REGULATORY IMPACT STATEMENT and COST-BENEFIT ANALYSIS (RISCBA)

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1 State Budget Office Office of Regulatory Reinvention 111 S. Capitol Avenue; 8th Floor, Romney Building Lansing, MI Phone: (517) FAX: (517) REGULATORY IMPACT STATEMENT and COST-BENEFIT ANALYSIS (RISCBA) PART 1: INTRODUCTION Under the Administrative Procedures Act (APA), 1969 PA 306, the agency that has the statutory authority to promulgate the rules must complete and submit this form electronically to the Office of Regulatory Reinvention (ORR) at no less than 28 days before the public hearing. 1. Agency Information Agency name: Department of Licensing and Regulatory Affairs Division/Bureau/Office: Bureau of Professional Licensing Name, title, phone number, and of person completing this form: Name of Departmental Regulatory Affairs Officer reviewing this form: Andria M. Ditschman Liz Arasim 2. Rule Set Information ORR assigned rule set number: LR Title of proposed rule set: Board of Pharmacy Controlled Substances PART 2: KEY SECTIONS OF THE APA a Small business defined. Sec. 7a. Small business means a business concern incorporated or doing business in this state, including the affiliates of the business concern, which is independently owned and operated, and which employs fewer than 250 full-time employees or which has gross annual sales of less than $6,000, Reducing disproportionate economic impact of rule on small business; applicability of section and MCL (3). Sec. 40. (1) When an agency proposes to adopt a rule that will apply to a small business and the rule will have a disproportionate impact on small businesses because of the size of those businesses, the agency shall consider exempting small businesses and, if not exempted, the agency proposing to adopt the rule shall reduce the economic impact of the rule on small businesses by doing all of the following when it is lawful and feasible in meeting the objectives of the act authorizing the promulgation of the rule: (a) Identify and estimate the number of small businesses affected by the proposed rule and its probable effect on small businesses. (b) Establish differing compliance or reporting requirements or timetables for small businesses under the rule after projecting the required reporting, record-keeping, and other administrative costs. (c) Consolidate, simplify, or eliminate the compliance and reporting requirements for small businesses under the rule and identify the skills necessary to comply with the reporting requirements. (d) Establish performance standards to replace design or operational standards required in the proposed rule. (2) The factors described in subsection (1)(a) to (d) shall be specifically addressed in the small business impact statement required under section 45. (3) In reducing the disproportionate economic impact on small business of a rule as provided in subsection (1), an agency shall use the following classifications of small business: (a) 0-9 full-time employees.

2 RISCBA Page 2 (b) full-time employees. (c) full-time employees. (4) For purposes of subsection (3), an agency may include a small business with a greater number of full-time employees in a classification that applies to a business with fewer full-time employees. (5) This section and section 45(3) do not apply to a rule that is required by federal law and that an agency promulgates without imposing standards more stringent than those required by the federal law. MCL (3) Except for a rule promulgated under sections 33, 44, and 48, the agency shall prepare and include with the notice of transmittal a regulatory impact statement which shall contain specific information (information requested on the following pages). [Note: Additional questions have been added to these statutorily-required questions to satisfy the cost-benefit analysis requirements of Executive Order ]. MCL b Information to be posted on office of regulatory reinvention website. Sec. 45b. (1) The office of regulatory reinvention shall post the following on its website within 2 business days after transmittal pursuant to section 45: (a) The regulatory impact statement required under section 45(3). (b) Instructions on any existing administrative remedies or appeals available to the public. (c) Instructions regarding the method of complying with the rules, if available. (d) Any rules filed with the secretary of state and the effective date of those rules. (2) The office of regulatory reinvention shall facilitate linking the information posted under subsection (1) to the department or agency website. PART 3: AGENCY RESPONSE Please provide the required information using complete sentences. Do not answer any question with N/A or none. Comparison of Rule(s) to Federal/State/Association Standards: 1. Compare the proposed rule(s) to parallel federal rules or standards set by a state or national licensing agency or accreditation association, if any exist. Each state establishes its own requirements with respect to the control of substances. The federal law also controls substances by scheduling. Under section 7204 of the Public Health Code, MCL , if a substance is scheduled under federal law the board shall similarly schedule the substance unless the board holds a meeting within 91 days of receiving notice of the scheduling and decides to not schedule the substance similarly to the federal law. Gabapentin is not a federally scheduled substance, however, the Board of Pharmacy has determined that gabapentin should be added to the schedule 5 list of drugs because: gabapentin has a low potential for abuse relative to the controlled substances listed in schedule 4; gabapentin has an accepted medical use in treatment in the United States; and the tendency of gabapentin to produce physical or psychological dependence is less in comparison to controlled substances listed in schedule 4. There is no federal rule or standard, or national licensing agency or accreditation association that requires a controlled substance licensee to take a training regarding opioids and controlled substances. Beginning March 31, 2019, or upon the date rules are promulgated under section 16204e of the Public Health Code, MCL e, whichever is earlier, section 7303a of the Public Health Code, MCL a, requires a bona fide prescriber-patient relationship before a licensed prescriber can prescribe a controlled substance listed in schedules 2 to 5. This requirement was established by 2017 PA 247,

