Class, let’s start with a show of hands…
- Who believes there is an opioid crisis/epidemic related to opioid abuse and misuse?
- Who believes that legitimate pain sufferers requiring opioids receive far less attention than those that abuse opioids?
- Who believes that the majority of opioid prescribers have the necessary time, education, and background that is necessary to safely prescribe opioids from chronic non-cancer pain?
- Who believes that GOVERNORS have all the necessary background to determine how best to address the opioid epidemic?
As I have suggested before, there are options that have not at all been considered!
On February 21, 2016, The NY Times posted Governors Devise Bipartisan Effort to Reduce Opioid Abuse. In this article, several governors are quoted. According to Gov. Peter Shumlin of VT, “Opioids are passed out like candy in America”. The usual rhetoric and statistics surrounding opioid-related deaths, the fault of Big Pharma, plans to limit prescription quantities and pharmacies that can dispense opioids, and how third party payers have limited reimbursement for opioid products, are addressed.
GOVERNORS, instead of alienating prescribing clinicians, how about holding their hands and offering help to them and the patients they are attempting to care for?
Is it about politics or is it about good patients care and saving lives?
FOOD FOR THOUGHT
Upshur and colleagues surveyed over 100 providers including medical attendings, residents, and nurse practitioners (NPs)/physician assistants (PAs) in “Primary Care Provider Concerns about Management of Chronic Pain in Community Clinic Populations”. They reported that almost 40% of all office visits in the primary care setting were typically for chronic pain. Respondents “… attributed problems with pain care and opioid prescribing more often to patient-related factors such as lack of self-management, and potential for abuse of medication than to provider or practice system factors. Nevertheless, respondents reported inadequate training for, and low satisfaction with, delivering chronic pain treatment.”
In 2009, Dr. Bill McCarberg eloquently pointed out in a Medscape article that “Moderate to severe pain is still one of the most common reasons for primary care visits in the United States. In a 2008 survey, more than 1 in 4 Americans reported an episode of pain during the previous year.” “Pain remains undertreated, especially in the primary care setting. Even when patients make the decision to visit a healthcare professional, inadequate training and resources may prevent proper assessment of their condition. Deficiencies in pain management related to patient gender, race, and socioeconomic status have been reported.
THINKING OUTSIDE OF THE [PILL] BOX
GOVERNORS, these educational issues are the real problems which are largely ignored. No matter what non-innovative things you do, limiting prescriptions for opioids will not adequately address the issues discussed at the National Governors Association Meeting. And, the discussions considered will more likely than not adversely affect legitimate pain patients unless you deal with the heart of the problem. That is, the far majority of opioid prescriptions are written by providers that lack the appropriate expertise, time, and energy to properly care for these patients. And most of them would welcome expert help. But how could they possibly get such help, and how can they afford it?
Instead of limiting community pharmacies from providing medications, instead of limiting physicians’ ability to care for patients, instead of limiting quantities which will inconvenience patients and increase the number of copayments, instead of enabling third party payers another excuse to withhold payments and inconvenience their insured members, instead, instead, instead…
I can go on and on. The real solution to the problem is common sense and has been ignored by government officials. That is, don’t decrease access to drugs that will no doubt increase heroin use and create other problems. Instead, INCREASE access to trained pharmacy pain clinicians and make sure that Congress expedites a Bill H. R. 592 to enable payment for these services. It’s a no brainer!
GOVERNORS, you have an opportunity to really help here by partnering with colleges of pharmacy and professional pharmacy organizations within your states to prioritize a Bill H. R. 592 that enables pharmacists to be employed by and PAID to see patients within a medical practice or other appropriate clinic venue.
This week I was stopped by no less than 10 physicians (primary care and board certified pain physicians) at the 32nd Annual American Academy of Pain Medicine Meeting asking me how they could find a trained clinical pharmacist to work with them in their practice. Although I answered their question, I always began with, “You do know that you won’t be paid for the pharmacist visit, right?”. Congress has not allowed provider status for pharmacists.
