Substances (NRS453.043) • Prescribing authority (NRS454.213; NRS453.375) • Dispense (NRS639.0065; NRS453.056) • Administer (NRS435.021) • Ultimate User (NRS454.00978; NRS453.141) • OTC (NRS639.007) • BTC (NRS453.352) • Deliver (NRS453.0151 • Furnish (NRS454.006) • Possess (NRS453.375) • RE-packing (NRS454.0098; NRS453.083) • Self Administration (NRS453.021) • Reasonable cause to believe (NRS453.3633)

  9. Response from Nevada State Board of Pharmacy Based on Letter of September 18, 2012 from General Counsel: Carolyn J Cramer • Four types of Drugs in Nevada • NRS 640B has no mention of pharmaceuticals inventory, administered, dispensed or furnished as being part of the practice of Athletic Training. Or the use of Ionto or Phonoporesis. • Athletic Trainers are not specifically authorized by the Nevada Legislature to possess or administer controlled substances or dangerous drugs or management of BTC drugs.

  10. Response from Nevada State Board of Pharmacy • All Prescription Drugs and Controlled Substances stored by a “team physician” must be locked and stored in a location that is registered with Nevada State Board of Pharmacy. Controlled Substances require additional registration with Nevada State Board of Pharmacy • “Athletic Training Facility “is not permitted to store or dispense Prescription Drugs or Controlled Substances, BTC or OTC • Any OTC drug use must follow the FDA recommendation and Standing orders by physician director cannot exceed the FDA recommendation. If physician wants a great dosage than OTC Label then a written prescription needs to address this change in dosage.

  11. Response from Nevada State Board of Pharmacy • “Ultimate User” agreement could be utilized for prescription medications by athlete and Athletic Trainer. Limited use for duration of prescription. Not transferable to other drugs. • All Drugs (four classes) must be secured against minors and theft. • OTC drugs are to be used by only the Ultimate User.

  12. Response from Nevada State Board of Pharmacy • Standing orders cannot apply to pharmaceuticals, BTC or OTC • Athletic Trainers are not drug re-packers and cannot break down bulk product into individual doses. • Nevada State Board of Pharmacy is not interested in overseeing Athletic Trainers or OTC usage

  13. Response from Nevada State Board of Pharmacy • Only Physicians (NRS 630 & NRS633), PA, ANP or Pharmacist or Dentist or Podiatrist or Veterinarians can store or possess Dangerous Drugs or controlled substances. • All Pharmacies must be licensed in the State of Nevada including wholesalers • Nevada State Athletic Training Board can set the regulation of Pharmaceuticals BTC and OTC based on proven professional preparation and education of Licensed Athletic Trainers. FDA regulations will not currently allow Nevada State Board to set regulations regarding Dangerous Drugs and Controlled Substances.

  14. What the Nevada Law Says • NRS 640B.90 • NRS 454;630;633; 639.0125 does not allow a physician to extend pharmaceutical action to healthcare providers except PA or ANP. • Ionto and Phonophoresis can be delivered by only Physical Therapist (NRS 454.213) • NRS 453.375 authority to possess or administer dangerous drug • Physician must identify and license with Nevada Pharmacy Board any office that prescription are dispensed from (NRS 639.0153)

  15. What the Nevada Law Says • BTC must be controlled (NRS 639.400; NRS 453.352) • Penalties for dispensing or administering or furnishing pharmaceuticals (NRS 454.321) • Hypodermic Devices (NRS 454.480) • Athletic Trainers can administer aspirin and effervescent saline analgesics

  16. Non-prescription medications cannot be administered by a licensed athletic trainer under the direction of a physician How about your State?

  17. What happens in the field? • At the secondary school or youth sports practice setting the current law really does not effect except for inhalers and EPI-pen issues.

  18. What historically happens in the field. Performing arts, collegiate, professional, NGB level is the problematic practice setting • Athletic Trainers order, furnish, dispense and advise athletes regarding OTC and BTC and medications • Store and inventory injectable medications, prescription medications, compounding medications for topical use and sometimes controlled substances • Deliver and administer ionto and phonophoresis • Travel with OTC, BTC, Inhalers, medical preparations and hypodermic equipment

  19. What historically happens in the field. Performing arts, collegiate, professional, NGB level is the problematic practice setting • Work under direction of Physician to inject, suture and deliver IV fluids • Monitor use of OTC and BTC drugs of athletes • Advise athletes on the effects of pharmaceuticals • Athletes expect and respect the Athletic Trainer to know all medications “reason to believe”.

  20. What the current Nevada law does not address • Licensed Athletic Trainers to do anything with any drug, medication, topical substance or injectable substance, IV, ionto, phono or supplement. • Possess, furnish, regulate, order or inventory any OTC or BTC except for personal use

  21. What the current Nevada law does not address • Follow the direction of a physician including under direct supervision by physician to administer, dispense, furnish or monitor any drug (Dangerous Drug, Controlled substance, BTC, OTC)

  22. Findings from Investigation • Enforcement of Practice Act is based on consumer complaints • What happens in your State dictates how you practice not a Consensus Statement • Changing your State Practice Act to match what happens in the field takes a long time. • OTC/BTC are “Dangerous Drugs” but the Public perception is that they are 100% Safe

  23. Findings from Investigation • State Professional Practice Boards are not aware of what Athletic Training Setting looks like • Poor documentation makes the profession look bad and primarily the basis for findings in investigations • Lack of Institution control of Coaches’ Actions and lack of education of coaches result in harm

  24. Applications to take home • Board must review all aspects of what happens in the field and balance it against what the law is • Communicate with other Boards and educate them on what Athletic Trainers do • Address through the law and Administrative Code how to address what happens in the field

  25. Applications to take home • Educate the Providers of Athletic Training how to practice within the law and consequences of failure to practice within the law • Athletic Training Providers must educate coaches and report unlawful and dangerous actions to Administration

  26. Applications to take home • Always follow FDA regulations requiring dosage • Use only individual dosage packaging for OTC • Do not exceed FDA dosage recommendations, remember Self Administration

  27. Applications to take home • If you choose to monitor OTC useage, log all dosage even on the road • Document that any Athletic Trainer dealing with pharmaceuticals must demonstrate knowledge of OTC and pharmaceuticals • If you provide BTC use individual dosage packaging and setup a log of units provided that meets both State and Federal Laws.

  28. What Nevada State Board of Athletic Trainers is doing to correct issues. • Working with State Attorney General’s office to develop new regulations that define the role of an Athletic Trainer and OTC/BTC

  29. What Nevada State Board of Athletic Trainers is doing to correct issues. • Board Authorized a Committee of Nevada Licensed Athletic Trainers to formulate the new regulation within the scope of practice allowed by NRS 454; NRS 640B; NRS 630; NRS633; NRS453. To be presented to the State Board September 2013.

  30. What Nevada State Board of Athletic Trainers is doing to correct issues. Submit the Regulation to Legislative Counsel Bureau for consideration by 2015 Nevada State Legislature

  31. What Nevada State Board of Athletic Trainers is doing to correct issues. • Educate all Nevada Licensed Athletic Trainers on approved Nevada Administrative Code (NAC 640B) and how to work within proposed Regulation until Legislative approval.

  32. www.bocatc.org Thank You Jim Porter Select Physical Therapy Athletic Training Services-Las Vegas, Nevada porterj@selectmedical.com 702-217-5501

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