3 RISCBA Page 3 effective December 27, 2017, and thereafter modified by 2018 PA 101, effective April 2, Section 16204e of the Public Health Code, MCL e, allows the Department to promulgate rules describing circumstances under which a bona fide prescriber-patient relationship is not required for purposes of prescribing a schedule 2 to 5 controlled substance. The rules may also include an alternative requirement for prescribing a schedule 2 to 5 controlled substance when a bona fide prescriber-patient relationship is not required by the rules promulgated under this section. The proposed rule allows a prescriber to delegate the tasks that are required for a bona fide prescriber-patient relationship to an individual licensed under article 15 of the Public Health Code. A. Are these rule(s) required by state law or federal mandate? Scheduling gabapentin is not mandated but is authorized by the Public Health Code. Sections 7201 and 7219 of the Public Health Code, MCL and MCL , authorize the Board of Pharmacy to add substances to the schedules. Requiring an opioid and controlled substances training for prescribers and dispensers of controlled substances is not mandated but is authorized by the Public Health Code. Section 7301 of the Public Health Code, MCL , authorizes the Board of Pharmacy to promulgate rules relating to controlled substances licensure. Providing for a bona fide prescriber-patient relationship is not mandated but is authorized by section 16204e of the Public Health Code, MCL e, which allows the Department to promulgate rules describing circumstances under which a bona fide prescriber-patient relationship is not required for purposes of prescribing a schedule 2 to 5 controlled substance. The rules may also include an alternative requirement for prescribing a schedule 2 to 5 controlled substance when a bona fide prescriber-patient relationship is not required by the rules. B. If these rule(s) exceed a federal standard, identify the federal standard or citation, describe why it is necessary that the proposed rule(s) exceed the federal standard or law, and specify the costs and benefits arising out of the deviation. The proposed rules do not exceed any federal standards. 2. Compare the proposed rule(s) to standards in similarly situated states, based on geographic location, topography, natural resources, commonalities, or economic similarities. Each state is responsible for implementing its own laws and rules pertaining to scheduling controlled substances, licensing individuals and entities that will handle controlled substances, and determining requirements and limitations on prescribers and dispensers of controlled substances. Illinois, Ohio, Minnesota, Pennsylvania, and Wisconsin do not require a separate controlled substance license or registration for prescribers. Iowa, Indiana, and West Virginia do require a separate controlled substance license or registration for prescribers. Most states in the region have not designated gabapentin as a controlled substance. Ohio requires pharmacies to report the sales of gabapentin. Minnesota has designated gabapentin as a controlled substance. Kentucky has moved gabapentin to a schedule 5 controlled substance. No states in the Great Lakes region require an opioid and controlled substances training for all prescribers and dispensers or a bona fide prescriber-patient relationship before controlled substances are prescribed in their controlled substances rules. In most states, each licensure board establishes the required continuing education, which could include a training on controlled substances or pain management. A. If the rule(s) exceed standards in those states, explain why and specify the costs and benefits arising out of the deviation.

