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.
So GOVERNORS,
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
- SOAP-R
- COMM
- 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
Competencies include:
- 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.
Please see this article regarding the state of PDMP. There’s problems with making it mandatory as stated below. http://www.pharmaciststeve.com/?p=14292
I went to a seminar several years ago which was put on by Pharmacists that were getting paid for working in physician practices… especially seeing higher acuity pts. It basically boiled down to the Pharmacist seeing the pt in the office setting… writing notes on pts and the physician basically does a “drive by visit” with the pt… to make sure all is good… the physician references the Pharmacist’s notes in his/her notes and this entitles the practice to bill for a higher acuity office visit and the physician is able to see/bill for more pts during the day at a average higher rate,,, which provides the practice with enough extra money to afford to pay to have a Pharmacist on staff. Generally speaking the Pharmacist doesn’t need an exam room .. just a office… and there is little extra other ancillary office expense.
I use my pain medication as prescribed by my Pain Management doctor. I have too many conditions to list. I truly believe it is not the governments place to tell the doctors what to do. They paid for their education, let them use their brain and education to help chronic pain patients like they should.
Sherry, If you’re lucky enough to have a clinician that treats your pain and you well, that is wonderful. Thank you for the comment.
Sherry- I agree with you whole heartedly. I don’t know what state you are in, but I am in Fl and trying to get pain meds here is frustrating, sometimes impossible, and sometimes impossible to fill even if you go to the dr,, are treated, given the prescriptions, the pharmacies do not have to fill them. I have been on serious pain meds for over 10 years and have at times gone around to 9 or more pharmacys trying to get them filled to no avail. If you have serious pain issues- currently I need neck, back and hip surgery and my doctor cannot prescribe what he wants me to have because laws have been passed down here that the pharmacies will only fill scripts for methadone, morphine etc for 120 pills. Even if the dr (who you state above, did pay and receive their educations, open offices and do whatever required to legally treat their patients so why should government be able to tell the drs they cannot prescribe?????) wants you to have more- and my dr has called the pharmacy, they wouldn’t fill it. Luckily after going through years of wild goose chases I have finally found a good pain dr and a pharmacy who is reliable and fills my meager scripts monthly without hassle. A couple years ago (and I know people who are still going through terrible problems trying to get their prescriptions filled now- which are completely legal etc!!!) So what would happen is I would go to my apt. and be seen, given my prescriptions ( which on what I was on you go into serious withdrawals if you don’t get your med.s) and I would go the pharmacy to be told they wouldn’t have it for 2 weeks to come back then. half the time they just didn’t want to fill your scripts because they didn’t like the color of your eyes or some such nonsensical thing, and then you were off on the wild goose chase of trying to find a pharmacy to fill them. The other half the time the pharmacies were given such a meager amount of the meds they didn’t have enough to fill the patients meds who were coming in. Its ridiculous. I had been going to ( I don’t know if I can name the chain) lets say Wallblues for years- over 10 easily to get prescriptions filled- all sorts- and the heavy pain meds and one day went in and there was a new pharmacist. I turned in my scripts and she took a quick look at them and said she couldnt fill them. This was one of the pharmacies who told me almost monthly they wouldn’t have the pills in stock to fill them on time-and it could be up to several weeks. And this is when you are filling your meds there every month on about the same day for the same amount etc Then she proceeds to tell me they wont fill my scripts for me anymore anyway- even if they had it. I guess she got her back up that I went over her head and had my dr call in and say that he wanted me to have the quantity of meds he had written for So then I asked her why that was if I had been getting them filled there for years. She tells me it is because I don’t pass their “Good Customer Checklist” or whatever she called it, I cant remember. I asked her what that was and she said it was something that they had always had and when I asked her more about it because I had never heard of it, what exactly was it and what had I done differently that month that I wasn’t passing it when apparently I had been passing it for a couple years straight without even knowing they had one? She got really touchy then and told me that she could not give me that information, that it was confidential!!!! I told her I could appreciate confidentiality but since it was MY report what was I not satisfying so that I could correct it and straighten out the problem. She kept insisting that the information was confidential to the store and the customer who it concerned could not have that information!!! I then called another pain dr and he told me that this chain of drug stores had had a pharmacist who had filled a script he shouldn’t have and the DEA was all over them and that they had to do something to pacify them and the Good Customer Report (or whatever it was called) had not been in practice llike the pharmacist had told me- that the stores were having such a problem, they put up this big smoke screen and only lately had started lying to the customers about this whole scam to fill less scripts for pain meds. (this was a good couple years ago) They knew you would go into withdrawals if you didn’t get your meds- but all they cared about was keeping their jobs. would say is “Sorry, call back next Friday etc.” And what were we supposed to do, we who had gone to our licensed physicians followed their care orders etc and were given basically worthless pieces of paper we couldn’t do anything with. Yes, people abuse pain pills and die. People also abuse alcohol, food etc and die. Government officials who have a little power under their belts and want to make some sort of name for themselves “saving the people from these dangerous drugs” are harming so many of us by not allowing our wonderful trained doctors to help us and they are doing the people such a disservice it is not even fathomable. Unless you are a