As I write this post, I am sitting on a plane, row 26 in Atlanta, Georgia waiting for the aircraft door to close. Now that it’s closed, the 10 passengers immediately in front of me are sitting in two emergency exit rows. The flight attendant approaches them…
- Are you willing and physically able to assist in case of an emergency evacuation?
- Is everybody in rows 24 and 25 at least 15 years of age or older?
- Passengers nodding…
- I need a verbal response from each person individually…
- Yes, yes, yes, yes, yes
Now imagine entering your doctor’s office for a yearly physical. You have a diagnosis of hypertension (BP=170/97), diabetes (A1C=11), and heart disease (EF=32). Upon check-in with the receptionist, you are asked to sign a waiver.
- [Y] [N] I decline physical exam
- [Y] [N] I decline any discussion of risk factors
- [Y] [N] I decline any discussion of harm reduction and lifestyle modification including but not limited to diet, exercise, alternative treatment options or other
[Y] [N] I agree to renewal of my prescriptions without discussion or counseling
Here’s another example for pain patients…
- [Y] [N] I decline physical exam
- [Y] [N] I decline any discussion of pain level, ability to carry out activities of daily living
- [Y] [N] I decline any discussion of anxiety, depression, constipation, suicidal thoughts, or other
- [Y] [N] I decline any monitoring including but not limited to urine drug screens
- [Y] [N] I decline any discussion of harm reduction, risk of opioid-induced respiratory depression, alternative treatment options in addition to or instead of opioids, and lifestyle modification including but not limited to diet, exercise, or non-medication options
- [Y] [N] I agree to renewal of my prescriptions without discussion or counseling
Rewind to three days ago when I entered a local pharmacy for a prescription refill, albeit a non-opioid. As I approach a student pharmacist who didn’t know I was a pharmacist, as she handed me my medications, she asked me to sign the routine electronic pad, “[Y] [N] I decline counseling”. Although this has become the standard of care among community pharmacies, I couldn’t help but think, when did the train get off the track?
Today we find ourselves in an environment with politicians and mainstream media hurling blame at everybody and their brother for a presumed prescription opioid crisis. The FDA has ratcheted up their risk evaluation mitigation strategy (REMS) program to include immediate release opioids, and other strategic changes; state after state is requiring 3 or more mandatory hours of continuing education in order for clinicians to maintain their ability to prescribe controlled substances; several states and insurance carriers have placed limits on days supply of opioids for acute pain; Medicare has implemented a new program that will require hard and soft edits of morphine equivalent doses at the 90mg and 200mg marks, each requiring communication between pharmacist and prescriber (which could delay prescriptions for patients requiring chronic opioid therapy thereby precipitating withdrawal)… Need go on?
I’m pretty sure that the chance of my plane crashing is far less than the risk of accidental or intentional opioid overdose, although we are experiencing significant turbulence at the moment which is making me second guess that. Yet, the stewardess needs to ensure the safety of passengers requiring a verbal affirmation from each that they understand the importance of their responsibility – although I feel like if we did crash, it wouldn’t make much difference – but the activity by this stewardess is standard practice and it’s mandatory!
The clinicians above would not meet the standard of practice in either scenario above for the diabetic or pain patient, and the suboptimal attention could result in patient harm, death, and significant liability.
Nevertheless, somehow it has become okay, in fact the standard, for pharmacists to neglect an important duty to counsel. And why? Because we live in a profit-driven medical world where time is money and patients are inpatient, or believe that the pharmacist has nothing new to offer in terms of counseling.
Although it’s sad that it has come to this, federal and state law should eliminate the option for “declined counsel” for any controlled substances, opioids or otherwise. Why, because these medications by DEA definition have a high risk of abuse.
Examples of other Controlled Substances
- Amphetamines for ADHD: Remind parents that these are the most highly abused drugs among college students. Remind parents that these stunt growth in young children and it’s beneficial to take a drug holiday during winter, spring, and summer breaks so that your child can catch up on the growth curve.
- Testosterone supplements: Remind patient that there is elevated risk of anger and aggressive behavior, mood swings, and should not be used if predisposed to prostate cancer. Ask if anything has changed to elevate that risk.
You have long-term pain and require chronic opioid therapy, and don’t feel like you need counseling? A simple chat and a few reminders are not a bad thing each month and it certainly wouldn’t harm you.
Here’s how it should go…
Mr. Smith, I know you’re very familiar with your oxycodone, but I just want to take a few minutes to review some items to maximize safety and minimize potential side effects or other problems. Have you had regular bowel movements; is the consistency regular for you; do you feel like you’re straining or have incomplete evacuation? Have you changed your diet at all? Have you started any natural food supplements or any new diets; these things can elevate or reduce your opioid levels and cause pain or too much sedation. Do you feel like your pain is adequately controlled; if the answer is no, ask what the issues are. Is it a new pain or worsening of the old pain? Is it burning/shooting pain, or does it feel like bone pain or something else? Oh, it’s burning pain – you really don’t have any medications on board to specifically address that, but there are several options – you should make an appointment with your medical provider and discuss various options. Patient asks, such as what? Answer; certain antidepressants that are also indicated for pain that effect norepinephrine in nerves such as duloxetine; various anticonvulsants such as gabapentin and others; perhaps a switch to a different opioid that could add more benefit over oxycodone, but you should be to your doctor to determine if any of these are appropriate options considering your pain diagnosis and medical history. Are you able to do the same things now that you were able to accomplish 1, 3, or 6-months ago since your prescriber has reduced your opioids; how has that affected your mood and function; have you had withdrawal symptoms? How is your mood, your sleep?
You get the picture.
The role of a pharmacist has expanded exponentially over the last several decades. It is unacceptable to allow any patient to decline counseling for opioids. The counseling should not be demeaning or derogatory; instead it should be genuine, engaging, serious, caring, comforting, and helpful.
On a weekly basis I see various prescribers besieged for prescribing too much opioid, even in legitimate cases, criticized by regulatory agencies for not keeping pristine notes or appropriately counseling patients. Yet the very last hands through which the prescription passes have the legal (and standard-of-care) option of no note, no counseling, no preemptive safety discussions, or pep-talks, NOTHING.
At the risk of stirring up ill-feelings amongst my pharmacist colleagues and throwing my own peeps under the bus, it bothers me immensely to know that we can have a huge impact and also be a neutral advocate for patients and their prescribing clinicians. I know time is limited and that pharmacists are overworked. I also know that the physician time is limited and they are overworked. I know that too much time is spent by both of these professionals dealing with insurance payers to obtain prior approval authorizations for medications or procedures. I get it.
What I don’t get is how we can allow an innocent patient to “decline counseling” when it is our professional duty to keep patients safe and functional. We need a parachute for this decline in professionalism to help patients safely land instead of crashing and burning. Counseling should be the standard, and it should be mandatory! #DitchTheDecline
As always, comments are encouraged and welcome!