4 RISCBA Page 4 The Board of Pharmacy has determined that gabapentin should be added to the schedule 5 list of drugs in Michigan because: gabapentin has a low potential for abuse relative to the controlled substances listed in schedule 4; gabapentin has an accepted medical use in treatment in the United States; and the tendency of gabapentin to produce physical or psychological dependence is less in comparison to controlled substances listed in schedule 4. The Board of Pharmacy has determined that requiring an opioid and controlled substances training for prescribers and dispensers of controlled substances will protect the public and result in a minimal cost to the licensee. The Department has determined that allowing a prescriber to delegate the tasks that are required for a bona fide prescriber-patient relationship to an individual licensed under article 15 of the Public Health Code will provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances. 3. Identify any laws, rules, and other legal requirements that may duplicate, overlap, or conflict with the proposed rule(s). There are no other Michigan laws, rules or other legal requirements that duplicate, overlap, or conflict with the proposed rules. A. Explain how the rule has been coordinated, to the extent practicable, with other federal, state, and local laws applicable to the same activity or subject matter. This section should include a discussion of the efforts undertaken by the agency to avoid or minimize duplication. Gabapentin is not a federally scheduled substance. However, the Board of Pharmacy has determined that gabapentin should be added to the schedule 5 list of drugs because: gabapentin has a low potential for abuse relative to the controlled substances listed in schedule 4; gabapentin has an accepted medical use in treatment in the United States; and the tendency of gabapentin to produce physical or psychological dependence is less in comparison to controlled substances listed in schedule 4. There are no other federal, state, or local law that requires an opioid and controlled substance training for prescribers and dispensers of controlled substances in order to obtain or maintain a controlled substance license in Michigan. Providing for a bona fide prescriber-patient relationship is authorized by section 16204e of the Public Health Code, MCL e, which allows the Department to promulgate rules describing circumstances under which a bona fide prescriber-patient relationship is not required for purposes of prescribing a schedule 2 to 5 controlled substance. The Department has determined that allowing a prescriber to delegate the tasks that are required for a bona fide prescriber-patient relationship to an individual licensed under article 15 of the Public Health Code will provide for timely medical treatment when the prescriber is not immediately present, while still protecting the public. Purpose and Objectives of the Rule(s): 4. Identify the behavior and frequency of behavior that the proposed rule(s) are designed to alter. The purpose of the proposed rules is set forth below: R : This proposed rule adds gabapentin to the schedule 5 list of drugs because the Board of Pharmacy has found that: gabapentin has a low potential for abuse relative to the controlled substances

5 RISCBA Page 5 listed in schedule 4; gabapentin has an accepted medical use in treatment in the United States; and the tendency of gabapentin to produce physical or psychological dependence is less in comparison to controlled substances listed in schedule 4. Once gabapentin is added to the schedules it is a controlled substance and is subject to Article 7 of the Public Health Code and the rules promulgated pursuant to Article 7, which together regulate the licensure, security records, prescribing, manufacturer, dispensing, administering and distribution of controlled substances. This will allow additional regulation of gabapentin in this state. R : This proposed rule requires an opioid and controlled substances awareness training for all controlled substance licensees who prescribe or dispense, and delegatees who prescribe, administer, or dispense on behalf of a licensee. This will require essential education for licensees and delegatees who are prescribing, administering, or dispensing controlled substances to the public. R a: The requirement for a bona fide prescriber-patient relationship before prescribing certain drugs is required by law March 31, This proposed rule provides an exception to allow a prescriber to delegate the tasks that are required for a bona fide prescriber-patient relationship to an individual licensed under article 15 of the Public Health Code to provide for timely medical treatment when the prescriber is not immediately present, while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances. A. Estimate the change in the frequency of the targeted behavior expected from the proposed rule(s). R : This proposed rule will regulate gabapentin and therefore reduce the abuse of gabapentin. R : There is currently no training required to obtain or maintain a controlled substances license. This proposed rule will increase the level of education regarding controlled substances for licensees and delegatees. R a: The requirement for a bona fide prescriber-patient relationship before prescribing certain drugs is required by law March 31, This exception, by rule, will provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances. B. Describe the difference between current behavior/practice and desired behavior/practice. R : This proposed rule will regulate gabapentin and therefore reduce the abuse of gabapentin. R : There is currently no training required to obtain or maintain a controlled substances license. This proposed rule will increase the level of education regarding controlled substances for licensees and delegatees. R a: The requirement for a bona fide prescriber-patient relationship before prescribing certain drugs is required by law March 31, This exception, by rule, will provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances. C. What is the desired outcome? R : This proposed rule will regulate gabapentin and therefore reduce the abuse of gabapentin.

