While political activists and politicians continue to overwhelm professional journals, mainstream media, and countless television networks regarding patient deaths related to prescribed opioid therapy, they all overlook a potential key group that could significantly help.
Recently I communicated with a physician that is variously aligned with Physicians for Responsible Opioid Prescribing (PROP). Although we are both concerned about patient safety, our personal and group-affiliated approaches to addressing opioid overdose risk have been vastly different. Regarding the recently released CDC guidelines I posed a question to him, “Do you feel it would have been advantageous to have a pharmacist on the panel with expertise in pain management and one practicing in psychiatry, residency trained in psychiatric pharmacotherapeutics?”
The answer? “I don’t know enough about how pharmacists are trained to have an opinion about including them.” Thank you very much for that answer because you fired me up enough to write this blog.
While it surprises me that the individual has not spent more time researching pharmacist education and skillsets, I am more disappointed in organized pharmacy leadership for dropping the ball on their constituents and the opioid [and other] patients that stand to benefit.
Many of you may not have connected the dots yet. But, large pharmacy organizations such as the American Pharmaceutical Association (APhA) and American Society of Health-system Pharmacists (ASHP), among others, have been spending hundreds of thousands of dollars over the last several years lobbying for pharmacists and encouraging Congress to recognize pharmacists as “providers”. Such a policy change would allow third party payers like Medicaid and Blue Cross to pay pharmacists for evaluating, prescribing, and counseling patients in clinics and in hospital settings. While on the one hand I applaud their efforts, I believe the organizations have not yet seen the forest through the trees.
Most non-pharmacists here probably don’t know this, but following the MD equivalent for pharmacists, the PharmD, many pharmacists go on to do a postgraduate general practice residency followed by a specialty residency and/or fellowship. There is no doubt that these highly trained pharmacists are at least as, and in most cases, more qualified in the area of medication therapeutics than the majority of clinicians nationwide that are prescribing opioids, or any drug for that matter. The federal government has recognized this for years, and within the Department of Veterans Affairs, the Department of Defense, and the Public Health Service, pharmacists see patients in primary care and specialty clinics regularly. They treat diabetes, hypertension, hepatitis, heart disease, infectious disease, cancer, psychiatric disorders, pain, and many other disease states in collaboration with medical doctors and other clinicians. No, they do not diagnose, nor do they want to. But given a diagnosis they prescribe medication, the choices of which are generally more cost-effective, order appropriate laboratory analysis, and triage new problems where immediate medical attention is required.
But there are two issues. #1, PharmD’s need to be paid for these services so that MD’s and large managed care groups can financially support their presence and incorporate them into medical practices nationwide, and #2, people “don’t know enough about how pharmacists are trained to have an opinion about including them”. True as also stated above, but OUCH!
So while organizations like APhA and ASHP are spending thousands of dollars to convince politicians on The Hill to favor Bill H.R. 592, they are missing the bigger picture. Notwithstanding, Bill H.R. 592 doesn’t even go far enough, but I suppose from the standpoint of professional organizations, it’s better than nothing.
Better than nothing – why do I say this?
Well, according to the APhA Website, “If enacted, the legislation would enable patient access to, and coverage of, Medicare Part B services by pharmacists in medically underserved communities. The legislation would improve patient access to health care through pharmacists and their patient care services.”
Newsflash: All pain patients are medically underserved and there is an opioid epidemic!
I for one am tired of seeing erstwhile pharmacist icons portrayed on television. Here the American pharmacist icon is seen dispensing medications and advocating for over-the-counter medications while standing behind a counter in a white coat as if behind a curtain in the Land of Oz. Don’t get me wrong, I know for certain that there is a lot more to their daily activities that go unnoticed by those lines of customers (who we really know as patients). They are checking for drug interactions that are ill-represented by computer software, contacting prescribers with recommendations and alternative therapies, giving vaccines, fighting for patients with insurance companies to obtain otherwise non-formulary or third tier drug options, counseling patients on medication and device use, and much more.
But, according to my daughter Sarah Hermalyn, a branding expert who grew up in a pharmacy environment, “the problem is that the profession as a whole needs to be rebranded. When people ask me what my father does for a living, I usually say he’s a PharmD and runs a pain clinic. If I tell them he’s a pharmacist they picture someone behind a counter, filling prescriptions.” To learn about branding see 100 Days to Define Branding.
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. So while our organizations are politicking on The Hill, and I continue to receive e-mails each week and year after year on how “we are getting closer” to approval of a Bill that allows billing for such partnerships, I’m still waiting as patients suffer.
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. It’s simply absurd!
If pharmacists expect that Senators and Congressman are going to support Bill H.R. 592, it needs to start with educating their constituents. Pharmacists need to explain to their communities what we can do and how we can do it. How can we possibly expect politicians to support such a bill when most of the country thinks we are smart people wearing a white coat in the Land of Oz?
So why this blog post? Don’t you see it? Pharmacy Doctors (Clinical Pharmacists) are in a perfect position to help medical doctors and other prescribing clinicians carefully and accurately assess opioid medication regimens; to determine if the patient should or should not be on an opioid; to stratify risk; to prescribe and train patients and caregivers on in-home naloxone; to determine if they’re on the best opioid or the wrong opioid; to transition them to a better opioid for their condition; to order, monitor and interpret urine drug screens and medication blood levels; to order and interpret pharmacogenetic tests; to anticipate otherwise unanticipated drug interactions due to Phase I, Phase II metabolisms and/or p-glycoproteins; to cost-effectively select the best medication based on insurance coverage; adjust doses based on kidney and hepatic function; comprehensively engage each patient’s third party payer to justify required prior drug authorizations; and much more.
It is We the [Pharmacy] People that need to foster support for Bill H. R. 592 and expand its utility because all communities have underserved pain management patients and the dangers associated with overprescribing or inadequate access to pain medications – not just opioids.
Here is a place where Congress could really make a difference for pain patients and also improve patient monitoring by enacting a bill that would capitalize on the expertise of residency trained pharmacists in the fields of behavior health and pain management.
It is inconceivable that pharmacists could do it better, improve outcomes and safety, at a lesser cost and with reduced medication-related hospitalizations, all of which have been studied and proven, yet NOBODY KNOWS.
Pharmacy needs to be rebranded!
I would love some comments and feedback from clinicians and patients. It will be especially interesting to hear if physicians would readily incorporate residency trained “pharmacists” into their clinics if they could bill for that visit. It would be equally enlightening to hear how and if patients would be accepting of seeing a clinical pharmacist on a follow-up visit instead of their physician, nurse practitioner, or physician assistant.