We have an opioid epidemic, a medically underserved population of pain patients, some medical providers who would give their right arm to partner with a clinical pharmacist for help with medication management in their pain patients, and a group of healthcare professionals that are being grossly underutilized. Nevertheless, most medical professionals and lay people really have no idea what pharmacists could contribute or how. More about this at Nobody Knows.
Medicaid and Blue Cross pay physicians, physician assistants, nurse practitioners, midwives, podiatrists, pyschologists, chiropractors, dentists, optometrists, physical therapists, social workers, and pretty much everyone else. But they don’t pay pharmacists.
Did you know that in our federally-based clinics, pharmacists do the following tasks as listed below? And, while reading this list, ask yourself if these items are all accomplished in the 15 minutes that a primary care provider has with their patient.
Also, ponder if you’ve ever considered all or any of the issues or if you know what they even mean?
Then ask yourself why any highly skilled pharmacist would want to do these things for free!
It’s a no brainer GOVERNORS, stop the rhetoric. Support Bill H. R. 592 and get clinicians where they need to be to help mitigate the opioid epidemic and work collaboratively with physician providers instead pf alienating patients and clincians.
Please readers, consider sending this to your local GOVERNORS, and of course, comment herein.
SPECIFIC PAIN RELATED ACTIVITIES INCLUDE:
- Comprehensive analgesic pain medication evaluation including all medication therapies but with a focus on analgesic therapies and potential drug interactions.
- Medication history review and reconciliation
- Initiation, modify and/or recommend medication regimens as allowable by current regulation
- Assessment of adherence to medications
- Risk assessments evaluations and documentation with validated tools and lab analysis
- Urine Drug Test evaluations
- Immune Assay
- Qualitative Testing (gas or liquid chromatography mass spectrometry (GC-LCMS)
- Adulteration Behavior Checks (ABC) and Specimen Validity Testing (SVT)
- Behavior modification techniques and follow-up services for nonadherence
- Pharmacokinetic and clinical monitoring of medications
- Pharmacogenetic testing and interpretation of results
- Patient education regarding self-administration and monitoring of medications
- Monitoring for therapeutic effects, drug interactions, and adverse drug events through drug regimen review, laboratory data/vital sign assessment and patient interview
- Identification of and monitoring for behaviors of medication misuse, abuse, and/or addiction
- Assist with the development of clinical protocols to encourage the systematic approach to and use of various analgesic therapies
- Provide educational conferences to staff and affiliates on topics related to pain pharmacotherapy
- Conduct academic-detailing and/or drug use evaluations and respective outcomes
- Assist with quality improvement projects to improve processes related to patient care
- Chronic pain syndromes
- Pain pharmacotherapy
- Knowledge of interventional therapies
- Risk assessment and management
- Toxicology and urine drug screening evaluation
- Responsible opioid prescribing/universal precautions
- Behavioral interventions
- Motivational interviewing
- Addiction medicine
- Inter-professional communication and collaboration
- Referrals when appropriate
- Prescribe medications
Functions and Scope of Practice Include:
- Conduct comprehensive appraisals of patients’ health status by taking health and drug histories. Relevant findings must be documented in the patient’s medical record.
- Evaluate drug therapy through direct patient care involvement, with clinical assessment and objective findings relating to patient’s responses to drug therapy and communicating and documenting those findings and recommendations to appropriate individuals and in appropriate records (i.e., patient’s medical record).
- Develop and document therapeutic plans utilizing the most effective, least toxic, and most economical medication treatments.
- Provide patient and health care professional education.
- Order, perform, review, and analyze appropriate laboratory tests and other diagnostic studies necessary to monitor and support the patient’s drug therapy.
- Perform the physical measurements necessary to ensure the patients appropriate clinical responses to drug therapy.
- Assist in the management of medical emergencies, adverse drug reactions, and acute and chronic disease states.
- Identify and take specific corrective action for drug-induced problems.
- Order consults ON BEHALF of PROVIDERS (i.e., Anesthesia interventionalists, imaging, dietician, social work, psychology), as appropriate, to maximize positive drug therapy outcomes.