6 RISCBA Page 6 R : There is currently no training required to obtain or maintain a controlled substances license. This proposed rule will increase the level of education regarding controlled substances for licensees and delegatees. R a: This rule will provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances. 5. Identify the harm resulting from the behavior that the proposed rule(s) are designed to alter and the likelihood that the harm will occur in the absence of the rule. R : This proposed rule will regulate gabapentin and therefore reduce the abuse of gabapentin. R : There is currently no training required to obtain or maintain a controlled substances license. This proposed rule will increase the level of education regarding controlled substances for licensees and delegatees. R a: This proposed rule will provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances. A. What is the rationale for changing the rule(s) instead of leaving them as currently written? R : This proposed rule will regulate gabapentin and therefore reduce the abuse of gabapentin. If the rule was left as currently written gabapentin would not be a controlled substance and therefore would not be subject to the additional restrictions that are placed on controlled substances because of their potential of being abused. R : This proposed rule will require that a licensee who prescribes or dispenses controlled substances will have at least a minimum level of education regarding the opioid crisis and the use and abuse of other controlled substances. If the rule was left as currently written there would be no required training, in addition to the training a health professional receives in his or her educational program before he or she enters the health profession, for prescribers and dispensers of controlled substances. R a: The requirement for a bona fide prescriber-patient relationship before prescribing certain drugs is required by law March 31, This exception, by rule, will allow a prescriber to delegate the work up that is required to assess a patient s need for the controlled substance. This proposed rule will provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances. If the statute was left as currently written without any exception, a prescriber would be required to review the patient s relevant medical or clinical records and complete a full assessment of the patient s medical history and current medical condition, including a relevant medical evaluation of the patient conducted in person or through telehealth, before prescribing a controlled substance listed in schedules 2 to Describe how the proposed rule(s) protect the health, safety, and welfare of Michigan citizens while promoting a regulatory environment in Michigan that is the least burdensome alternative for those required to comply. R : This proposed rule will regulate gabapentin and therefore reduce the abuse of gabapentin. This is the least burdensome form of regulation of a drug in this state.

7 RISCBA Page 7 R : There is currently no training required to obtain or maintain a controlled substances license. This proposed rule will increase the level of education regarding controlled substances for licensees and delegatees. This is a one-time training and it allows the participant to attend more than 1 program in order to meet the training requirements. R a: The requirement for a bona fide prescriber-patient relationship before prescribing certain drugs is required by law March 31, This exception, by rule, will provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances. 7. Describe any rules in the affected rule set that are obsolete or unnecessary and can be rescinded. There are no rules being rescinded. Fiscal Impact on the Agency: Fiscal impact is an increase or decrease in expenditures from the current level of expenditures, i.e. hiring additional staff, higher contract costs, programming costs, changes in reimbursement rates, etc. over and above what is currently expended for that function. It does not include more intangible costs or benefits, such as opportunity costs, the value of time saved or lost, etc., unless those issues result in a measurable impact on expenditures. 8. Describe the fiscal impact on the agency (an estimate of the cost of rule imposition or potential savings). The Department does not expect the implementation of the proposed rules to result in additional costs or savings for the Department. 9. Describe whether or not an agency appropriation has been made or a funding source provided for any expenditures associated with the proposed rule(s). The licensing and regulation of the profession, including the promulgation and implementation of rules, is funded by the collection of licensing fees. As a result, there was no reason to make an agency appropriation or provide a funding source. Also, the Department does not expect the proposed rules to increase expenditures. 10. Describe how the proposed rule(s) is necessary and suitable to accomplish its purpose, in relationship to the burden(s) it places on individuals. Burdens may include fiscal or administrative burdens, or duplicative acts. R : This proposed rule will regulate gabapentin and therefore reduce the abuse of gabapentin. There is a burden on licensees to follow all of the controlled substances regulations including obtaining and maintaining a controlled substances license, however, this rule protects the public welfare by more closely regulating gabapentin which will reduce the likelihood of its abuse. R : There is currently no training required to obtain or maintain a controlled substance license. This proposed rule will increase the level of education regarding controlled substances for licensees and delegatees. There is a burden on licensees and delegatees to take the training which may include a nominal cost, however, the proposed rule ensures that licensees and their delegatees are appropriately educated on opioids and other controlled substances. R a: The requirement for a bona fide prescriber-patient relationship before prescribing certain drugs is required by law on March 31, This exception, by rule, will provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances.