prescribing doctor who is frustrated because he cant help his poor patient because of these nonsensical government guidelines, or the poor patient who is in an ungodly amount of pain, can hardly get around, has to go on scavenger hunts to get the meager amount of meds the THE GOVERNMENT has decided they can have. My one doctor was so frustrated because he could prescribe what he thought I needed, but the pharmacy would not fill it. And then the poor pharmacist would tell me how frustrated he was because he also was trained to do his job and could not give the people what the doctors had prescribed for them. What is wrong with this picture? Everything.I guess all we can do is write letters in and fight against city hall- and you know how far you get dong that. Sorry for the length here but I was fired up, I had my pain dr apt today and was given my script for the 120 pills the government says I can have, even though my doctor says I need more and had me on 3 times that amount before the “120 amount of pain pills” bill or whatever it was was filled. Then was I was lucky enough to be standing there waiting for my order to be filled, this poor person comes in and is on the wild goose hunt trying to find out if they csn fill their prescriptions. The poor pharmacist told them that they were sorry they couldn’t because they were only allowed to have so many pills given to the store each month and there just wasn’t enough that they could fill this persons scripts. Of course then the person asks if the pharmacist can recommend anywhere else and she said she didn’t know- made a couple attempts to name places which I knew they wouldn’t and the poor person left with no satisfaction about getting his pills or where he might be able to go get them. I guess they had just been put on the pain pills and didn’t know the drill yet..Everyone I know here in Fl no matter which pain med they are on (and you know the ones we are talking about here) is only allowed to have 120 of them!! per month. 2 kinds. ! I don’t know if the same nonsense holds true wherever you are but it is unbelievable to me that they have the power to go over your doctors head and tell you what you should or shouldn’t have. How can they judge all people to need no more than 120 pills a month. Your above comment really hits the nail on the head. HOw can this be happening? I don’t wish anyone ill health but sometimes I think if these lawmakers or their family members were to have our medical problems and be treated as we are- they might realize how large a harm they are doing us poor citizens and get on the stick and GIVE THE POWER BACK TO THE DOCTORS WHERE IT BELONGS. Its as if you were to buy a car, license it, buy insurance, get it inspected or registered or whatever- and then be told you cant drive it on the road even though you had done everything legally. I am so tired of being classified as a druggie by the government because I have a defective hip replacement in me now, had 2 previous hip operations and need neck and back surgery. thank God for people like this Doctor here who try to help us and realize the frustrating and unreasonable regulations the government puts upon us. Sorry for the typos etc, but I hurt too bad to go back and correct them.
So the question is- how do we accomplishment what you so very correctly stated in your above comment.? Is there any hope for us?
“Then ask yourself why any highly skilled pharmacist would want to do these things for free!” Both HR592 and S314 contain a payment provision: “with respect to pharmacist services (as defined in section 1861(s)(2)(GG)), the amounts paid shall be equal to 80 percent of the lesser of the actual charge or 85 percent of the fee schedule amount provided under section 1848 if such services had been furnished by a physician.” I support both bills. If enacted into law, these changes would apply to Medicare coverage of pharmacist services only and the covered pharmacist would have to be “legally authorized to perform [the services] in the State in which the individual performs such services.” Lastly, for more than a century, federal and state laws have recognized the corresponding responsibility of the pharmacist to validate prescriptions prepared by physicians and mid-level physicians. Because these bills, if they become law, would alter that relationship and function, I think it would be appropriate to require that when the pharmacist services proposed in these bills include dispensing controlled substances, that it be done only after the pharmacist reviews the state’s PDMP for the patient(s) in question and inserts a record of this in the patient’s medical file. HR592 was introduced by Representative Brett Guthrie (R-KY) on January 28, 2015 and has 264 cosponsors. The companion bill in the Senate was introduced the next day by Sen Chuck Grassley (R-IA), and has 41 cosponsors. KY has been in the forefront of addressing prescription drug abuse. A decade ago, when the National All Schedules Prescription Electronic Reporting Act (NASPER) became law, it was modeled after the Kentucky All Schedules Prescription Electronic Reporting (KASPER) statute. NASPER was supported at the time by the American Society of Interventional Pain Physicians (ASIPP), the American Society of Anesthesiologists, the American Medical Association, and the American Association of Nurse Practitioners. The intent of NASPER was to increase state PDMP data collection for all schedules of controlled substances, and to permit access to PDMP data for physicians and pharmacists to assist them in detecting and preventing substance abuse disorders in their patients. Inasmuch as pharmacists under the proposed bills would be expected to dispense controlled substances, they would have to report this information to the state PDMP anyway. It makes sense that they would query the system beforehand to prevent fraudulent dispensing and/or instances of uncoordinated medical care involving prescription drugs. Given that these bills are presently (and have been for more than a year) in committee, offering a simple amendment to include a PDMP check might just be what’s needed to get them enacted before this session of Congress expires. Prescription drug abuse is a serious concern of the Congress and the President, more so than the expansion of pharmacists’ services under Medicare, and anything that promises to address prescription drug abuse and its dire health consequences may resonate with the folks on the Hill.
John, Thank you so much for the time you put into this response. To clarify, I don’t think that a pharmacist evaluating a patients and/or prescribing an opioid in states where it is allowed, should ever fill the prescription. That should remain separate so there are checks and balances in place.