8 RISCBA Page 8 A. Despite the identified burden(s), identify how the requirements in the rule(s) are still needed and reasonable compared to the burdens. R : This proposed rule will regulate gabapentin and therefore reduce the abuse of gabapentin. There is a burden on licensees to follow all of the controlled substances regulations including obtaining and maintaining a controlled substances license, however, this rule protects the public welfare by more closely regulating gabapentin which will reduce the likelihood of its abuse. R : There is currently no training required to obtain or maintain a controlled substances license. This proposed rule will increase the level of education regarding controlled substances for licensees and delegates. There is a burden on licensees and delegatees to take the training which may include a nominal cost, however, the proposed rule ensures that licensees and their delegatees are appropriately educated on opioids and other controlled substances. R a: The requirement for a bona fide prescriber-patient relationship before prescribing certain drugs is required by law on March 31, This exception to the law, by rule, will provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances. Impact on Other State or Local Governmental Units: 11. Estimate any increase or decrease in revenues to other state or local governmental units (i.e. cities, counties, school districts) as a result of the rule. Estimate the cost increases or reductions for such other state or local governmental units as a result of the rule. Include the cost of equipment, supplies, labor, and increased administrative costs in both the initial imposition of the rule and any ongoing monitoring. There are no anticipated increases or decreases in revenues to other state or local government units as a result of the proposed rules. A. Estimate the cost increases or reductions for other state or local governmental units (i.e. cities, counties, school districts) as a result of the rule. Include the cost of equipment, supplies, labor, and increased administrative costs in both the initial imposition of the rule and any ongoing monitoring. There are no anticipated increases or decreases in costs to other state or local government units as a result of the proposed rules. 12. Discuss any program, service, duty or responsibility imposed upon any city, county, town, village, or school district by the rule(s). There are no anticipated or intended programs, services, duties, or responsibilities imposed on any city, county, town, village, or school district as a result of these proposed rules. A. Describe any actions that governmental units must take to be in compliance with the rule(s). This section should include items such as record keeping and reporting requirements or changing operational practices. There are no actions that governmental units must take to be in compliance with these proposed rules. 13. Describe whether or not an appropriation to state or local governmental units has been made or a funding source provided for any additional expenditures associated with the proposed rule(s). No appropriations have been made to any governmental units as a result of these rules. No additional expenditures are anticipated or intended with the proposed rules. Rural Impact:

9 RISCBA Page In general, what impact will the rule(s) have on rural areas? The proposed rules are not expected to impact rural areas. The proposed rules apply to controlled substances licensees, and those individuals who use gabapentin, regardless of their location. A. Describe the types of public or private interests in rural areas that will be affected by the rule(s). The proposed rules are not expected to impact rural areas. The proposed rules apply to controlled substances licensees, and those individuals who use gabapentin, regardless of their location. Environmental Impact: 15. Do the proposed rule(s) have any impact on the environment? If yes, please explain. No, the rules will not have an impact on the environment. Small Business Impact Statement: 16. Describe whether and how the agency considered exempting small businesses from the proposed rule(s). The proposed rules impose requirements on individual licensees who prescribe scheduled drugs and individuals that use gabapentin rather than small businesses. Even if a licensee s practice qualifies as a small business, the Department could not exempt his or her business because it would create a disparity in the regulation of controlled substance licenses. The requirement for a bona fide prescriber-patient relationship before prescribing certain drugs is required by law on March 31, The Department is authorized to promulgate rules describing circumstances under which a bona fide prescriber-patient relationship is not required for purposes of prescribing a schedule 2 to 5 controlled substance. The Department considered exempting hospice settings from the bona fide prescriber-patient relationship but determined that allowing a prescriber to delegate the tasks that are required for a bona fide prescriber-patient relationship to an individual licensed under article 15 of the Public Health Code will provide for timely medical treatment when the prescriber is not immediately present, while still protecting the public as was intended by the legislation. 17. If small businesses are not exempt, describe (a) how the agency reduced the economic impact of the proposed rule(s) on small businesses, including a detailed recitation of the efforts of the agency to comply with the mandate to reduce the disproportionate impact of the rule(s) upon small businesses as described below, per MCL (1)(a)-(d), or (b) the reasons such a reduction was not lawful or feasible. The rules regarding the scheduling of gabapentin and requiring an opioid and controlled substances training cannot exempt small businesses because the rules do not directly regulate small businesses, but individual licensees and individuals that use gabapentin. While licensees may practice independently or as part of a small business, the law does not allow the rules to exempt these individuals from the requirements of the rules. However, the impact on licensees who practice as part of a small business is minimized in the proposed rules, as the rules are written broadly. The proposed rule changes will have a minimal impact on licensees. As a result, a licensee, whether in small business or not, should not be significantly impacted by the changes. A. Identify and estimate the number of small businesses affected by the proposed rule(s) and the probable effect on small business. The department does not collect or have access to information that would allow it to identify and estimate the number of small businesses that may be affected. No matter what type of business environment a licensee works in, he or she will have to take the necessary steps in order to comply with the proposed rules. The rules do not affect small businesses differently. The

10 RISCBA Page 10 anticipated effects on licensees are minimal because they clarify what is already required of licensees and not of the business in which they may work. B. Describe how the agency established differing compliance or reporting requirements or timetables for small businesses under the rule after projecting the required reporting, record-keeping, and other administrative costs. The agency did not establish separate compliance or reporting requirements for small businesses. C. Describe how the agency consolidated or simplified the compliance and reporting requirements for small businesses and identify the skills necessary to comply with the reporting requirements. The agency did not consolidate or simplify compliance and reporting requirements with the proposed rules. D. Describe how the agency established performance standards to replace design or operation standards required by the proposed rule(s). The agency did not establish performance standards to replace design or operation standards required by these rules. 18. Identify any disproportionate impact the proposed rule(s) may have on small businesses because of their size or geographic location. The proposed rules affect individual licensees and individuals that use gabapentin, rather than small businesses. Therefore, there is no disproportionate effect on small businesses because of their size or geographic location. 19. Identify the nature of any report and the estimated cost of its preparation by small businesses required to comply with the proposed rule(s). The proposed rules require controlled substance prescribing licensees to create and maintain records of a patient s condition, which is already required of controlled licensees by law regardless of where the licensee is employed. There is no separate cost for report preparation to small businesses. 20. Analyze the costs of compliance for all small businesses affected by the proposed rule(s), including costs of equipment, supplies, labor, and increased administrative costs. There are no expected increased costs for small businesses concerning the costs of equipment, supplies, labor, or administrative costs. 21. Identify the nature and estimated cost of any legal, consulting, or accounting services that small businesses would incur in complying with the proposed rule(s). There are no expected increased costs for small businesses concerning legal, consulting, or accounting services. 22. Estimate the ability of small businesses to absorb the costs without suffering economic harm and without adversely affecting competition in the marketplace. There are no expected costs to small businesses that will cause economic harm to a small business or the marketplace as a result of the proposed rules. 23. Estimate the cost, if any, to the agency of administering or enforcing a rule that exempts or sets lesser standards for compliance by small businesses. The proposed rules: impose requirements on individuals who use gabapentin; require an opioid and controlled substances training on controlled substance licensees who prescribe and dispense; and require a bona fide prescriber-patient relationship on controlled substance licensees who prescribe. All of these requirements are imposed on individuals rather than small businesses. Even if a licensee s employer qualifies as a small business, the department could not exempt his or her business because it

11 RISCBA Page 11 would create disparity in the regulation of controlled substance licenses. Therefore, exempting or setting lesser standards of compliance for small businesses is not in the best interest of the public. 24. Identify the impact on the public interest of exempting or setting lesser standards of compliance for small businesses. The proposed rules impose requirements on individual licensees and individuals who use gabapentin rather than small businesses. Even if a licensee s employer qualifies as a small business, the department could not exempt his or her employer because it would create disparity in the regulation of controlled substance licenses. Therefore, exempting or setting lesser standards of compliance for small businesses is not in the best interest of the public. 25. Describe whether and how the agency has involved small businesses in the development of the proposed rule(s). The Department worked with the Board of Pharmacy in the development of the proposed rules. The Board is composed of members of health professions, individuals with controlled substance licenses, both small and large business entities in Michigan, as well as public members. Before the bona fide prescriber-patient relationship rule was proposed, the Department met with prescribing board chairs to gather their input. Concerns were also received from various associations. A. If small businesses were involved in the development of the rule(s), please identify the business(es). The Department worked with the Board of Pharmacy in the development of the proposed rules. The Board is composed of members of health professions, individuals with controlled substance licenses, both small and large business entities in Michigan, as well as public members. Before the bona fide prescriber-patient relationship rule was proposed, the Department met with prescribing board chairs to gather their input. Concerns were also received from various associations. Cost-Benefit Analysis of Rules (independent of statutory impact): 26. Estimate the actual statewide compliance costs of the rule amendments on businesses or groups. The Department does not expect any statewide compliance costs of the proposed rules on businesses or groups. A. Identify the businesses or groups who will be directly affected by, bear the cost of, or directly benefit from the proposed rule(s). The Department does not expect any businesses or groups to be directly affected by, bear the cost of, or directly benefit from the proposed rules. B. What additional costs will be imposed on businesses and other groups as a result of these proposed rules (i.e. new equipment, supplies, labor, accounting, or recordkeeping)? Identify the types and number of businesses and groups. Be sure to quantify how each entity will be affected. The Department does not expect the proposed rules to result in any additional costs such as new equipment, supplies, labor, accounting, or recordkeeping on businesses or other groups. 27. Estimate the actual statewide compliance costs of the proposed rule(s) on individuals (regulated individuals or the public). Include the costs of education, training, application fees, examination fees, license fees, new equipment, supplies, labor, accounting, or recordkeeping. Regulated individuals may incur a fee for the one-time training on opioids and other controlled substances, however, portions of the trainings may be available at no cost on the internet.

12 RISCBA Page 12 The Department does not expect the other proposed rules to result in any additional educational costs, training, application fees, examination fees, license fees, new equipment, supplies, labor, accounting, or record keeping on regulated individuals or the public. A. How many and what category of individuals will be affected by the rules? Individuals that use gabapentin will be affected by the rules as gabapentin will now be on the list of schedule 5 drugs and therefore subject to more regulation. Licensees with a controlled substance license, and nurses who are delegated prescribing, dispensing or administering of controlled substances will be required to attend an opioid and controlled substances training. There are currently 54,000 licensees with a controlled substance license, and 188,000 nurses in Michigan. Only those nurses who are delegated prescribing, dispensing or administering of controlled substances are required to attend the training. The requirement for a bona fide prescriber-patient relationship before prescribing certain drugs is required by law on March 31, This exception to the law, by the proposed rule, will affect licensees who prescribe controlled substances and those individuals who are being prescribed controlled substances. There are currently approximately 54,000 licensees with a controlled substance license. B. What qualitative and quantitative impact does the proposed change in rule(s) have on these individuals? Individuals that use gabapentin will be impacted by the more regulated environment for controlled substances. Licensees with a controlled substance license, and nurses who are delegated prescribing, dispensing or administering of controlled substances will be required to attend an opioid and controlled substances training. These individuals may incur a one-time fee for the training. The requirement for a bona fide prescriber-patient relationship before prescribing controlled substances is required by law on March 31, The proposed exception to the law, to allow the bona fide prescriber-patient relationship to be delegated, may impact how prescribers evaluate when a controlled substance on the 2 to 5 list is appropriate, and it may also impact how often an individual receives a controlled substance. 28. Quantify any cost reductions to businesses, individuals, groups of individuals, or governmental units as a result of the proposed rule(s). There are no expected reductions in costs to businesses, individuals, groups of individuals or governmental units as a result of the proposed rules. 29. Estimate the primary and direct benefits and any secondary or indirect benefits of the proposed rule(s). Provide both quantitative and qualitative information, as well as your assumptions. R : This proposed rule will regulate gabapentin and therefore reduce the abuse of gabapentin. This rule protects the public welfare by more closely regulating gabapentin which will reduce the likelihood of its abuse. R : There is currently no training required to obtain or maintain a controlled substance license. This proposed rule will increase the level of education regarding controlled substances for licensees and delegatees. The proposed rule ensures that licensees and their delegatees are appropriately educated on opioids and other controlled substances.

13 RISCBA Page 13 R a: The requirement for a bona fide prescriber-patient relationship before prescribing certain drugs is required by law on March 31, This exception, by rule, will provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances. 30. Explain how the proposed rule(s) will impact business growth and job creation (or elimination) in Michigan. The rules are not expected to have an impact on business growth, job creation, or job elimination. 31. Identify any individuals or businesses who will be disproportionately affected by the rules as a result of their industrial sector, segment of the public, business size, or geographic location. There is not expected to be a disproportionate effect due to industrial sector, segment of the public, business size, or geographic location. 32. Identify the sources the agency relied upon in compiling the regulatory impact statement, including the methodology utilized in determining the existence and extent of the impact of a proposed rule(s) and a cost-benefit analysis of the proposed rule(s). Centers for Disease Control and Prevention CDC Guideline for Prescribing Opioids for Chronic Pain Food and Drug Administration National Association of State Controlled Substances Authorities U.D. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Illinois Illinois Rules Illinois Statute 70%2F&ChapterID=53&ChapterName=CRIMINAL+OFFENSES&ActName=Illinois+Controlled+Sub stances+act%2e Indiana Indiana Rules

14 RISCBA Page 14 Indiana Statute Ohio Board of Pharmacy Ohio Controlled Substances Statute Ohio Controlled Substances Rules Pennsylvania Pennsylvania Rules or Pennsylvania Statutes Wisconsin Wisconsin Statutes and Rules A. How were estimates made, and what were your assumptions? Include internal and external sources, published reports, information provided by associations or organizations, etc., which demonstrate a need for the proposed rule(s). R : No estimates or assumptions were made as the scheduling of controlled substances is mandated by statute if the substance has a potential for abuse. R : Licensees with a controlled substance license, and nurses who are delegated prescribing, dispensing or administering of controlled substances will be required to incur a onetime fee of up to $ dollars depending on where and how they receive the training. This estimate is made based on the myriad of trainings offered by the Federal government, associations, and non-profit agencies. R a: No estimates or assumptions were made. Before the bona fide prescriber-patient relationship exception rule was proposed, the Department met with prescribing board chairs to gather their input. Concerns were also received from various associations. Alternatives to Regulation: 33. Identify any reasonable alternatives to the proposed rule(s) that would achieve the same or similar goals. Include any statutory amendments that may be necessary to achieve such alternatives. R : This proposed rule adds gabapentin to the schedule 5 list of drugs. The same goal would be achieved if gabapentin was added to the schedule 5 list of drugs by legislation.

15 RISCBA Page 15 R : This proposed rule requires an opioid and controlled substances awareness training for all controlled substance licensees who prescribe or dispense, and delegatees who prescribe, administer, or dispense on behalf of a licensee. There is no other reasonable alternative to the proposed rule that would achieve the same or similar goal. R a: The requirement for a bona fide prescriber-patient relationship before prescribing certain drugs is required by law on March 31, This exception, by rule, will provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriber-patient relationship before prescribing controlled substances. Since section 16204e of the Public Health Code, MCL e, allows the Department to promulgate rules describing circumstances under which a bona fide prescriber-patient relationship is not required for purposes of prescribing a schedule 2 to 5 controlled substance; and the rules may include an alternative requirement for prescribing a schedule 2 to 5 controlled substance when a bona fide prescriber-patient relationship is not required; there may be alternative rule language, however, the Department does not believe that there are other alternatives that would achieve the same or similar goals to provide for timely medical treatment when the prescriber is not immediately present while still protecting the public as was intended by the requirement to have a bona fide prescriberpatient relationship before prescribing controlled substances. A. In enumerating your alternatives, include any statutory amendments that may be necessary to achieve such alternatives. R : This proposed rule adds gabapentin to the schedule 5 list of drugs. The same goal would be achieved if gabapentin was added to the schedule 5 list of drugs by legislation. 34. Discuss the feasibility of establishing a regulatory program similar to that in the proposed rule(s) that would operate through private market-based mechanisms. Include a discussion of private market-based systems utilized by other states. Since the rules are authorized by statute, private market-based systems cannot serve as an alternative. Each state is responsible for implementing its own laws and rules pertaining to scheduling controlled substances, licensing individuals and entities that will handle controlled substances, and determining requirements and limitations on prescribers and dispensers of controlled substances. Private marketbased systems are not used for regulating controlled substances. The licensing and regulation of controlled substances are state functions, so a regulatory program independent of state intervention cannot be established. 35. Discuss all significant alternatives the agency considered during rule development and why they were not incorporated into the rule(s). This section should include ideas considered both during internal discussions and discussions with stakeholders, affected parties, or advisory groups. R : The Board of Pharmacy considered scheduling gabapentin as a schedule 2, 3, 4, or 5 drug. Since scheduling gabapentin is the only manner in which the drug can be regulated by the state, and it is appropriately schedule 5 drug, there were no alternatives to the proposed rules that the agency could consider. R : During rule development the Department considered having each health profession board add an opioid training requirement to its continuing education requirements. However, the Department determined that the training should be required for all prescribers and dispensers of controlled substances regardless of the health profession they work in, and therefore the training requirement is proposed for a controlled substance licensee that prescribes or dispenses. R a: An emergency rule was considered however, the legislature extended the effective date of the bona fide prescriber-patient requirement to March 31, 2019, which therefore no longer necessitated using the emergency process.